Pyelonephritis

Defenition
• Pyelonephritis is a bacterial infection that attacks the kidneys, which are
both acute and chronic.
• Pyelonephritis is a bacterial infection of the kidney cup (renal pelvis),
tubules, and interstinal tissue of one or both of the worm (Brunner &
Suddarth, 2002: 1436).
• Pyelonephritis is an infection in the kidney that can arise hematogenously
or retrograde ureteric flow (J. C. E. Underwood, 2002: 668)
Classification
1. Acute pyelonephritis (PNA)
Acute pyelonephritis is an inflammatory process of the renal
parenchyma caused by a bacterial infection.
2. Chronic pyelonephritis (PNK)
Chronic pyelonephritis may be a result of prolonged bacterial
infection or infection since childhood. Urinary tract obstruction and
vesicoureteric reflux with or without chronic bacteriuria are often
followed by the formation of renal parenchymal connective tissue
characterized by specific chronic pyelonephritis.
Acute pyelonephritis
- Usually short (1 to 2 weeks) and frequent recurring infections due to
incomplete therapy or new infections.
- 20% of recurrent infections occur after two weeks after therapy is
finished.
Epidemiology
• Acute pyelonephritis is a kidney disease that is often encountered. This
disorder can not be released from urinary tract infections.
• Kidney infections are more common in women, this is because the lower
urinary tract (urethra) is shorter than men, and the urinary tract is located
close to the vagina and anus, so it reaches the bladder faster and spreads to
the kidneys.
• The incidence of this disease will also increase in pregnant women and over
the age of 40 years. Likewise, people with diabetes / diabetes mellitus and
other kidney diseases are more susceptible to kidney and urinary tract
infections.
Pathophysiology
Bacterial infection of the lower urinary tract toward the kidneys, this
will affect kidney function.
1. Upper urinary tract infection is associated with a blanket of bacterial
antibodies in the urine.
2. Kidney usually enlarges accompanied by interstitial infiltration of
inflammatory cells.
3. Abscesses can be found in the kidney capsule and in the corticomarynx link.
4. Eventually, atrophy and damage to the tubules and glomerulus occur.
Chronic pyelonephritis
Pathophysiology
• Derived from bacteria, but can also be due to other factors such as urinary
tract obstruction and urine reflux.
• Can permanently damage kidney tissue due to repeated inflammation and
scarring and can cause chronic renal failure. The kidneys also form
progressive scarring, contracting and not functioning. The process of
developing chronic kidney failure from repeated kidney infections takes
place several years or after a serious infection.
• Often found in pregnant women, usually begins with hydro ureter and
hydronephrosis due to ureteral obstruction due to an enlarged uterus.
Etiology
a. Bacteria
• Escherichis colli
Escherichia coli (a bacterium that is normally found in the large intestine) is a
cause of infection that is often found in acute pyelonephritis without
complications
• Basilus proteus and Pseudomonas auroginosa.
Pseudomonas are also pathogens in humans and are a cause of infections in
the urinary tract.
• Klebsiella enterobacter
Klebsiella enterobacter is a contagious pathogen that generally causes
respiratory infections, but can also cause urinary tract infections
• Proteus species
Proteus which normally found in the digestive tract, become pathogenic when
in the urinary tract.
• Enterococus
Refers to a species of streptococus that inhabits the gastrointestinal
tract and is pathogenic in the urinary tract
• Lactobacillus
Is normal flora in the oral cavity, gastrointestinal tract, and vagina,
considered as urinary tract contaminants. If more than one type of
bacteria is found, the specimen must be considered contaminated.

b. Urinary track obstruction. For example kidney stones or prostate

enlargement.
c. Reflux, which is a reverse flow of urine from the bladder back into the
ureter.
d. Pregnancy
Pathophysiology
Bacteria can enter the urinary tract through 3 pathways. That is :
a. Ascenden : Stool bacteria enter the bladder through the urethra or into the kidneys
through the ureter. Women often develop pyelonephritis through this route because
women have a short urethral size. Lack of environmental hygiene activities and the
close distance between the urethra and the anal opening can increase a woman's
vulnerability to pyelonephritis. In general the ascending pathway is caused by faecal
microorganisms.
b. Hematogenous : The pathway is infrequent when compared to the ascenent
pathway. The hematogenous pathway is caused due to the presence of bacteria in the
blood. Staphylococcus bacteria is a bacterium that often attacks from this pathway.
Staphylococcus spreads in the cortex or kidneys which will result in abscess formation
c. Direct Expansion : Urinary tract infections in this pathway are caused by the
formation of abscesses or fistulas such as colovesical fistula. This pathway causes
recurrence of Pyelonephritis in sufferers.
Anatomical
Pathology

