Pyelonephritis is often known as a Urinary Tract Infection (UTI) that spreads to the kidney and is commonly caused by the bacteria Escherichia coli. Given that the kidneys are closely associated with the urinary tract, it’s likely that an infection of the urinary tract could harm the kidneys as well. ‘Kidneys commonly get infected and inflamed when the bacteria spread up the urinary tract or travel through the bloodstream to reach the kidneys,’ says Dr Avinash Ignatius, a Senior Consultant Nephrologist with DaVita NephroLife, Pune. It can also result from obstruction of the ureters(Tubes that allow drainage of urine from the kidney to the bladder), causing backflow of urine into the kidneys and ureters.
Types
Pyelonephritis can be either acute or chronic,’ says Dr Avinash.
Acute pyelonephritis: It occurs rapidly and is a life-threatening infection of the kidneys that can lead to renal scarring. It is of 2 types
Uncomplicated: This condition occurs in healthy people with no comorbidities and no functional or structural issues in the urinary tract.
Complicated: This condition occurs in pregnant women or individuals with comorbidities or abnormalities of the urinary tract.
Chronic pyelonephritis: It is a permanent damage. The kidney is scarred due to repeated episodes of acute pyelonephritis, or even a single episode of acute pyelonephritis.
Symptoms
Symptoms of the disease can vary depending on your age and the severity of the condition. Common symptoms include:
Fever
Chills
Nausea
Vomiting
Uncomfortable pressure above the pubic bone is seen mostly in female
Feeling of fullness in the rectum is seen in men
Reddened skin(location) There is no particular location as it is like a rash.
Flank pain
Changes in urine like foul-smelling urine, cloudy urine, abnormally coloured urine and haematuria(blood in urine)
Changes in urination like painful urination, inability to urinate despite the feeling of urgency, burning sensation while urinating, increased urination etc.
General feeling of sickness
Tiredness
Pain around mid-back
‘Severe pyelonephritis may cause septicaemia and shock associated with shivering and occasionally disorientation,’ says Dr Avinash. ‘Recurrent episodes or severe episodes of kidney infection can lead to significant scarring and irreversible damage to the kidneys. It can lead to chronic kidney disease (CKD) that gradually progresses to end-stage renal disease (ESRD), where dialysis or kidney transplant may be needed,’ he says.
Causes And Risk Factors
Causes
Pyelonephritis is the medical term used for inflammation of the kidneys. Clinically, it is more commonly referred to as a type of urinary tract infection that spreads to the kidneys. Kidney infection can be caused by viruses or bacteria. But the bacterium Escherichia coli is the common causative agent for the disease. Usually, bacteria are flushed out of the urinary tract. However, in certain conditions, they may accumulate and cause urinary tract infection.
These conditions include:
Structural abnormalities like kidney stones may block urine flow and cause accumulation of urine.
Backflow (reflux) of urine to the kidney from the bladder.
Uncontrolled diabetes mellitus
An enlarged prostate gland compressing the urethra.
Weakened immunity reduces the ability of the body to fight against the bacteria, increasing the chances of an infection.
Pregnancy, during which time the enlarging uterus reduces the flow of urine due to compression of the ureters, allowing the bacteria to reach the kidneys.
Risk Factors
A few people have an increased chance of suffering from pyelonephritis. These include people who have
Bladder infection,
Structural or anatomic problem in the urinary tract
Diabetic individuals
People with a weak immune system.
Women have shorter urethras, which are closer to the rectum, making it easier for bacteria to enter the urinary tract and move towards the kidney.
Catheters
Pregnancy
Poor hygiene
Age (UTI’s are more frequently seen in older adults and young children)
Genetic predisposition
Changes in vaginal flora caused due to a variety of things like menopause or use of spermicides
Structural problems in the urinary tract.
