1,266views

Notes

PYELONEPHRITIS

KEY POINTS
NOTES
DEFINITION
  • Inflammation of kidneys and renal pelvis

PHYSIOLOGY
  • Kidneys
    • Composed of renal parenchyma and collecting system
  • Renal parenchyma
    • Functional part of kidneys
    • Blood filtered
    • Urine produced
  • Collecting system
    • Urine drained into renal pelvis
    • Ureter
    • Bladder
    • Urine exits through urethra

CAUSES AND RISK FACTORS
  • Causes
    • Bacterial infection
    • Fungal infection
  • Risk factors
    • Urinary stasis or retention
    • Urinary obstruction
    • Urinary reflux
    • Reduced bladder tone
    • Lower urinary tract infection
    • Female at birth
    • Hospitalization
    • Indwelling urinary catheter
    • Immunocompromised

PATHOPHYSIOLOGY
  • Ascending urinary tract infection
    • Bacteria colonize urethra and bladder
    • Travel up to ureters and kidneys
  • Infection through bloodstream
  • Infection adheres to renal epithelium of the tubules
  • Triggers inflammatory response
  • Acute or chronic

SIGNS AND SYMPTOMS
  • Acute 
    • Fever, chills, malaise
    • Flank pain or abdominal discomfort
    • Nausea and vomiting
    • Nocturia
    • Urgency or frequency
    • Dysuria
    • Hematuria
    • Cloudy urine
    • Cardiovascular symptoms
      • Tachypnea
      • Tachycardia
      • Hypotension
    • Elderly
      • Confusion
      • Unexplained anorexia
      • Failure to thrive
  • Chronic 
    • Hypertension
  • Complications
    • Renal abscesses
    • Renal failure
    • Urosepsis
    • Septic shock
    • Death

DIAGNOSIS
  • History
  • Physical assessment
  • Laboratory tests
  • Urine culture
  • Ultrasound
  • X-ray
  • CT scan
  • Cystourethrogram

TREATMENT
  • Nutrition and hydration
  • Antipyretics and analgesics
  • Antibiotics
  • Surgical interventions
  • Dialysis
  • Nephrectomy

MANAGEMENT OF CARE
  • Goals of care
    • Treat the infection
    • Manage symptoms
    • Prevent complications
  • Assess weight and vital signs
  • Fluid intake and output
  • Urine assessment
  • Monitor laboratory test results
  • Administer IV fluids, antipyretics, antibiotics
  • Report to HCP
    • Signs of acute kidney injury
    • Signs of urosepsis
  • Assess pain
  • Administer analgesics
  • Offer warm, moist compresses
  • Prevent CAUTI

PATIENT AND FAMILY TEACHING
  • Explain condition, plan of care, and how to safely self-administer medications
  • Keep follow-up appointments
  • Ways to decrease risk of UTIs
  • Notify HCP
    • Signs of recurrent infection
  • Chronic pyelonephritis
    • Blood pressure control
    • Notify HCP
      • Signs of kidney disease
      • Signs of infection
      • Changes in urine color or odor
    • Increase fluid intake

Transcript

Watch video only

Pyelonephritis is an ascending urinary tract infection that causes inflammation of the kidneys and the renal pelvis.

Alright, let’s quickly review the anatomy and physiology of the urinary tract. The kidneys are bean-shaped organs located behind the peritoneum on either side of the vertebral column, just below the rib cage. Now, the kidneys are composed of the renal parenchyma and a collecting system. The renal parenchyma is the solid, functional part of the kidneys, where blood is filtered and urine is produced. This urine is then drained into the renal pelvis, which then narrows to form the ureter, and transports urine to the bladder. Ultimately, urine exits the bladder through another structure called the urethra.

Now, pyelonephritis is most often caused by bacterial infection; and the most common bacteria are Escherichia coli. Other potential bacteria include Proteus species, Enterobacter species, Enterococcus species, and Klebsiella species, as well as Pseudomonas aeruginosa. Less frequently, pyelonephritis is caused by Staphylococcus species, Salmonella species, and fungi like Candida species.

One of the main risk factors for pyelonephritis is urinary stasis or retention. This occurs when the bladder is not able to completely empty, and can be associated with prolonged bed rest or paralysis, or with obstruction of the urinary tract. Obstruction can be caused by structural abnormalities like strictures; kidney stones or tumors; and scarring from pelvic radiation or surgery, recurrent infections, or traumatic injuries.

Another important risk factor for pyelonephritis is urinary reflux, which refers to the backflow of urine from the bladder to the ureters or kidneys. This can be caused by structural abnormalities, like narrowing in the bladder neck or urethra, or an abnormal ureter valve that stays open even when the bladder is full, allowing backflow of urine. Other causes of urinary reflux include bladder stones, bladder tumors, and benign prostate enlargement.

In addition, both stasis and reflux can also occur due to reduced bladder tone from diabetic neuropathy, spinal cord injuries, and neurodegenerative diseases like multiple sclerosis. Finally, additional risk factors for pyelonephritis can include having a lower urinary tract infection, as well as being assigned female at birth, hospitalization, having indwelling urinary catheters, and being immunocompromised.

Most often, the pathology of pyelonephritis develops as an ascending urinary tract infection, meaning bacteria start by colonizing the urethra and bladder, and then make their way up the ureters and kidneys. Less frequently, the kidneys can get infected via spread through the bloodstream, usually as a consequence of bacteremia.

Once bacteria reach the kidneys, they usually start by adhering to the renal epithelium of the tubules; this ultimately triggers an inflammatory response, and attracts white blood cells that fight off the infection.

Now, pyelonephritis can either be acute or chronic. With acute pyelonephritis, there’s a sudden infection of the kidney that results in inflammation, local edema, and even necrosis. On the other hand, chronic pyelonephritis usually results from recurrent episodes of acute pyelonephritis, which can eventually lead to fibrosis and scarring of the kidney.

Moving on to the clinical manifestations, clients with acute pyelonephritis usually experience fever, chills, and malaise, along with flank pain or abdominal discomfort, as well as nausea and vomiting.

Urinary symptoms include nocturia, urgency or frequency of urination, and dysuria or burning sensation when urinating; as well as hematuria and cloudy urine.

In addition, some clients may present with signs like tachypnea, tachycardia, and hypotension; while elderly clients may also have confusion, unexplained anorexia, or failure to thrive.

Now, chronic pyelonephritis has a similar presentation, and additionally, clients can often present with hypertension.