Pyelonephritis

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Classification according to ICD-10
N10 Acute pyelonephritis
N11.0 Non-obstructive reflux-related chronic pyelonephritis
N11.1 Chronic obstructive pyelonephritis
N11.8 Non-Obstructive Chronic Pyelonephritis NOS
N20.9 Pyelonephritis in urinary stones
ICD-10 online (WHO version 2019)

The pyelonephritis (from Greek πύελο | ς pyelo | s = "pools, vascular" νεφρ | ός nepʰr | ós = "kidney", itis = "inflammatory disease") or pyelonephritis is usually caused by bacterial infection, acute or chronic Progressive inflammation of the renal pelvis with involvement of the kidney parenchyma (bacterial interstitial nephritis , purulent nephritis). It can occur on one side (more often) or on both sides. Differentiating pyelonephritis from severe urinary tract infection is difficult and controversial. Women get sick two to three times as often as men because of the shorter urethra .

Risk factors

Patients are particularly affected

Acute pyelonephritis that has not healed often changes into the chronic form, which can also arise primarily.

Pathogen

Escherichia coli is the predominant pathogen in more than 80% of acute pyelonephritis. Some strains have P- fimbriae , with which they can specificallycolonize urothelium (epithelium of the lower urinary tract) by attachment. Immunocompromised patients are more prone to infections with Klebsiella , Enterococci , Clostridia and Candida albicans , which are also associated with an increased risk of more severe pyelonephritis. Other pathogens are Proteus mirabilis , Pseudomonas , Serratia , Staphylococcus saprophyticus .

Pathogenesis

In most cases, the renal pelvis and the kidneys are infected by pathogens that rise from the bladder via the ureter ( ascending infection). The ascent is facilitated by a reflux of urine from the urinary bladder into the renal pelvis or an accumulation of the bladder and a backflow into the kidneys. The descending infection via the lymph or the blood , also in the context of sepsis, is much rarer . In the course of pyelitis , the inflammation can spread to the kidney tissue.

The pathogenetically in the foreground is initially the adhesion (binding) of the pathogens to the cells of the urinary tract (uroepithelia). The adhesion takes place via binding sites of the bacteria, mostly so-called type I fimbriae, or pili (small hairs) with membrane components of the cell surfaces. These are similar or identical to blood group antigens or their subgroups. After binding, bacteria, if they are virulent , can also penetrate the cells of the urogenital tract and cross the epithelial barrier (invasion). Even if the body's defense against infection by leukocytes , antibodies and complement overcomes the primary infection by killing the pathogens, these can still remain as dead fragments in the tissue, e.g. B. the kidney or the bladder persist (so-called "persisters"). It is believed that these persisters can sustain chronic pyelonephritis.

Pathohistology

Macroscopically , focal or small diffuse yellow foci ( abscesses ) are visible on the kidney surface . On the cut surface of the kidney there are stripes of pus from the medulla to the cortex. Histologically , renal tubules and glomerula are destroyed . Abscessed (ulcerated) pyelonephritis shows typical meltdowns and then usually heals with scarring .

Symptoms

Characteristic of the acute form is a sudden severe feeling of illness. There are also symptoms that indicate an infection of the upper urogenital tract, such as fever , chills , flank pain, knocking and pressure pain in the area of ​​the kidney, nausea , dizziness and, if the course is severe, vomiting . Symptoms of cystitis may also be present. These include pollakiuria (frequent emptying of the bladder without increasing the amount of urine), dysuria (difficult or painful urination), hematuria (bloody urine ).

In acute pyelonephritis, kidney function is not impaired.

Up to a third of the elderly patients do not have a fever; gastrointestinal and pulmonary symptoms dominate here.

In the chronic form, the symptoms may initially be absent. The focus here is on unspecific symptoms such as decreased performance, headaches, inappetence with weight loss, fatigue or pollakiuria . In contrast to acute pyelonephritis, the course is gradual or intermittent.

Diagnosis

The unequivocal diagnosis of pyelonephritis as distinct from a severe lower urinary tract infection (bladder and urethra) requires the detection of bacteria from a puncture in the renal pelvis. Due to the possible complications, this is only carried out if a percutaneous nephrostomy is performed at the same time .

If at least one of the two parameters is positive in the urine test for leukocytes (leukocyturia) and nitrite , this is a urinary tract infection with a sensitivity of 75% to 84% and a specificity of 82 to 98%. Possibly also can erythrocytes (hematuresis) and small proteins such as α 1 -microglobulin (tubular proteinuria ) can be detected.

The midstream urine is also examined bacteriologically (pathogen and resistance determination). Urine cultures are positive in 90% of patients with acute pyelonephritis.

Leukocytosis (an increase in white blood cells) and an increase in CRPs ( acute phase protein ) occur in the blood . Blood cultures are taken if sepsis is suspected . Excretory urography can detect changes in kidney tissue. The sonography and computed tomography come with more complicated histories to exclude complications apply.

The use of the 99 Tc - DMSA - Nierenszintigrafie the extent of scarring can be estimated by the pyelonephritis.

