Pyelonephritis is an inflammation of the kidney and upper urinary tract that usually results from noncontagious bacterial infection of the bladder (cystitis ).
Acute pyelonephritis is most common in adult females but can affect people of either sex and any age. Its onset is usually sudden, with symptoms that often are mistaken as the results of straining the lower back. Pyelonephritis often is complicated by systemic infection. Left untreated or unresolved, it can progress to a chronic condition that lasts for months or years, leading to scarring and possible loss of kidney function.
Causes and symptoms
The most common cause of pyelonephritis is the backward flow (reflux) of infected urine from the bladder to the upper urinary tract. Bacterial infections also may be carried to one or both kidneys through the bloodstream or lymph glands from infection that began in the bladder. Kidney infection sometimes results from urine that becomes stagnant due to obstruction of free urinary flow. A blockage or abnormality of the urinary system, such as those caused by stones, tumors, congenital deformities, or loss of bladder function from nerve disease, increases a person's risk of pyelonephritis. Other risk factors include diabetes mellitus, pregnancy, chronic bladder infections, a history of analgesic abuse, paralysis from spinal cord injury, or tumors. Catheters, tubes, or surgical procedures may also trigger a kidney infection.
The bacteria most likely to cause pyelonephritis are those that normally occur in the feces. Escherichia coli causes about 85% of acute bladder and kidney infections in patients with no obstruction or history of surgical procedures. Klebsiella, Enterobacter, Proteus, or Pseudomonas are other common causes of infection. Once these organisms enter the urinary tract, they cling to the tissues that line the tract and multiply in them.
Symptoms of acute pyelonephritis typically include fever and chills, burning or frequent urination, aching pain on one or both sides of the lower back or abdomen, cloudy or bloody urine, and fatigue. The patient also may have nausea, vomiting, and diarrhea. The flank pain may be extreme. The symptoms of chronic pyelonephritis include weakness, loss of appetite, hypertension, anemia, and protein and blood in the urine.
The diagnosis of pyelonephritis is based on the patient's history, a physical examination, and the results of laboratory and imaging tests. During the physical examination, the doctor will touch (palpate) the patient's abdomen carefully in order to rule out appendicitis or other causes of severe abdominal pain.
In addition to collecting urine samples for urinalysis and urine culture and sensitivity tests, the doctor will take a sample of the patient's blood for a blood cell count. If the patient has pyelonephritis, the urine tests will show the presence of white blood cells, and bacteria in the urine. Bacterial counts of 100,000 organisms or higher per milliliter of urine point to a urinary tract infection. The presence of antibodycoated bacteria (ACB) in the urine sample distinguishes kidney infection from bladder infection, because bacteria in the kidney trigger an antibody response that coats the bacteria. The blood cell count usually indicates a sharp increase in the number of white blood cells.
The doctor may order ultrasound imaging of the kidney area if he or she suspects that there is an obstruction blocking the flow of urine. X rays may demonstrate scarring of the kidneys and ureters resulting from long-standing infection.
Treatment of acute pyelonephritis may require hospitalization if the patient is severely ill or has complications. Therapy most often involves a two- to three-week course of antibiotics, with the first few days of treatment given intravenously. The choice of antibiotic is based on laboratory sensitivity studies. The antibiotics used most often include ciprofloxacin (Cipro), ampicillin (Omnipen), or trimethoprim-sulfamethoxazole (Bactrim, Septra). Several advances in antibiotic therapy have been made in recent years. In 2003, the U.S. Food and Drug Administration (FDA) approved Cipro extended release tablets (Cipro XR) that could be taken once daily for acute uncomplicated pyelonephritis. A study in Europe also showed that a shorter course than that normally used in the United States could eradicate the bacteria that cause the disease. The primary objective of antimicrobial therapy is the permanent eradication of bacteria from the urinary tract. The early symptoms of pyelonephritis usually disappear within 48 to 72 hours of the start of antibacterial treatment. Repeat urine cultures are done in order to evaluate the effectiveness of the medication.
Chronic pyelonephritis may require high doses of antibiotics for as long as six months to clear the infection. Other medications may be given to control fever, nausea, and pain. Patients are encouraged to drink extra fluid to prevent dehydration and increase urine output. Surgery sometimes is necessary if the patient has complications caused by kidney stones or other obstructions, or to eradicate infection. Urine cultures are repeated as part of the follow-up of patients with chronic pyelonephritis. These repeat tests are necessary to evaluate the possibility that the patient's urinary tract is infected with a second organism as well as to assess the patient's response to the antibiotic. Some persons are highly susceptible to reinfection, and a second antibiotic may be necessary to treat the organism.
Bacteremia— The presence of bacteria in the bloodstream.
Cystitis— Inflammation of the bladder, usually caused by bacterial infection.
Reflux— The backward flow of a fluid in the body. Pyelonephritis is often associated with the reflux of urine from the bladder to the upper urinary tract.