Prevention
Here are some expert tips to prevent recurring kidney infection
Take antibiotics as prescribed
Ensure you complete the course of antibiotics, even if there are no symptoms
Drink adequate fluid to have a urine output of about 2.5 litres. However, this may not be possible in patients with CKD or heart failure, as they may need fluid restriction
Urinate completely: Empty your bladder completely, do not hold urine in your bladder.
Urinate after having sex: Urinating after sex helps remove any bacteria that may have gotten into the body.
Practice good hygiene
For women keeping the genital area dry and wiping front to back after excretion.
Diagnosis
Many other reasons can cause symptoms similar to that of a kidney infection. The following tests help to diagnose Pyelonephritis:
Usually, based on the patient’s history and physical examination, the doctor may suggest urinalysis to detect white blood cells and bacteria in the urine. Some other tests that might be needed include:
Urine culture: It helps to identify contamination of urine samples with bacteria.
CT scan: It is used to visualise inflammatory masses and obstruction of the urinary tract.
Ultrasonography: This test is also used for identifying urinary obstruction.
Cystoscopy: A flexible tube is inserted into the urethra. It contains a viewing device to check the bladder, kidney, urethra for obstructions or renal calculi(kidney stones)
Voiding cystourethrogram (VCUG) : An x-ray image helps identify bladder problems. It is taken while the bladder is full and during urination.
Dimercaptosuccinic acid (DMSA) scintigraphy: Used to check for kidney scarring or damage.[8]
Renal Function can be checked by metabolic panel testing.
Digital rectal examination (DRE): To check for an enlarged prostate.
Treatment
Dr Avinash says, ‘Acute pyelonephritis usually responds to antibiotics. But in case there are stones or complete obstruction of the urinary tract, surgical intervention may be required.’
The main method for treating acute pyelonephritis is analgesics, antipyretics and antibiotics.
Nonsteroidal anti-inflammatory drugs (NSAID’)s are used to treat fever and pain.
Usually, antibiotic therapy of 2 weeks or more is required to eliminate the infection as well as to prevent relapse. Antibiotics like fluoroquinolones or cephalosporine are commonly used. Nitrofurantoin and a combination of Trimethoprim-sulfamethoxazole(TMP-SMX) can also be used.
Antibiotics need to be selected based on urine culture results and tailored according to patient needs. Other regimes for non-hospitalised patients can be :
Ciprofloxacin 1,000 mg extended-release daily for 7 days, or levofloxacin 750 mg daily for 5 days along with Oral ciprofloxacin 500 mg twice daily for 7 days.
Oral b-lactams are considered to be less effective than other agents for the treatment of pyelonephritis. If used, a one-time IV dose of ceftriaxone or an aminoglycoside is initially recommended, after which a 10- to 14-day course of the b-lactam agent is administered.
IV Antibiotics may be needed for severe infections. These include an initial one-time IV dose of fluoroquinolone, ceftriaxone, and a 24-hour dose of an aminoglycoside.
After improvement, oral agents can be used.
For treating an obstruction in the urinary tract, surgery may be needed.
Surgical procedures include the following:
Pyeloscopy: This procedure is performed in case there are stones in the kidney. An endoscope is used to visualise the kidney drainage system. The endoscope also has a port and micro-basket that allows introduction of laser to break down larger stones as well as their retrieval.
Percutaneous nephrostomy or percutaneous nephrolithotomy: A percutaneous nephrostomy is when a catheter is placed in the kidney to allow the urine to drain. Percutaneous nephrolithotomy is when a medical instrument is passed to the kidney through the skin to remove the kidney stones.
‘Acute pyelonephritis can recur, especially if the predisposing cause is not corrected. Some factors like uncontrolled sugar level, abnormalities in the urinary tract, enlarged prostate gland, presence of kidney stones and lowered immunity can increase the risk of recurrence,’ he says.
Lifestyle/management
Lifestyle changes such as
Not eating spicy food, coffee or alcohol
Drinking adequate water
Quitting smoking
may help in reducing the chances of recurrence.