Complications

Pyelonephritis can cause the pathogen to spread into the blood because of the good blood flow to the kidneys. This urosepsis is life threatening. When the inflammation penetrates the kidney capsule, a perinephritic abscess forms. These abscesses need to be punctured or surgically repaired. Chronic pyelonephritis leads to the loss of functional kidney tissue up to pyelonephritic shrunken kidneys and renal insufficiency . During pregnancy, pyelonephritis can lead to significantly increased maternal and fetal disease rates and mortality.

Emphysematous pyelonephritis is rare and almost exclusively affects diabetics. It is characterized by the accumulation of gas in the parenchyma of the kidney and the surrounding tissue and is caused by gas-producing aerobes and facultative anaerobes.

Xanthogranulomatous pyelonephritis is also rare ( incidence 1.7 / 100,000) and develops mainly in the case of urinary flow disorders. The kidney is enlarged and nodular with the inclusion of lipoid-containing macrophages. It is difficult to differentiate clinically and using imaging techniques from renal cell carcinoma ; the diagnosis is usually made histologically.

therapy

Non-specific measures

It is important to drink plenty of fluids (more than two liters per day) in order to flush the urinary tract and thus reduce the number of germs. It also serves to compensate for the fluid loss caused by the fever. Bed rest should be observed.

The benefits of acidifying urine, e.g. B. with methionine is controversial.

Antibiotics

In acute pyelonephritis, antibiotics must be administered for at least 10 days. In the case of an existing pregnancy, hospitalization is always required. Serious infections should be treated with fluoroquinolones , e.g. B. ciprofloxacin , or with broad-spectrum cephalosporins , also in combination with aminoglycosides , are treated. For use also come amoxicillin , piperacillin with tazobactam and imipenem . If possible, therapy (differentiated according to the type of pyelonephritis: acute uncomplicated, severe infection, nosocomial acquired, febrile, complicated) is carried out after the pathogen and resistance have been determined.

The oral administration is preferable if the patient allows the clinical condition. In a study with 141 patients, intravenous administration of ciprofloxacin was not superior to oral administration.

Antifungal drugs

If a fungal infection is detected, therapy with fluconazole or amphotericin B takes place .

Surgically

If there is a urinary flow disorder, this is treated accordingly. An infected urinary stasis kidney requires immediate drainage of the urinary tract; a percutaneous nephrostomy is an option . Existing abscesses are drained using percutaneous abscess drainage. In emphysematous or xanthogranulomatous pyelonephritis as well as sepsis that cannot be stabilized, nephrectomy is the method of choice.

See also

Older literature

  • Joachim Frey : Hemorrhagic nephritis. In: Ludwig Heilmeyer (ed.): Textbook of internal medicine. Springer-Verlag, Berlin / Göttingen / Heidelberg 1955; 2nd edition ibid. 1961, pp. 926-951, here: pp. 940-945 ( purulent nephritis , pregnancy kidney ).

swell

  1. ↑ GB Piccoli, V. Consiglio, L. Colla, P. Mesiano, A. Magnano, M. Burdese, C. Marcuccio, E. Mezza, V. Veglio, G. Piccoli: Antibiotic treatment for acute "uncomplicated" or "primary "Pyelonephritis: a systematic," semantic revision ". In: Int J Antimicrob Agents . August 28, 2006; Suppl 1, pp. 49-63; Epub July 18, 2006, PMID 16854569
  2. ↑ a b P. F. Bass, JA Jarvis, CK Mitchell: Urinary tract infections. In: Prim Care. 2003; 30, pp. 41-61.
  3. ^ MG Bergeron: Treatment of pyelonephritis in adults. In: Med Clin North Am. 1995; 79, pp. 619-649.
  4. ^ WE Stamm, TM Hooton: Management of urinary tract infections in adults. In: N Engl J Med . 1993; 329, pp. 1328-1334.
  5. ↑ a b K. Ramakrishnan, DC Scheid: Diagnosis and management of acute pyelonephritis in adults. In: Am Fam Physician. 2005, 71 (5), pp. 933-942. PMID 15768623
  6. ↑ W. Höchtlen-Vollmar: Differential diagnosis of proteinuria. In: Laborinformation / Klin. Chemie. 12, 09/2007.
  7. ↑ Joachim Misselwitz: Therapy and long-term consequences of urinary tract infections in childhood. Volume 19, Issue 7–8, 2008, pp. 397–401. (PDF)
  8. ↑ LK Millar, SM Cox: Urinary tract infections complicating pregnancy. In: Infect Dis Clin North Am. 1997 Mar; 11 (1), pp. 13-26. PMID 9067782
  9. ^ E. Kaiser, R. Fournier: Emphysematous pyelonephritis: diagnosis and treatment. In: Ann Urol (Paris). 2005 Apr; 39 (2), pp. 49-60. PMID 16004203
  10. ↑ Gesundheit.de
  11. ^ A b C. Rollino: Acute pyelonephritis in adults. In: G Ital Nefrol. 2007 Mar-Apr; 24 (2), pp. 121-131. PMID 17458827
  12. ^ Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 137 ( pyelonephritis ).
  13. ↑ G. Mombelli, R. Pezzoli, G. Pinoja-Lutz, R. Monotti, C. Marone, M. Franciolli: Oral vs intravenous ciprofloxacin in the initial empirical management of severe pyelonephritis or complicated urinary tract infections: a prospective randomized clinical trial . In: Arch Intern Med . 1999 Jan 11; 159 (1), pp. 53-58. PMID 9892331 .

Web links

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