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Acute Pyelonephritis in Adults: A Case Series of 223 Patients
Acute Pyelonephritis in Adults: A Case Series of 223 Patients
Acute Pyelonephritis in Adults: A Case Series of 223 Patients
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Received for publication: 31.3.2011; Accepted in revised form:
30.10.2011
1
Department of Nephrology and Dialysis, San Giovanni Bosco Hospital, Turin, Italy and 2Department of Radiology, San Giovanni
Bosco Hospital, Turin, Italy
Abstract
Background. Acute pyelonephritis (APN) is a common
disease which rarely evolves into abscesses.
Methods. We prospectively collected clinical, biochemical and radiological data of patients hospitalized with a
diagnosis of APN from 2000 to 2008.
Results. Urinary culture was positive in 64/208 patients
(30.7%) and blood cultures in 39/182 cases (21.4%). Two
hundred and thirteen patients were submitted to computed
tomography (CT) or nuclear magnetic resonance (NMR):
conrmation of APN was obtained in 196 patients (92%).
Among these, 46 (23.5%) had positive urine culture, 31
(15.8%) had positive blood culture and 15 (7.6%) had
positive cultures of both urine and blood. In 98 patients,
either urine or blood cultures were negative, but CT/NMR
were positive for APN. Fifty of the 213 patients submitted
to CT/NMR (23.5%) had intrarenal abscesses: only 2
were evidenced by ultrasound examination. No differences were found between patients with positive or negative CT with regards to fever, leucocytosis, C-reactive
protein, pyuria, urine cultures and duration of symptoms
before hospitalization. No differences were found between
patients with or without abscesses with regards to these
parameters and risk factors. Patients with abscesses had a
longer duration of treatment and hospitalization.
Conclusions. Our data suggest that in APN it is not
always possible to routinely document urinary infection in
a clinical setting. This nding could be explained by previous antibiotic treatment, low bacterial growth or atypical
pathogens. Systematic CT or NMR is necessary to
exclude evolution into abscesses, which cannot be suspected on clinical grounds or by ultrasound examination
and may also develop in the absence of risk factors.
Introduction
Acute pyelonephritis (APN) in the USA has an incidence
as high as 250 000 cases per year and requires 100 000
hospitalizations every year [1].
Women are affected ve times more frequently than
men but have a lower mortality (7.3 versus 16.5 death/
1000 cases) [1]. Evolution into abscess is considered
infrequent.
APN develops when uropathogens, mainly Escherichia
coli [2], ascend to the kidneys from faecal ora; rarely, it
is caused by seeding of the kidneys by bacteraemia. Risk
factors include frequency of sexual intercourse, genetic
predisposition, old age, urinary instrumentation, diabetes
and urinary tract infections in the previous months [3].
The exact correlation between APN and vesicoureteral
reux (VUR) in adults is not clearly dened.
Diagnosis of APN is mainly clinical, but computed
tomography (CT) or nuclear magnetic resonance (NMR)
examination allows precise denition of the inammatory
areas [4, 5] and evidence of abscesses.
We conducted a prospective analysis of the cases of
APN hospitalized in the Nephrology Unit from January
2000 to August 2008.
Materials and methods
We prospectively recorded all patients hospitalized in our Nephrology
Department from January 2000 to August 2008 with a diagnosis of APN
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Cristiana Rollino1, Giulietta Beltrame1, Michela Ferro1, Giacomo Quattrocchio1, Manuela Sandrone2
and Francesco Quarello1
Statistical analysis
Values are expressed as mean SD. Statistical analysis was conducted
with Students t or 2 tests.
Results
We collected the records of 223 patients (202 women, 21
men, mean age 37.77 17.61 years; mean age of women
was 36.56 0.53, of men 49.43 18.60). Distribution of
patients in age groups is reported in Figure 1.
Clinical presentation is reported in Table 1.
Leucocytosis was evident in 183 patients (82.06%);
mean leucocytes of these patients were 16 960 5869/
mm3. Leucocytosis normalized in 4.21 3.73 days. Mean
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C. Rollino et al.
223
202/21
1.5
37.77 17.61
5.79 11.15
39.18 0.79
5.34 6.85
183 (82.06%)
16 960 5869
15.65 8.56
64/208 (30.7%)
39/182 (21.4%)
19/171 (11.1%)
147/223 (65.92%)
60/223 (26.9%)
21/223 (9.4%)
11 11
Diabetes
Pregnancy
Renal transplant
Recent hospitalization (by 3 months)
Kidney stones
Vesico-ureterale reux
Anatomical defects (ureteral duplication, ureteropyelic junction
stenosis, renal ectopia)
Neurological bladder
New bladder after cystectomy
Prostatitis
Self-catheterization
Endocarditis
Balanoposthitis
Actinic cystitis
Permanent catheter
a
14
2
6
11
13
9
5
3
3
2
2
1
1
1
1
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Leucocytes (/mm3)
CRP (mg/dL)
Duration of symptoms before hospitalization (days)
Temperature (C)
a
CT/NMR negative
CT/NMR positive
Signicance
18 290.59 12 216.05
12.22 80.6
10.63 21.11
39.17 0.94
15 209.19 5777.37
16.09 8.63
5.45 10.10
39.21 0.78
n.s. (P 0.06)
n.s. (P 0.08)
n.s. (P 0.08)
n.s. (P 0.85)
Table 4. Comparison between positive and negative CT/NMR patients concerning urine and blood culturea
CT/NMR negative
CT/NMR positive
Signicance, P
10/17 (58.8%)
8/11 (72.7%)
11/13 (84.6%)
46/183 (25.1%)
30/165 (18.1%)
59/192 (30.7%)
0.0033
0.000001
0.0001
a
The data express the number of positive urine and/or blood culture out of the number of cultures obtained in the subgroups of CT/NMR negative or
positive patients. Note that negative CT/NMR patients were more frequently found to have positive cultures.
