PYELONEPHRITIS

Dr. dr. Shahrul Rahman, Sp.PD, FINA

Departemen Ilmu Penyakit Dalam
Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara

Etiology

Inflammation of the
structures of the
kidney:
the renal pelvis
renal tubules
interstitial tissue

Almost always caused

by E.coli

Etiology

Usually seen in association with:

Pregnancy
diabetes mellitus
Polycystic
hypertensive kidney disease
insult to the urinary tract from

catheterization, infection, obstruction or

trauma

What happens to the

kidney? The kidney becomes

edematous and inflamed

and the blood vessel are
congested
The urine may be cloudy
and contain pus, mucus and
blood
Small abscesses may form
in the kidney

Pyelonephritis
1.
Inflammation of renal pelvis and
parenchyma (functional kidney tissue)
2.
Acute pyelonephritis
a. Results from an infection that ascends to
kidney from lower urinary tract
Risk factors
1. Pregnancy
2. Urinary tract obstruction and congenital
malformation
3. Urinary tract trauma, scarring
4. Renal calculi
5. Polycystic or hypertensive renal disease
6. Chronic diseases, i.e. diabetes mellitus
7. Vesicourethral reflux

Pathophysiology
1. Infection spreads from renal pelvis to
renal cortex
2. Kidney grossly edematous; localized
abscesses in cortex surface
3. E. Coli responsible organism for 85% of
acute pyelonephritis; also Proteus, Klebsiella
Manifestations
1. Rapid onset with chills and fever
2. Malaise
3. Vomiting
4. Flank pain
5. Costovertebral tenderness
6. Urinary frequency, dysuria

Clinical Manifestations
Acute pyelonephritis may be unilater or

bilateral, causing chills, fever, prostration

and flank pain.
Studies has shown that chronic
pyelonephritis may develop in association
with other renal disease unrelated to
infection processes
Azotemia (the retention in the blood of
excessive amounts of nitrogenous
compounds) develops if enough nephrons
are nonfunctional

Acute Pyelonephritis
Affects cortex with sparing of glomeruli and
vessels. White cell casts in urine are
pathognomonic.
Bacteria infection can result from
hematogenous spread or from ascending
infection (usually due to predisposing
condition)
Usually: E. coli. Also: Proteus, Klebsiella, and
enterobacter.
Presents with fever/CVA tenderness
Its just a cute pyelonephritis (Not too bad)

Signs and Symptoms

Subjective Data in acute pyelonephritis:

pt will become acutely ill, w/ malaise

and pain in the costovertebral angle

(CVA)
CVA tenderness to percussion is a
common finding
In the chronic phase the pt may show

unremarkable symptoms such as nausea and

general malaise

PIELONEFRITIS AKUT
-Gejala cepat berkembang ( jam s/d hari)
-Demam, mual, muntah, diare
-Takhikardi
-Nyeri otot
-Sepsis
-Leukositosis
-Pyuria dengan leukosit cast
-Hematuria (mula-mula)
DD : - BSK
- TBC ginjal
- Tumor ginjal

White blood cell casts

Highly

significant!
Presence
suggests
pyelonephriti
s

Acute uncomplicated
pyelonephritis in young
Largely a clinical diagnosis
women
Pyuria is usually present; about 20% have

positive blood cultures; causative organisms

the same as with cystitis
Predisposing factors: structural abnormalities;
strains of E. coli with unique markers;
genetically-determined carbohydrate
receptors on uroepithelial cells

 Chronic
The
autopsy
Pyelonephritis
specimen
consists of a bisected
kidney which is
markedly shrunken
because of chronic
inflammation and
Scarring.
(B) multiple calculi in
the proximal ureter
(A) Calyceal system

Chronic pyelonephritis
a.
Involves chronic inflammation and
scarring of tubules and interstitial tissues
of kidney
b.
Common cause of chronic renal failure
c.
May develop from chronic hypertension,
vascular conditions, severe vesicourteteral
reflux, obstruction of urinary tract
d.
Behaviors
1. Asymptomatic
2. Mild behaviors: urinary frequency,
dysuria, flank pain

Chronic Pyelonephritis
Coarse, asymmetric
corticomedullary scarring.
Thyroidization of the Kidney
Eosinophilic casts seen in
tubules
Chronic Pye &
T - Thyroidization
E - Eosinophilic Casts
A - Assymetric Scarring

PIELONEFRITIS KRONIK
-Abnormalitas urologik
-Gejala klinis (-), Lab (-)
-Urine sering steril
-Waktu serangan : - pyuria dengan leukosit cast
- IVP Outline ireguler, caliectasis,
cortical scar
-Patologi : - Ginjal tidak simetris
- Permukaan ireguler
- Banyak jaringan parut
- Leukosit cast
- Eosinofilia

GEJALA KLINIK

-Minimal dan tidak spesifik

-Lama-lama penurunan aliran darah & GFR
-Uremia
-Hipertensi
-Urine : Leukosit cast
-IVP : mula-mula normal ------- contracted kidney

Signs and Symptoms

Objective data includes assessing the pt for:

Elevated Temperature
Chills
Pus in the urine

Systemic signs occur as a result of the

chronic disease:
elevated BP
Vomiting
Diarrhea

Diagnostic Tests
Diagnosis is confirmed by bacteria and pus

in the urine and leukocytosis

A clean-catch or catheterized urinalysis
with culture and sensitivity identifies the
pathogen and determines appropriate
antimicrobial therapy

Diagnostic
Tests

IVP will Identify the

presence of
obstruction or
degenerative
changes caused by
the infection process
BUN and Creatine
levels of the blood
and urine may be
used to monitor
kidney function

Medical Management
Pt w/ mild signs and symptoms may be

treated on an outpatient basis with

antibiotics for 14 to 21 days
Antibiotics are selected according to
results of urinalysis culture and sensitivity
and may include broad-spectrum
medications

PROGNOSIS ------------ GGK

TERAPI :
-AB Sesuai Sensitifiti test
-OAH

Medicines
Ampicillin or

vancomycin combined
with an aminoglycoside
(Nebcin, Garamycin)

Cipro

Septra

Bactrim

Floxin

Medical Management
Adequate fluids at least eight 8-oz. glasses

per day
Urinary analgesics such as Phenazopyridine
(Pyridium)
is helpful
Follow up urine culture is indicated

Nursing Intervention
& Patient Teaching
Pt is taught to identify Fatigue
the S&S of infection: General malaise
Pt should also be taught:
Elevated temp.
Indications
Flank pain
Chills

Dose

Fever
Nausea

Length of course
Side effects

Vomiting

Importance of follow up

Urgency

care with the physician

on a routine basis

Prognosis
Prognosis is dependent upon early detection

and successful treatment

Baseline assessment for every pt must
include urinary assessment because
pyelonephritis may occur as a primary or
secondary disoder