The prognosis for most patients with acute pyelonephritis is quite good if the infection is caught early and treated promptly. The patient is considered cured if the urine remains sterile for a year. Untreated or recurrent kidney infection can lead to bacterial invasion of the bloodstream (bacteremia), hypertension, chronic pyelonephritis with scarring of the kidneys, and permanent kidney damage. In 2003, a report on long-term follow-up of adults with acute pyelonephritis looked at kidney scarring and resulting complications. Kidney damage that causes complications is rare after 10 to 20 years, even though many women showed renal scarring.
Persons with a history of urinary tract infections should urinate frequently, and drink plenty of fluids at the first sign of infection. Women should void after intercourse which may help flush bacteria from the bladder. Girls should be taught to wipe their genital area from front to back after urinating to avoid getting fecal matter into the opening of the urinary tract.
Jancin, Bruce. "Short-course Cipro for Pyelonephritis: Unapproved Regimen Shows Promise." OB GYN News November 1, 2003: 5.
Mangan, Doreen. "The FDA has Approved Ciprofloxacin Extended Release Tavlets (Cipro XR), a Once-daily Formulation, for the Treatment of Complicated Urinary Tract Infections (cUTIs) and Acute Pyelonephritis (AUP), or Kidney Infection." RN November 2003: 97.
Raz, Paul, et al. "Long-term Follow-up of Women Hospitalized for Acute Pyelonephritis." Clinical Infectious Diseases (October 15, 2003):1014-1017.
American Foundation for Urologic Disease. 1128 N. Charles St., Baltimore, MD 21201. (401) 468-1800. 〈http://www.afud.org〉.
Nephritis is inflammation of the kidney.
The most prevalent form of acute nephritis is glomerulonephritis. This condition affects children and teenagers far more often than it affects adults. It is inflammation of the glomeruli, or small round filters located in the kidney. Pyelonephritis affects adults more than children, and is recognized as inflammation of the kidney and upper urinary tract. A third type of nephritis is hereditary nephritis, a rare inherited condition.
Causes and symptoms
Acute glomerulonephritis usually develops a few weeks after a strep infection of the throat or skin. Symptoms of glomerulonephritis include fatigue, high blood pressure, and swelling. Swelling is most notable in the hands, feet, ankles and face.
Pyelonephritis usually occurs suddenly, and the acute form of this disease is more common in adult women. The most common cause of this form of bacterial nephritis is the backward flow of infected urine from the bladder into the upper urinary tract. Its symptoms include fever and chills, fatigue, burning or frequent urination, cloudy or bloody urine, and aching pain on one or both sides of the lower back or abdomen.
Hereditary nephritis can be present at birth. The rare disease presents in many different forms and can be responsible for up to 5% of end-stage renal disease in men.
Diagnosis of nephritis is based on:
- the patient's symptoms and medical history
- physical examination
- laboratory tests
- kidney function tests
- imaging studies such as ultrasound or x rays to determine blockage and inflammation
Urinalysis can reveal the presence of:
- albumin and other proteins
- red and white blood cells
- pus, blood, or bacteria in the urine
Treatment of glomerulonephritis normally includes drugs such as cortisone or cytotoxic drugs (those that are destructive to certain cells or antigens). Diuretics may be prescribed to increase urination. If high blood pressure is present, drugs may be prescribed to decrease the hypertension. Iron and vitamin supplements may be recommended if the patient becomes anemic.
Acute pyelonephritis may require hospitalization for severe illness. Antibiotics will be prescribed, with the length of treatment based on the severity of the infection. In the case of chronic pyelonephritis, a sixmonth course of antibiotics may be necessary to rid the infection. Surgery is sometimes necessary.
Treatment of hereditary nephritis depends of the variety of the disease and severity at the time of treatment.
Alternative treatment of nephritis should be used as a complement to medical care and under the supervision of a licensed practitioner. Some herbs thought to relieve symptoms of nephritis include cleavers (Galium spp.) and wild hydrangea.
Prognosis for most cases of glomerulonephritis is generally good. Ninety percent of children recover without complications. With proper medical treatment, symptoms usually subside within a few weeks, or at the most, a few months.
Pyelonephritis in the acute form offers a good prognosis if diagnosed and treated early. Follow-up urinalysis studies will determine if the patient remains bacteria-free. If the infection is not cured or continues to recur, it can lead to serious complications such as bacteremia (bacterial invasion of the bloodstream), hypertension, chronic pyelonephritis and even permanent kidney damage.
If hereditary nephritis is not detected or treated, it can lead to complications such as eye problems, deafness or kidney failure.
Pyelonephritis can best be avoided if those with a history of urinary tract infections take care to drink plenty of fluids, urinate frequently, and practice good hygiene following urination.
Hereditary nephritis can not be prevented, but research to combat the disease continues.
American Kidney Fund AKF). Suite 1010,6110 Executive Boulevard, Rockville, MD 20852. (800) 638-8299. 〈http://220.127.116.11/Default.htm〉.
ne·phri·tis / nəˈfrītis/ • n. Med. inflammation of the kidneys. Also called Bright's disease.