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3: MED2 Y3 - Renal and Urinary [17] > Pyelonephritis > Flashcards

Pyelonephritis Flashcards

1
Q

What is pyelonephritis?

A

Inflammation of the kidney parenchyma and renal pelvis

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2
Q

What typically causes pyelonephritis?

A

Bacterial infection

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3
Q

Who can acute pyelonephritis affect?

A

Patients of all ages

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4
Q

Who has the highest incidence of pyelonephritis?

A

Women aged 15-29

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5
Q

What can pyelonephritis be classified as?

A
  • Uncomplicated

- Complicated

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6
Q

What is uncomplicated pyelonephritis?

A

Present in structurally or functionally normal urinary tract in a non-immunocompromised host

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7
Q

Why are urinary tract infections in males complicated by definition?

A

Because they will be associated with abnormal urinary tracts

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8
Q

What does acute pyelonephritis result from?

A

Bacterial infection of the renal pelvis and parenchyma

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9
Q

How can bacteria reach the kidney?

A
  • Ascending from lower urinary tract
  • Directly from blood stream
  • Lymphatics
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10
Q

When is pyelonephritis caused by lymphatic spread seen?

A

In cases of retroperitoneal abscess

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11
Q

What happens once bacteria have infected the kidney?

A

Neutrophils infiltrate the tubules and interstitial and cause suppurative inflammation. These are often small renal cortical abscesses and streaks of pus in renal medulla

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12
Q

What is the most common causative organism of pyelonephritis?

A

E. coli

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13
Q

What other organisms can cause pyelonephritis?

A
  • Klebsiella
  • Proteus
  • Enteroccocus faecialis
  • Staphylococcus saprophyticus
  • Pseudomonas
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14
Q

Which of these bacteria cause pyelonephritis in catheterised patients?

A
  • S. aureus
  • E. faecalis
  • Pseudomonas
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15
Q

What can cause pyelonephritis in immunocompromised patients?

A
  • S. saprophytic
  • Mycobacterium spp.
  • Other fungi
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16
Q

What are the risk factors for pyelonephritis?

A
  • Factors reducing antegrade flow of urine
  • Factors promoting retrograde ascent of bacteria
  • Factors predisposing to infection or immunocompromisation
  • Factors promoting bacterial colonisation
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17
Q

What factors reduce the antegrade flow of urine?

A
  • Obstructed urinary tract, including BPH

- Spinal cord injury, resulting in neuropathic bladder

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18
Q

What factors promote the retrograde ascent of bacteria?

A
  • Female gender
  • Indwelling catheter or ureteric stents/nephrostomy tubes
  • Structural renal abnormalities, e.g. VUR
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19
Q

What factors predispose to infection or immunocompromise?

A
  • Diabetes mellitus
  • HIV
  • Corticosteroid use
  • Infection
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20
Q

What factors promote bacterial colonisation?

A
  • Renal calculi
  • Sexual intercourse
  • Oestrogen depletion
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21
Q

What is the classical triad of pyelonephritis?

A
  • Fever
  • Unilateral loin pain (or rarely bilateral)
  • Nausea and vomiting
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22
Q

Over what time frame does pyelonephritis develop?

A

24-48 hours

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23
Q

What other symptoms might be present in pyelonephritis?

A

Symptoms of co-existing lower urinary tract infection (frequency, urgency, dysuria), and haematuria

24
Q

What may be found on examination with pyelonephritis?

A

Patients often look unwell, often pyrexial and features of sepsis.
Will have unilateral or bilateral costovertebral angle tenderness, with or without suprapubic tenderness

25
What should be assessed on examination in pyelonephritis?
- Fluid status - Measure post-void residual volumes - Evidence of AAA
26
What are the differentials for pyelonephritis?
- Ruptured AAA - Renal calculi - Acute cholecystitis - Ectopic pregnancy - Pelvic inflammatory disease - Lower lobe pneumonia - Diverticulitis
27
Who should ruptured AAA be considered in?
Any patient with back pain and tachycardia and/or hypotension, especially if elderly or with sufficient risk factors
28
What investigations are required in suspected pyelonephritis?
- Urine - Bloods - Imaging
29
What urine investigations are required in pyelonephritis?
- Urinalysis, assessing for nitrates and leucocytes - Urinary beta-hCG (women of child-bearing age) - Urine culture
30
What bloods should be done in pyelonephritis?
- FBC - CRP - U&Es
31
What imaging should be done in pyelonephritis?
Renal US scan
32
Why should a renal US be done in pyelonephritis?
Look for evidence of obstruction (infected obstructed system is urological emergency)
33
What should be done if an obstruction is suspected in pyelonephritis?
Non-contrast CT imaging of renal tract
34
What will patients who are systemically unwell with pyelonephritis require for management?
A-E approach and appropriate resuscitation
35
How should patients with pyelonephritis be initially managed?
Start empirical antibiotics based on local protocols and IV fluids as appropriate, also prescribing suitable analgesia and anti-emetics
36
What should be done once bacterial sensitivities are available?
Tailor antibiotic therapy
37
Where can many uncomplicated cases of pyelonephritis be treated?
In community
38
When should admission be considered for pyelonephritis?
- Clinically unstable - Significant dehydration - Co-morbidities such as diabetes mellitus, renal transplant graft, or immunocompromised
39
What may be warranted in the management of severe or non-responding cases?
Catheterisation and high-dependency unit monitoring
40
What should be considered in severe or non-responding cases of pyelonephritis?
Early CT imaging
41
Why should early CT imaging be considered in severe or non-responding cases of pyelonephritis?
To check for obstruction and complications of pyelonephritis
42
What are the complications of pyelonephritis?
- Severe sepsis and multi-organ failure - Renal scarring leading to CKD - Pyonephrosis - Preterm labour in pregnant women
43
What can repeated infections of pyelonephritis lead to?
Chronic pyelonephritis
44
What can chronic pyelonephritis lead to?
Fibrosis and ultimately destruction of the kidney
45
When is chronic pyelonephritis more common?
In obstructed systems resulting in urinary reflux
46
What can cause urinary reflux?
- UTIs - VUR - Anatomical abnormalities
47
How is a diagnosis of chronic pyelonephritis made?
Radiologically, when evidence of small, scarred, shrunken kidney seen
48
Who is chronic pyelonephritis most commonly seen in?
Children
49
Why might chronic pyelonephritis be hard to diagnosis?
May be asymptomatic or first presentation of CKD
50
What is the mainstay of management of chronic pyelonephritis?
- Reverse underlying causes - Optimise renal function - Consider prophylactic antibiotics
51
What is emphysematous pyelonephritis?
A rare and severe form of acute pyelonephritis caused by gas forming bacteria
52
How does emphysematous pyelonephritis present?
Similar to acute, however typically fails to respond to empirical IV antibiotics
53
What will CT show in emphysematous pyelonephritis?
Evidence of gas within and around the kidney
54
Who is emphysematous pyelonephritis most common in?
Diabetic patients
55
Why is emphysematous pyelonephritis most common in diabetic patients?
High glucose allows CO2 production from fermentation by enterobacteria
56
How can mild cases of emphysematous pyelonephritis be treated?
Broad-spectrum anti-microbial cover
57
How might severe cases of emphysematous pyelonephritis be treated?
Nephrostomy insertion or percutaneous drainage of any collections present

3: MED2 Y3 - Renal and Urinary [17] (17 decks)

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