eMedicine Specialties > Nephrology > Tubulointerstitial Diseases of the Kidney

Pyelonephritis, Chronic

Author: Anupama Gowda, MBBS, MD, Consulting Staff, Atlanta Nephrology Associates, PC
Coauthor(s): Chike Magnus Nzerue, MD, Associate Dean for Clinical Affairs, Meharry Medical College
Contributor Information and Disclosures

Updated: Sep 15, 2008

Introduction

Background

Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection. It occurs almost exclusively in patients with major anatomic anomalies, including urinary tract obstruction, struvite calculi, renal dysplasia, or, most commonly, vesicoureteral reflux (VUR) in young children. Sometimes, this diagnosis is established based on radiologic evidence obtained during an evaluation for recurrent urinary tract infection (UTI) in young children. VUR is a congenital defect that results in incompetence of the ureterovesical valve due to a short intramural segment. The condition is present in 30-40% of young children with symptomatic UTIs and in almost all children with renal scars. VUR may also be acquired by patients with a flaccid bladder due to spinal cord injury. VUR is classified into 5 grades (I-V), according to the increasing degree of reflux.

See related CME at Renal Tract Malformations: Perspectives for Nephrologists.

Pathophysiology

Chronic pyelonephritis is associated with progressive renal scarring, which can lead to end-stage renal disease (ESRD), for example, reflux nephropathy. Intrarenal reflux of infected urine is suggested to induce renal injury, which heals with scar formation. In some cases, scars may form in utero in patients with renal dysplasia with perfusion defects. Infection without reflux is less likely to produce injury. Dysplasia may also be acquired from obstruction. Scars of high-pressure reflux can occur in persons of any age. In some cases, normal growth may lead to spontaneous cessation of reflux by age 6 years.

Factors that may affect the pathogenesis of chronic pyelonephritis are as follows: (1) the sex of the patient and his or her sexual activity; (2) pregnancy, which may lead to progression of renal injury with loss of renal function; (3) genetic factors; (4) bacterial virulence factors; and (5) neurogenic bladder dysfunction. In cases with obstruction, the kidney may become filled with abscess cavities (see Pyonephrosis).

Frequency

United States

VUR may be present in 30-45% of children with UTIs.

The prevalence rate of VUR in siblings of patients with chronic pyelonephritis is approximately 35%.

VUR and chronic pyelonephritis are less common in African American children than in white children.

Mortality/Morbidity

Conditions associated with mortality and morbidity related to chronic pyelonephritis include the following: (1) progressive renal scarring, (2) proteinuria, (3) hypertension, (4) end-stage renal disease, (5) focal glomerulosclerosis, and (6) xanthogranulomatous pyelonephritis (XPN). XPN occurs in 8.2% of patients and in 25% of patients with pyonephrosis.

Race

Chronic pyelonephritis is 3 times more common in white children than in African American children.

Sex

Chronic pyelonephritis is 2 times more common in females than in males.

Age

Chronic pyelonephritis occurs more often in infants and young children (younger than 2 y) than in older children and adults.

Clinical

History

  • Many cases of VUR are suggested based on prenatal sonography findings.
  • Patients with chronic pyelonephritis may report the following:
    • Fever
    • Lethargy
    • Nausea and vomiting
    • Flank pain or dysuria
  • Some children may present with failure to thrive.

Physical

  • The following may be noted:
    • Hypertension
    • Failure to thrive in young children
    • Flank tenderness

Causes

  • Chronic pyelonephritis is renal injury induced by recurrent or persistent renal infection.

More on Pyelonephritis, Chronic

Overview: Pyelonephritis, Chronic
Differential Diagnoses & Workup: Pyelonephritis, Chronic
Treatment & Medication: Pyelonephritis, Chronic
Follow-up: Pyelonephritis, Chronic
References
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References

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Further Reading

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Keywords

chronic pyelonephritis, reflux nephropathy, kidney disease, renal injury, renal disease, kidney infection, renal infection, urinary tract obstruction, struvite calculi, renal dysplasia, vesicoureteral reflux, VUR, UTI, urinary tract infection, renal scar, renal scarring, flaccid bladder, end-stage renal disease, ESRD, end-stage kidney disease, intrarenal reflux, intra-renal reflux, progressive renal scarring, proteinuria, hypertension, focal glomerulosclerosis, FGS, xanthogranulomatous pyelonephritis, XPN, failure to thrive, Proteus, Escherichia coli, E coli, azotemia

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Contributor Information and Disclosures

Author

Anupama Gowda, MBBS, MD, Consulting Staff, Atlanta Nephrology Associates, PC
Disclosure: Nothing to disclose.

Coauthor(s)

Chike Magnus Nzerue, MD, Associate Dean for Clinical Affairs, Meharry Medical College
Chike Magnus Nzerue, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Society of Nephrology, and National Kidney Foundation
Disclosure: Nothing to disclose.

Medical Editor

Richard A Santucci, MD, FACS, Chief of Urology, Detroit Receiving Hospital; Specialist-in-Chief of Urology, Detroit Medical Center; Chief of Urologic Trauma Surgery, Sinai Grace Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State College of Medicine
Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, and Société Internationale d'Urologie (International Society of Urology)
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Roche Honoraria Consulting

Chief Editor

Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology
Disclosure: Nothing to disclose.

 
 
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