acute pyelonephritis the most frequent of all nephropathies
TRANSCRIPT
![Page 1: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/1.jpg)
ACUTE PYELONEPHRITISThe most frequent of all nephropathies
Experience based on 276 cases over 12 years
Alain MeyrierHôpital Georges Pompidou and Broussais
Université René Descartes, Paris
![Page 2: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/2.jpg)
Pierre Rayer
P. Rayer
Pyelo -- renal pelvis
-- nephritis: renal infection
at autopsy
1836
![Page 3: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/3.jpg)
CT scan
DMSA scintigraphy
2006Pyelonephritis
Ascending renal tissue suppuration and ischemia
Uropathogenic E. coli
![Page 4: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/4.jpg)
Acute Pyelonephritis
Primary = in a normal urinary tract 250 000 cases per year per million in the US
Secondary = complication of:Vesico-ureteral refluxMegaureterPosterior urethral valvesProstatic obstruction
NephrolithiasisMedullary sponge kidneyRenal cystsIndwelling catheter
Major cause of end-stage renaldisease in the third world
Still a cause of chronic renalinsufficiency in Western
countries
![Page 5: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/5.jpg)
Cystitis in normal female
![Page 6: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/6.jpg)
Simple pyelonephritis
in normal female
![Page 7: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/7.jpg)
Complicated pyelonephritis
in normal female
![Page 8: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/8.jpg)
Complicated pyelonephritis
in male with prostatitis
![Page 9: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/9.jpg)
Complicated pyelonephritis(Ureteral stone)
![Page 10: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/10.jpg)
Signs and symptoms
TypicalLomboabdominal pain. Enlarged, tender kidneyHigh fever and shaking chillsCystitis often lackingESR >>> 20 mm CRP >>> 20 mg/LPyuria = leukocytes > 105/ml + bacteria > 106/ml
MisleadingPainless: diabetic, malnourished alcoholic (autonomous
neuropathy), elderlyHypothermia: sepsisAseptic bacteriuria: uroculture following treatment
![Page 11: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/11.jpg)
Acute pyelonephritisEncounter between an aggressor and a host
1) The vulnerable hostChildMaleDiabeticPregnant womanMenopauseAlcoholicTransplant recipient
2) The aggressor: a uropathogenic strain
Enterobacteria, mostly E. coli and ProteusStaphylococcus saprophyticus
![Page 12: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/12.jpg)
Commensal microorganisms responsiblefor community acquired pyelonephritis (%)
E. coli 71-89 E. coli 60
P. mirabilis 1,1-9,7 P. mirabilis 15
Klebsiella,Enterobacter 1-9,2Enterococcus 1-3,2S. saprophyticus 3-7Other 2-6
Klebsiella 20
Other 5
FIRST EPISODEOR REMOTE
RELAPSE
RELAPSEBY SHORT-TERM
REINFECTION
![Page 13: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/13.jpg)
Bacteria responsible for hospital acquired pyelonephritis
Van Poppel & al, Infection, 16:337, 1988
![Page 14: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/14.jpg)
Factors of uropathogenicity
1) Physico-chemical factors• Enterobacteriaceae are electronegative but their charge is insufficient to
be repelled by the electronegativity of the urothelium, and by the ions
adsorbed on their surface
• They require and use other virulence factors to adhere to the epithelial
cells, the renal tubules, Bowman's capsule and vessel walls
2) Factors independent of fimbriae
3) Fimbrial adhesion
![Page 15: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/15.jpg)
UPEC = UPEC = UropathogenicUropathogenic E. ColiE. Coli
CrossCross--sectionsection ofof thethe humanhuman kidneykidney displayingdisplaying UPEC UPEC fimbrialfimbrial adhesinadhesin--bindingbinding sitessites
Source: Source: LaneLane MC & MC & MobleyMobley HLT KI, 2007; 72:19HLT KI, 2007; 72:19--2525
![Page 16: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/16.jpg)
Factors of uropathogenicityE. coli
Factors independent of fimbriae- Serotype O: O1, O2, O4, O6, O7, O16, O18, O75 are
found in 28 % of the intestinal flora sampling and are responsible for 80 % of pyelonephritis, 60% of cystitisand 30% of asymptomatic bacteriuria
- Aerobactin: siderophore that allows acquisition of ironfrom the urothelium and the urine
- Hemolysin: cytotoxic to the urothelial cells- Resistance to serum bactericidal activity, allowing E. coli
encapsulation
![Page 17: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/17.jpg)
Factors of uropathogenicityE. coli
Fimbrial, and bacterial membrane adhesins
Fimbriae (Pili) carry epitopes (adhesins), lectins that bind to oligosaccharide motifs of the urothelial (and other) cell membranes, especially galactose-galactose (Gal-Gal) sequences
They also recognize blood group epitopes such as P (hence: 'P-fimbriae') and M
Women who are non-secretor of some blood group antigens elaborateglycolipid Gal-globoside receptors and are more susceptible to E. coli adhesion
The P epitope is located at the tip of fimbriae and assumes a fibrillarstructure
![Page 18: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/18.jpg)
Uropthogenic E. coli: pili ("fimbriae")
![Page 19: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/19.jpg)
Transmission electron micrographs of UPEC expressing different fimbriae. (a and b) CFT073 fim L-ON, a mutant that constitutively expresses type 1 fimbriae. (c and d) CFT073 fim L-OFF, a mutant that is unable to express type 1 fimbria produces another type offimbriae. a and c are at 34 000 magnification, and b and d are at 64 000 magnification.
