Merck Manual

Please confirm that you are a health care professional

honeypot link

Chronic Pyelonephritis

(Chronic Infective Tubulointerstitial Nephritis)

By

Talha H. Imam

, MD, University of Riverside School of Medicine

Last full review/revision Jul 2021| Content last modified Jul 2021
Click here for Patient Education

Chronic pyelonephritis is continuing pyogenic infection of the kidney that occurs almost exclusively in patients with major anatomic abnormalities. Symptoms may be absent or may include fever, malaise, and flank pain. Diagnosis is with urinalysis, culture, and imaging tests. Treatment is with antibiotics and correction of any structural disorders.

Xanthogranulomatous pyelonephritis (XPN) is an unusual variant that appears to represent an abnormal inflammatory response to infection. Giant cells, lipid-laden macrophages, and cholesterol clefts account for the yellow color of the infected tissue. The kidney is enlarged, and perirenal fibrosis and adhesions to adjacent retroperitoneal structures are common. The disorder is almost always unilateral and most often occurs in middle-aged women with a history of recurrent UTIs. Long-term urinary tract obstruction (usually by a calculus Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more ) and infection increase risk. The most common pathogens are Proteus mirabilis and Escherichia coli.

Symptoms and Signs

Symptoms and signs are often vague and inconsistent. Some patients have fever, flank or abdominal pain, malaise, or anorexia. In xanthogranulomatous pyelonephritis, a unilateral mass can usually be palpated.

Diagnosis

  • Urinalysis and urine culture

  • Imaging

Chronic pyelonephritis is suspected in patients with a history of recurrent urinary tract infections (UTIs) and acute pyelonephritis Acute pyelonephritis Bacterial urinary tract infections (UTIs) can involve the urethra, prostate, bladder, or kidneys. Symptoms may be absent or include urinary frequency, urgency, dysuria, lower abdominal pain... read more . However, most patients, except for children with vesicoureteral reflux (VUR), do not have such a history. Sometimes the diagnosis is suspected because typical findings are incidentally noted on an imaging study. Symptoms, because they are vague and nonspecific, may not suggest the diagnosis.

Urinalysis Urinalysis In patients with renal disorders, symptoms and signs may be nonspecific, absent until the disorder is severe, or both. Findings can be local (eg, reflecting kidney inflammation or mass), result... read more Urinalysis and urine culture and usually imaging tests are done. Urinary sediment is usually scant, but renal epithelial cells, granular casts, and occasionally white blood cell (WBC) casts are present. Proteinuria is almost always present and can be in the nephrotic range if VUR causes extensive renal damage. When both kidneys are involved, defects in concentrating ability and hyperchloremic acidosis may appear before significant azotemia occurs. Urine culture may be sterile or positive, usually for gram-negative organisms.

Initial imaging is usually with ultrasonography, helical CT, or intravenous urography (IVU). The hallmark of chronic pyelonephritis (usually with reflux or obstruction) on imaging is classically a large, deep, segmental, coarse cortical scar usually extending to one or more of the renal calyces. The upper pole is the most common site. Renal cortex is lost, and the renal parenchyma thins. Uninvolved renal tissue may hypertrophy locally with segmental enlargement. Ureteral dilation may be present, reflecting the changes induced by chronic severe reflux. Similar changes can occur with urinary tract tuberculosis Genitourinary TB Tuberculosis outside the lung usually results from hematogenous dissemination. Sometimes infection directly extends from an adjacent organ. Symptoms vary by site but generally include fever... read more Genitourinary TB .

In xanthogranulomatous pyelonephritis, urine cultures almost always grow P. mirabilis or E. coli. CT imaging is done to detect calculi Urinary Calculi Urinary calculi are solid particles in the urinary system. They may cause pain, nausea, vomiting, hematuria, and, possibly, chills and fever due to secondary infection. Diagnosis is based on... read more or other obstruction. Imaging shows an avascular mass with a variable degree of extension around the kidney. Sometimes, to differentiate cancer (eg, renal cell carcinoma Renal Cell Carcinoma Renal cell carcinoma (RCC) is the most common renal cancer. Symptoms can include hematuria, flank pain, a palpable mass, and fever of unknown origin (FUO). However, symptoms are often absent... read more ), biopsy may be required, or tissue removed during nephrectomy can be examined.

Prognosis

The course of chronic pyelonephritis is extremely variable, but the disease typically progresses very slowly. Most patients have adequate renal function for 20 years after onset. Frequent exacerbations of acute pyelonephritis, although controlled, usually further deteriorate renal structure and function. Continued obstruction predisposes to or perpetuates pyelonephritis and increases intrapelvic pressure, which damages the kidney directly.

Treatment

  • Correction of the obstruction

  • Long-term antibiotic therapy

  • Sometimes nephrectomy, sometimes followed by renal transplantation

If obstruction cannot be eliminated and recurrent urinary tract infections are common, long-term therapy with antibiotics (eg, trimethoprim/sulfamethoxazole, trimethoprim, a fluoroquinolone, nitrofurantoin) is useful and may be required indefinitely. Complications of uremia or hypertension Hypertensive Emergencies A hypertensive emergency is severe hypertension with signs of damage to target organs (primarily the brain, cardiovascular system, and kidneys). Diagnosis is by blood pressure (BP) measurement... read more must be treated appropriately.

For xanthogranulomatous pyelonephritis, an initial course of antibiotics should be given to control local infection, followed by en bloc nephrectomy with removal of all involved tissue.

Key Points

  • Chronic pyelonephritis usually affects patients predisposed to urinary reflux into the renal pelvis (eg, by VUR, obstructive uropathy, or struvite calculi).

  • Suspect chronic pyelonephritis if patients have recurrent acute pyelonephritis, but the diagnosis is often first suspected based on incidental findings on imaging.

  • Obtain an imaging study (ultrasonography, helical CT, or intravenous urography [IVU]).

  • If obstruction cannot be relieved, consider long-term antibiotic prophylaxis.

Drugs Mentioned In This Article

Drug Name Select Trade
FURADANTIN, MACROBID, MACRODANTIN
No US brand name
Click here for Patient Education
NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
Professionals also read

Test your knowledge

Gynecomastia
A 45-year-old man comes to the office for routine evaluation. Medical history includes hypertension treated with spironolactone, hypothyroidism treated with levothyroxine, seasonal allergies treated with cetirizine, and occasional erectile dysfunction treated with sildenafil, as needed. Physical examination shows no abnormalities except for gynecomastia. Which of the following drugs is most likely responsible for this finding? 
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
Download the Manuals App iOS ANDROID
 

Also of Interest

 
TOP