Abscess absence
Abscess presence
Signicance
47/149 (31.5%)
102/153 (66.6%)
14 979.67 6434.85
16.06 8.48
39.16 0.81
5.44 7.52
8.63 9.67
6.23 12.69
10/50 (20%)
30/48 (62.5%)
16 912.72 6676.36
14.87 9.09
39.38 0.66
5.48 4.23
16.68 14.15
4.51 4.16
n.s. (P 0.07)
n.s. (P 0.59)
n.s. (P 0.11)
n.s. (P 0.4)
n.s. (P 0.12)
n.s. (P 0.98)
P 0.000008
n.s. (P 0.35)
a
The data express the number of positive urine and/or blood culture out of the number of cultures obtained in the subgroups of patients with and
without abscesses. n.s., not signicant.
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Outcome
Discussion
Our interest in APN originated from the observation of
the increasing frequency of this disease and from the uncertain indications in the literature with regard to the opportunity of performing CT/NMR. Moreover, we noted
that not all our patients had positive urine culture.
Hence, since 2000, we prospectively collected data of
patients admitted in the Nephrology Unit with a diagnosis
of APN made by the Emergency Department; 95.5% of
them were submitted to CT scan or NMR (since 2006,
when it became available in our hospital) or both.
The most signicant data resulting from our study are
that only 23.5% of patients with diagnosis of APN conrmed by either CT scan or NMR had positive urine
culture (Table 4) and that 23.5% of the 213 patients submitted to CT/NMR had single or multiple intrarenal abscesses (Figure 3).
The low frequency of positive urine culture may be explained by previous antibiotic treatment, either self-prescribed or prescribed by the general practitioner, and by
the possibility that infection was conned to the renal parenchyma. Moreover, atypical organisms, such as Ureaplasma urealyticum (responsible for 4.8% of APN cases
[7]) and Mycoplasma hominis, which are not found
References
1. Ramakrishanan K, Schedi DC. Diagnosis and management of acute
pyelonephritis in adults. Am Fam Physician 2005; 71: 933942.
C. Rollino et al.
10. Meyrier A, Calderwood SB, Baron EL. Renal and perirenal abscess.
http://www.uptodate.com/contents/renal-and-perinephric-abscess (7
December 2011, date last accessed).
11. Meyrier A, Guibert J. Diagnosis and drug treatment of acute pyelonephritis. Drugs 1992; 44: 5659.
12. Wallin L, Bajc M. Typical technetium dimercaptosuccinic acid distribution patterns in acute pyelonephritis. Acta Paediatr 1993; 82:
10611065.
13. Majd M, Rushton HD, Jantausch B et al. Relationship among vesicoureteral reux, P-mbriated Escherichia coli, and acute pyelonephritis in children with febrile urinary tract infection. J Pediatr
1991; 119: 578585.
14. Gupta K, Hooton TM, Naber KG et al. International clinical
practice guidelines for the treatment of acute uncomplicated cystitis
and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis 2011; 52:
e103e120.
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after therapy for acute pyelonephritis. BJU Int 2006; 98:
141147.
Received for publication: 2.5.2011; Accepted in revised form:
30.12.2011
Institute of Pathology, Hannover Medical School, Hannover, Germany, 2Department of Nephrology and Hypertension, Hannover
Medical School, Hannover, Germany, 3Clinic for Urology, Hannover Medical School, Hannover, Germany and 4Clinic for
Haematology, Haemostaseology and Oncology, Hannover Medical School, Hannover, Germany
Correspondence and offprint requests to: Jan Ulrich Becker; E-mail: JanBecker@gmx.com
*Both authors contributed equally to this work.
Abstract
Background. Benign nephrosclerosis (bN) is the most
prevalent form of hypertensive damage in kidney biopsies. It is dened by early hyalinosis and later brosis of
renal arterioles. Despite its high prevalence, very little is
known about the contribution of arteriolar vascular
smooth muscle cells (VSMCs) to bN. We examined classical and novel candidate markers of the normal contractile and the pro-brotic secretory phenotype of VSMCs in
arterioles in bN.
Methods. Sixty-three renal tissue specimens with bN and
eight control specimens were examined by immunohistochemistry for the contractile markers caldesmon, alpha-
The Author 2012. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
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