Source: Lane MC & Mobley HLT KI, 2007; 72:19-25
UPEC = Uropathogenic E. Coli
![Page 20: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/20.jpg)
UPEC adhesion to epithelial cells
![Page 21: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/21.jpg)
Scanning electronmicroscopy
UPEC
Stick to theurothelial cell
membrane
![Page 22: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/22.jpg)
![Page 23: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/23.jpg)
(Le (Le BouguenecBouguenec C & al, J Clin C & al, J Clin MicrobiolMicrobiol, 39:1738, 2001), 39:1738, 2001)
![Page 24: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/24.jpg)
Fimbriae are not solely pathogenicthrough their adhesive properties
• Type 1 adhesins bind to mannose and elicithemagglutination
• Hemagglutination increases the inflammatoryresponse to infection
• In a murine model of pyelonephritis Dr -fimbriaebind to Bowman's capsule and tubular cellbasement membranes through the complement'Decay accelerating factor' and type IV collagen
![Page 25: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/25.jpg)
Factors of uropathogenicityP. mirabilis
Mobley HLT & al Kidney Int 46:S129-36, 1994
Specific factors
Four types of adhesins. MR/P in the kidney and PMF in the bladder
Non specific factorsFlagellaeHemolysinUrease → NH3 urinary pH → struvite staghorn stones
![Page 26: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/26.jpg)
Lessons from animal modelsRoberts JA AJKD 1991
Model: primate
1) Flushing UPEC into the ureter2) Renal vein blood:
ReninComplementThromboxane A2
3) Renal tissue histology:Edema, PMNs, haemorrhage, tubular necrosis, capillarythromboses
Ischemia
1
2
3
![Page 27: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/27.jpg)
Lessons from animal modelsHill GS & Clark RL Invest Radiol 1972
Model: rabbit. Flushing of UPEC in the ureter
VascularVascular neopreneneoprene injectioninjectionHistologyHistology
![Page 28: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/28.jpg)
Summary
• Gram negative pathogenic bacteria progress from theperineum to the urethra, the bladder and spread from themedulla outwards into the renal tissue
• They induce intense vasoconstriction, PMNs influx, capillary plugging, edema and hemorrhagic suffusions
• The involved areas are ischemic• Ischemia may lead to necrosis and walled off cavity
formation = abscess• Ischemia may induce papillary necrosis• The corresponding cortex may undergo sclerosis leaving
definitive cortical scars
![Page 29: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/29.jpg)
Pyelonephritickidney removedsurgically as a salvage procedure in a diabetic.
Whitish areas * denote suppuration.
