Acute and Chronic Pyelonephritis

DESCRIPTION/ETIOLOGY: More common in women and men older than age 65

Single episodes of acute pyelonephritis may result from the entry of bacteria, especially during pregnancy, obstruction, or reflux.

Chronic pyelonephritis usually occurs with structural deformities or obstruction with reflux often caused by stones or neurogenic impairment of voiding.

Reflux is more common in children who have acquired scarring during acute infection or as a result of anatomic anomalies.

Reflux and scarring contribute to chronic pyelonephritis as an adult.

Chronic pyelonephritis in adults who did not have reflux as a child usually occurs with spinal cord injury, bladder tumor, prostate enlargement, or urinary tract stones.

Other high risk groups:

Patients who have undergone manipulation of the urinary tract (e.g., placement of a urinary catheter

Patients with diabetes mellitus, the reduced bladder tone increases the risk for pyelonephritis.

 Patients with chronic stone disease, stones may retain organisms, resulting in ongoing infection and kidney scarring. NSAID use can lead to papillary necrosis and reflux. PATHOPHYSIOLOGY: Pyelonephritis is either the presence of active organisms in the kidney or the effects of kidney infections.

Acute pyelonephritis is the active bacterial infection, whereas chronic pyelonephritis results from repeated or continued upper urinary tract infections or the effects of such infections.

Chronic pyelonephritis often occurs with a urinary tract defect, obstruction, or, most commonly, when urine refluxes from the bladder back into the ureters.

The vesicoureteral junction is the point at which the ureters join the bladder and where reflux occurs (reverse or upward flow of urine toward the renal pelvis and kidney).

In pyelonephritis, organisms move up from the urinary tract into the kidney tissue. Bacteria trigger the inflammatory response, and local edema results.

Acute pyelonephritis involves acute tissue inflammation, tubular cell necrosis, and possible abscess formation. The infection is scattered

within the kidney; healthy tissues can lie next to infected areas. Fibrosis and scar tissue develop from the inflammation. The calices thicken, and scars develop in the interstitial tissue.

Reflux of infected urine from the bladder into the ureters and kidney is responsible for most cases of chronic pyelonephritis.

Inflammation and fibrosis lead to deformity of the renal pelvis and calices.

Repeated or continuous infections create additional scar tissue, changing blood vessel, glomerular, and tubular structure.

As a result, filtration, reabsorption, and secretion are impaired and kidney function is reduced PATHOPHYSIOLOGY Acute Pyelonephritis

Fever

Chills

Tachycardia and tachypnea

Flank, back, or loin pain

 Tender costovertebral angle (CVA)

Abdominal, often colicky, discomfort

Nausea and vomiting

General malaise or fatigue

Burning, urgency, or frequency of urination

Nocturia

Recent cystitis or treatment for urinary tract infection (UTI)

Chronic Pyelonephritis

Hypertension

Inability to conserve sodium

Decreased urine concentrating ability, resulting in nocturia

 Tendency to develop hyperkalemia and acidosis LAB/DIAGNOSTIC TESTS Urinalysis shows leukocytes, bacteria, nitrites, and red blood cells; may see white blood cell casts.

Urine culture identifies organism. Sensitivity shows which antibiotics the organism is most responsive to.

CBC shows leukocytosis.

An x-ray of the kidneys, ureters, and bladder (KUB) and IV urography are performed to diagnose stones or obstructions. A cystourethrogram is indicated for some patients.

These procedures define urinary tract structures and identify any defects.

Specific defects to be identified include foreign bodies, such as stones; obstruction to the outflow of urine, such as tumors, structural defects, or prostate enlargement; and urine reflux caused by incompetent bladder-ureter valve closure

MEDICAL MANAGEMENT Administer antibiotics to treat infection- Broad spectrum initially then narrow spectrum when the results of the urine C&S are known.

Administer antipyretics (Tylenol) for fever. (NSAIDS like Motrin are

nephrotoxic)

Administer fluids for dehydration due to vomiting and diarrhea- at least 2 liters per day unless contraindicated

Administer phenazopyridine for relief of dysuria symptoms

Repeat urine culture after completion of antibiotic course.

Surgical interventions can correct structural problems causing urine reflux or obstruction of urine outflow or can remove the source of infection.

The surgical procedures may be one of these: pyelolithotomy (stone removal from the kidney), nephrectomy (removal of the kidney), ureteral diversion, or reimplantation of ureter to restore proper bladder drainage.

For Chronic Pyelonephritis, BP medicine may be started to control hypertension and slow decline of renal function. NURSING MANAGEMENT/PATIENT EDUCATION Administer antibiotics, antipyretic and analgesics as prescribed and monitor patients response to gauge effectiveness or presence of side effects.

Monitor the patients vital signs, I&O and labs

Educate patient about:

 Drug regimen (purpose, timing, frequency, duration, and possible side effects) and the importance of finishing the entire course of antibiotics. Make sure patient knows phenazopyridine will turn their urine bright orange.

The role of nutrition and adequate fluid intake

The manifestations of disease recurrence