CHRONIC PYELONEPHRITIS

Definition
Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection. It occurs
almost exclusively in patients with major anatomic anomalies, including urinary tract
obstruction, struvite calculi, renal dysplasia, or, most commonly, vesicoureteral reflux (VUR) in
young children. Sometimes, this diagnosis is established based on radiologic evidence obtained
during an evaluation for recurrent urinary tract infection (UTI) in young children. VUR is a
congenital defect that results in incompetence of the ureterovesical valve due to a short
intramural segment. The condition is present in 30-40% of young children with symptomatic
UTIs and in almost all children with renal scars. VUR may also be acquired by patients with a
flaccid bladder due to spinal cord injury. VUR is classified into 5 grades (I-V), according to the
increasing degree of reflux.
Pathophysiology
Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage
renal disease (ESRD), for example, reflux nephropathy.

Intrarenal reflux of infected urine is
suggested to induce renal injury, which heals with scar formation. In some cases, scars may form
in utero in patients with renal dysplasia with perfusion defects. Infection without reflux is less
likely to produce injury. Dysplasia may also be acquired from obstruction. Scars of high-pressure
reflux can occur in persons of any age. In some cases, normal growth may lead to spontaneous
cessation of reflux by age 6 years.
Factors that may affect the pathogenesis of chronic pyelonephritis are as follows: (1) the sex of
the patient and his or her sexual activity; (2) pregnancy, which may lead to progression of renal
injury with loss of renal function; (3) genetic factors; (4) bacterial virulence factors; and (5)
neurogenic bladder dysfunction. In cases with obstruction, the kidney may become filled with
abscess cavities.
Clinical Finding
History Taking
Many cases of VUR are suggested based on prenatal sonography findings.
Patients with chronic pyelonephritis may report the following:
o Fever
o Lethargy
o Nausea and vomiting
o Flank pain or dysuria
Some children may present with failure to thrive.

Physical Examination
The following may be noted:
o Hypertension
o Failure to thrive in young children
o Flank tenderness
Causes
Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection.



Workup diagnosis
Laboratory Studies
Urinalysis
o Urinalysis results may reveal pyuria.
o Obtain a urine culture, which often isolates gram-negative bacteria, such as
Escherichia coli or Proteus species.
o A negative result from urine culture does not exclude a diagnosis of chronic
pyelonephritis.
o Proteinuria may be present and is a negative prognostic factor for this disease.
Serum creatinine and blood urine nitrogen levels are elevated (azotemia).
Imaging Studies
Findings from an intravenous urogram help establish the diagnosis of pyelonephritis
because they reveal caliceal dilatation and blunting with cortical scars. Ureteral dilatation
and reduced renal size also may be evident.
Voiding cystourethrogram (VCUG) findings may document the reflux of urine to the
renal pelvis and ureteral dilatation in children with gross reflux.


Radioisotopic scanning with technetium dimercaptosuccinic acid is more sensitive than
intravenous pyelography for helping detect renal scars. This is the preferred test for many
pediatric nephrologists and radiologists because it is sensitive and easy to perform.
Cystoscopy images show evidence of reflux at the ureteral orifices.
Renal sonography images may show calculi.
CT scan is the procedure of choice to help diagnose XPN.


Renal ultrasonography images may show calculi, but ultrasound is not a sensitive
screening procedure for reflux nephropathy.


Histologic Findings
Renal biopsy specimens show focal glomerulosclerosis in advanced reflux nephropathy, while
XPN must be distinguished from renal malakoplakia based on the presence of inclusions called
Michaelis-Gutmann bodies.
Medical Care
Stages I and II VUR
o This is reflux of urine to the ureter or renal pelvis without ureteral dilatation.
o Medical therapy with antibiotics, such as amoxicillin,
trimethoprim/sulfamethoxazole (Bactrim), trimethoprim alone, or nitrofurantoin,
is usually sufficient.
o Continue antibiotic therapy until reflux resolves.
o The rule in these cases is spontaneous resolution; surgery is not indicated.
Stages III and IV VUR (severe reflux)
o Data from the Birmingham Reflux Study (international reflux study in children)
show that medical and surgical therapies for reflux are equally effective.


o Surgery for severe reflux involves reimplantation of the ureters.
o The indications for surgery include the following: (1) medical noncompliance
with formation of new scars, and (2) reflux persisting after puberty in women
(should be surgically treated to prevent possible complications, eg, pyelonephritis,
abortions in pregnancy).
Surgical Care
The following are indications for surgical therapy:
o Failure to comply with medical regimen
o Breakthrough infections occurring in patients who are compliant
o Women of childbearing age who prefer surgical therapy
Surgery entails the reimplantation of the ureters with the creation of an adequate
submucosal tunnel and detrusor support.
Diet
Progressive renal injury can be reduced by restricting dietary protein intake.

Medication
The penicillins (amoxicillin) and first-generation cephalosporins are the drugs of choice because
of good activity against gram-negative rods and good oral bioavailability. In infants, the choice
of antibiotics is either amoxicillin or a first-generation cephalosporin. In patients aged 3-6
months, therapy can be changed to sulfamethoxazole or nitrofurantoin. Older children and adults
may be treated with trimethoprim-sulfamethoxazole (Bactrim). Once one antibiotic is chosen,
frequent changes in the antibiotic regimen are discouraged to help prevent the development of
resistance.
Prevention
Diet: Progressive renal injury can be reduced by dietary protein restriction.
Hypertension therapy: Aggressive blood pressure control is beneficial to slow the
progression of renal failure. ACE inhibitors are particularly beneficial in this setting.
Pregnancy: Careful follow-up and monitoring of renal function is beneficial. Vigorously
treat a UTI or bacteriuria in a patient who is pregnant to prevent renal failure,
preeclampsia, and abortions.


Screening: Renal sonography is recommended for siblings of patients with VUR.

If an
abnormality is found, then perform a VCUG.
Complications
Proteinuria
Focal glomerulosclerosis
Progressive renal scarring leading to end-stage renal disease
XPN (may occur in approximately 8.2% of cases)


Pyonephrosis (may occur in cases of obstruction)
Progressive renal scarring (reflux nephropathy)
o The characteristic renal scars of VUR are often present at the time of initial
diagnosis of chronic pyelonephritis.
o New renal scars may develop in 3-5% of patients after the initial evaluation.
o The progression of renal scars is inversely related to the promptness with which
specific antibiotic therapy is instituted.
o The presence of new scars often suggests the occurrence of breakthrough
infections.
Hypertension
o Hypertension contributes to the accelerated loss of renal function in persons with
this disease.
o Reflux nephropathy is the most common cause of hypertension in children,
occurring in 10-20% of children with VUR and renal scars.
o The resolution of reflux does not appear to correct hypertension.
Prognosis
Although most children with chronic pyelonephritis due to VUR may experience
spontaneous resolution of reflux, approximately 2% can still progress to renal failure and
5-6% can have long-term complications, including hypertension.
The Birmingham Reflux Study clearly shows that medical and surgical management are
equally effective in preventing subsequent renal damage.


Almost all children should receive a trial of medical management.