Arrows show abscess formation
*
![Page 30: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/30.jpg)
Renal biopsy
Edema, inflammatory infiltrate * leukocyte casts in the tubules
*
![Page 31: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/31.jpg)
Renal biopsy, human. Edema, PMNs, hemorrhagic suffusions
![Page 32: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/32.jpg)
Imaging• Emergency CT enhanced helical CT scan may reveal a ureteral
calculus requiring immediate referral to the urologist. Sensitivity98%, specificity 100% (Fielding JR, Am J Radiol 71:1051-3, 1998). Absolute superiority over IVP
• Ultrasound examination: not for assessing obstruction (dilatation lacks in 20% of cases. Found in only 65%), but shows parenchymallesions and discloses abscesses > 1 cm
• CT scan: hypodense images indicating vasoconstriction in suppurative areas. Shows abscesses
• DMSA scintigraphy: when available, extremely sensitive, results in two hours. Inexpensive. The imaging technique of choice in children
• Gallium scan: rarely indicated nowadays
![Page 33: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/33.jpg)
Ultrasound diagnosis of pyelonephritis
![Page 34: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/34.jpg)
Pyélonéphrite vue en échographieUltrasound diagnosis of pyelonephritis
![Page 35: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/35.jpg)
Abscess
![Page 36: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/36.jpg)
Bilateral pyelonephritisHypodense radiating appearance of presuppurative areas
CT scan
![Page 37: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/37.jpg)
Large nodular hypodense "nephronia" from medulla to cortex Note the perirenal edema *
*
CT scan
![Page 38: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/38.jpg)
Juxta cortical hypodense area
in a swollen, edematous
kidney
CT CT scanscan
![Page 39: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/39.jpg)
Left sided pyelonephritis. Large edematous kidney with twohypodense, ischemic areas
![Page 40: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/40.jpg)
Cortical scars two months later
![Page 41: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/41.jpg)
Further progression to chronic interstitial nephritis
![Page 42: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/42.jpg)
Abscess
![Page 43: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/43.jpg)
Pseudo-renal cancer: febrile, painless renal abscess in a malnourishedchronic alcoholic patient Note calcifying pancreatitis
![Page 44: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/44.jpg)
Pseudorenal cancer: febrile, painless renal abscess in a malnourishedchronic alcoholic patient Note calcifying pancreatitis
![Page 45: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/45.jpg)
Gallium scan beforetreatment
![Page 46: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/46.jpg)
Gallium scan aftertreatment
![Page 47: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/47.jpg)
****
*** ***RL
Clinically right sided PN. In fact, bilateral on scintigraphy
99mTc-DMSA scintigraphy
![Page 48: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/48.jpg)
Scintigraphy
CT scan
![Page 49: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/49.jpg)
Pyelonephritis in pregnancy
• Frequent• Heralded by asymptomatic bacteriuria• Occurring in a physiological state of
immunodepression• Difficult imaging (dilatation of the urinary tract is
physiological)• Dangerous: risk of contractions and premature
labor
![Page 50: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/50.jpg)
Patterson & al
Kidney Int
45:571, 1994
![Page 51: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/51.jpg)
Patterson & al
Kidney Int
45:571, 1994
![Page 52: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/52.jpg)
![Page 53: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/53.jpg)
VUR
The most commoncause ofpyelonephritis in children
Risk of renal growtharrest, cortical scars, chronicpyelonephritis
Best diagnostic procedure:
DMSA scintigraphy
![Page 54: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/54.jpg)
Compound papillae
![Page 55: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/55.jpg)
Diabetics
• Male + Obese + Poor glycemic control• Bladder autonomic neuropathy + Glycosuria +
Neutrophil phagocytic impairment• May be painless• Leads to hyperosmolarity and acidocetosis• Abscess formation and papillary necrosis• Rescue nephrectomy may be the last recourse
![Page 56: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/56.jpg)
Necrosis and abscess formation
![Page 57: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/57.jpg)
Papillary necrosis
![Page 58: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/58.jpg)
Papilla recovered in the urine
![Page 59: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/59.jpg)
Acute pyelonephritis
Young woman
No urologic disease
No compromisedbackground
"Simple" pyelonephritis
Apparentlybenign
Ten dayambulatory Rx
Apparentlysevere
Hospitalization
Male
Elderly
Diabetic
Pregnant
Child
![Page 60: ACUTE PYELONEPHRITIS The most frequent of all nephropathies](https://reader033.vdocuments.site/reader033/viewer/2022051200/58761b1e1a28ab8a468b9273/html5/thumbnails/60.jpg)
Antibiotic treatmentNot advisable before sensitivity tests
• Ampicillin• Cotrimoxazole
Recommended first line regimen
70 % of community acquiredenterobacteriaceae are now resistant
Aminoglycoside 4 days
Fluoroquinolone 10 days
Pregnancy3rd generation β lactamin
Children
Aminoglycoside + 3rd generation β lactamin