Figure 1. Kidney tissue measuring 11x6x4 cm, weighing 100 grams,

accompanied by a ureter length of 21 cm. on a brownish-white
incision with a solid, springy consistency.
Figure 2. Cross-section of the incised kidney seen pyelum kidney Figure 3. Cross-section of a kidney experiencing swelling and
dilated until damaged / destroyed and there is a urolith in pyelum. hyperemia. On the supcapsular surface can be found yellow abscesses
with various sizes of round or wedge-shaped hemorrhagic hems
Figure 4. Swollen cross-section of the kidneys, a lot of fluid and abscesses, when in
the pyridis are filled the kidneys dilate until they are damaged / destroyed.
Transmission
Caused by bacteria that are actually normal in the digestive tract
but enter the urinary tract. Possible bacteria include E. coli (70-80%) and
Enterococcus faecalis, as well as other bacteria, Clebsiella spp.,
Pseudomona aeruginosa.
Transmission is generally through bacterial contamination of
food and beverages, as well as contamination from items
contaminated with bacteria and then eaten by animals, enter the
intestine and move into the urinary tract which then causes infection.
Clinical Symptoms
- The most common symptom can be sudden fever.
- Then it can be accompanied by chills, lower back pain, nausea, and vomiting.
- In some cases also show symptoms of lower UTI which can include urinary pain and
increased urination frequency.
- Renal colic can occur, where the patient feels severe pain caused by ureteral spasms.
Seizures can occur due to irritation due to infection or due to passage of kidney
stones.
- Enlargement can occur in one or both kidneys. Sometimes also accompanied by
strong abdominal muscles to contract.
- In children, symptoms of kidney infection are often very mild and more difficult to
recognize.
a. Acute pyelonephritis
Characterized by:
- kidney swelling or widening of the cross section of the kidney
- The assessment found that there was a high fever, chills, nausea,
- low back pain, headaches, muscle aches and physical weakness.
- Percussion in the CVA area is marked by tenderness.
- Clients are usually accompanied by dysuria, frequency, urgency in a
few days.
- In the urine examination obtained turbid colored urine or hematuria
with a sharp odor, besides that there is also an increase in white blood
cells.
b. Chronic pyelonephritis
Chronic pyelonephritis Occurs due to repeated infections, so that both kidneys
slowly become damaged. Signs and symptoms:
- The presence of repeated attacks of acute pyelonephritis usually does not have
specific symptoms.
- There is fatigue.
- Headache, low appetite and decreased BB.
- The presence of polyuria, excessive thirst, azotemia, anemia, acidosis,
proteinuria, pyuria and decreased urine density.
- The patient's health deteriorates, eventually the patient experiences kidney
failure.
- Multiple abnormalities and injuries to the cortex.
- Kidney is shrinking and the ability of the nephron decreases due to tissue injury.
- Suddenly when hypertension is found.
Diagnostic Examination
a. Whole blood
b. Urinalysis
c. Ultrasound and Radiology: Ultrasound and X-rays can help find kidney
stones, structural abnormalities or other causes of urinary obstruction
d. BUN
e. Creatinin
f. Electrolytes Serum
g. Kidney biopsy
h. IVP examination: Intravenous pyelogram (IVP) identifies structural changes
or abnormalities
Treatment
The purpose of this treatment is to hold the course of the disease, so that kidney
failure does not occur. An acute kidney infection after being treated for a few weeks will
usually heal completely. However, bacterial infection residues can cause the disease to
recur, especially in patients with weak immunity such as diabetics or the presence of
obstruction / obstruction of urine flow, for example by stones, tumors and so on.
- Blood pressure is lowered and avoided from glomerucus hyperfusion with a low protein
and low salt diet.
- Antibiotics are immediately given to patients who are found to have a fever, pain in the
lumbar region, dysuria and pyuria. In kidney failure the use of antibiotics must be careful to
reduce the dose of certain antibiotics. The safest antibiotics without reducing doses in
patients with kidney failure are: penicillin, sucfadimidine, ampicillin, amoxycilin, doxyciclin,
and erytromicin.
- Vesicoureteral reflux is considered operative if it is accompanied by an infection that is
difficult to control with antibiotics.
- Can be treated with the principles of kidney failure such as: Following the principle of
therapy in the urinary tract, performing Neprhectomy in asymmetric pyelonephritis,
Changing urine pH (C. renale attachment to urine alkaline pH, E. coli in urine acidic pH), and
Referring to cystitis therapy .
Medical management according to Barbara K. Timby and Nancy E. Smith
in 2007:
a. Reduce fever and pain and determine antimicrobial drugs such as
trimethroprim-sulfamethoxazole (TMF-SMZ, Septra), gentamycin with or
without ampicillin, cephelosporin, or ciprofloxacin (cipro) for 14 days
b. Relaxing the smooth muscles of the ureter and bladder, increasing
comfort, and increasing bladder capacity using additional antispasmodic
and anticholinergic pharmacological drugs such as oxybutinin (Ditropan)
and propantheline (Pro-Banthine)
c. In chronic cases, treatment is focused on preventing progressive
kidney damage.
Complication
There are three important complications to be found in acute pyelonephritis
(General & Systematic Pathology J. C. E. Underwood, 2002: 669)
a. Renal papilla necrosis. As a result of the inflammatory process, blood supply in the
medullary area will be disrupted and necrosis of the papilla kidney will be followed,
especially in people with diabetes mellitus or at the site of obstruction.
b. Fionefrosis. Occurs when total obstruction is found in the ureter which is very close
to the kidney. The fluid protected in the pelvis and the cervical system is suppurated,
so the kidneys are stretched due to pus.
c. Perinefric abscess. When the infection reaches the renal capsule, and extends into
the perirenal tissue, perinefric abscess occurs.

Complications of chronic pyelonephritis include end-stage kidney disease

(ranging from loss of nephron progression due to chronic inflammation and scarring),
hypertension, and formation of kidney stones (due to chronic infection with urea-
decomposing organisms, which results in the formation of stones) (Brunner &
Suddarth, 2002: 1437 ).
Prevention
• To prevent kidney infection:
1. Make sure you never experience urinary tract infections, among others by paying
attention to how to clean after defecation, especially in women. Always clean from
front to back, not from back to front. This is to prevent bacterial contamination from
faeces during bowel movements so as not to enter through the vagina and invade the
urethra.
2. At the time of installation of the catheter must be considered hygiene and sterility
of the tool to avoid infection.

• To help treat kidney infections, here are a few things to do:

a. drink plenty of water (about 2.5 liters) to help empty the bladder and urine
contamination.
b. Pay attention to food (diet) so that kidney stones do not form
c. lots of rest in bed
d. antibiotic therapy