Prognosis And Complications
Prognosis
With appropriate treatment with antibiotics, the prognosis is good. It is important that the course of antibiotics is completed even after the symptoms are reduced to prevent antibiotic resistance. There is a chance of death in patients above 65 years with comorbidities and impaired renal function.
The prognosis of Chronic Pyelonephritis changes from patient to patient. Many patients may suffer from just a kidney infection occasionally, while others may require a kidney transplant or dialysis treatment.
Complications
Complications of chronic pyelonephritis include scarring of kidneys which can cause end-stage failure. Acute pyelonephritis can have several complications such as renal abscess formation, sepsis, papillary necrosis, thrombosis of the renal vein or acute renal failure.[10] Another complication is Emphysematous pyelonephritis(EPN) which is a kidney infection caused by E. coli or Klebsiella pneumoniae bacteria that causes necrosis. EPN is usually seen in diabetics and occurs more frequently in women.
Alternative Treatments
Several alternate treatments have been found to help in the treatment of Pyelonephritis
Vaccines: Studies have been conducted to immunise people against urinary pathogens to prevent recurrent UTI. Several studies are going on to test the different types of vaccines. These vaccines target different parts of the pathogen like Metabolism, capsules etc.
Cranberry can be used in prophylaxis of recurring UTI.
D-Mannose: Can help prevent acute and chronic UTI.
References
Kidney Infection (Pyelonephritis); Symptoms, Treatment, Prevention[Internet] Available at: https://my.clevelandclinic.org/health/diseases/15456-kidney-infection-pyelonephritis Accessed on Jun 16, 2021
Urinary Tract Infections (UTIs) - Health Encyclopedia - University of Rochester Medical Center Available at:https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P01497 Accessed on Jun 16, 2021
Colgan R, et al, Diagnosis and Treatment of Acute Pyelonephritis in Women - American Family Physician Am Fam Physician. 2011 Sep 1;84(5):519-526
Chronic pyelonephritis Kidney Care UK [Internet] Available at: https://www.kidneycareuk.org/about-kidney-health/conditions/chronic-pyelonephritis/ Accessed on Jun 16, 2021
Urinary Tract Infections (for Teens) - Nemours KidsHealth [Internet] Available on : https://kidshealth.org/en/teens/uti.html Accessed on Jun 16, 2021
When urinary tract infections keep coming back Harvard Health Publishing [Internet] Available at https://www.health.harvard.edu/bladder-and-bowel/when-urinary-tract-infections-keep-coming-back Accessed on Jun 16,2021
Urinary tract infections (UTIs) – NHS [Internet] Available on: https://www.nhs.uk/conditions/urinary-tract-infections-utis/ Accessed on Jun 16,2021
References
Kidney Infection (Pyelonephritis); Symptoms, Treatment, Prevention[Internet] Available at: https://my.clevelandclinic.org/health/diseases/15456-kidney-infection-pyelonephritis Accessed on Jun 16, 2021
Urinary Tract Infections (UTIs) - Health Encyclopedia - University of Rochester Medical Center Available at:https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid=85&contentid=P01497 Accessed on Jun 16, 2021
Colgan R, et al, Diagnosis and Treatment of Acute Pyelonephritis in Women - American Family Physician Am Fam Physician. 2011 Sep 1;84(5):519-526
Chronic pyelonephritis Kidney Care UK [Internet] Available at: https://www.kidneycareuk.org/about-kidney-health/conditions/chronic-pyelonephritis/ Accessed on Jun 16, 2021
Urinary Tract Infections (for Teens) - Nemours KidsHealth [Internet] Available on : https://kidshealth.org/en/teens/uti.html Accessed on Jun 16, 2021
When urinary tract infections keep coming back Harvard Health Publishing [Internet] Available at https://www.health.harvard.edu/bladder-and-bowel/when-urinary-tract-infections-keep-coming-back Accessed on Jun 16,2021
Urinary tract infections (UTIs) – NHS [Internet] Available on: https://www.nhs.uk/conditions/urinary-tract-infections-utis/ Accessed on Jun 16,2021
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