Chronic Pyelonephritis Treatment & Management

Updated: Sep 17, 2019
  • Author: James W Lohr, MD; Chief Editor: Vecihi Batuman, MD, FASN  more...
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Treatment

Approach Considerations

In the child with vesicoureteral reflux (VUR) who is experiencing chronic pyelonephritis, the goals of management of are to 1) prevent recurring febrile urinary tract infections (UTIs); 2) prevent renal injury; and 3) minimize the morbidity of treatment and follow-up. Preventive strategies include the administration of prophylactic antibiotics, endoscopic injection of dextranomer hyaluronic acid, and antireflux surgery. [4]  Selecting the treatment option for different grades of VUR  depends on the clinical presentation and renal function.

If symptomatic breakthrough UTI occurs during preventive therapy, a change in therapy is recommended. The clinical scenario (ie, VUR grade, degree of renal scarring, and evidence of bowel/bladder dysfuntion), as well as parental preferences, will guide the choice of alternative treatment. In the absence of new renal cortical abnormalities, a change in the antibiotic used for prophylaxis may be effective. Therapy with curative intent, including open surgery, offers protection against febrile UTI, but is associated with morbidity. Endoscopic injection therapy may have decreased success in VUR resolution. [4]

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Medical Care

Continuous antibiotic prophylaxis (CAP), such as amoxicillin, trimethoprim/sulfamethoxazole (Bactrim), trimethoprim alone, or nitrofurantoin, is often the initial treatment. CAP should continue until puberty or until reflux resolves. 

 

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Surgical Care

Endoscopic Injections

Endoscopic injection have advantages over open surgery, including less postoperative pain and fewer bladder spasms and infections, and the absence of surgical scarring. Endoscopic injection can be performed in a shorter operation time, in an outpatient setting, and with minimal use of postoperative analgesics and is preferred as the first-line treatment for children with VUR. [23]  

The American Urological Association (AUA) Vesicoureteral Reflux Guideline Update Committee analyzed data from 17,972 patients, and reported that the overall success rate of a single endoscopic treatment was 83.0% compared to 98% success rates for open surgery. [4] When an injection treatment fails, open ureteral reimplantation may be needed to treat persistent VUR. [23]

Open Ureteral Reimplantation

Surgery entails the reimplantation of the ureters, with the creation of an adequate submucosal tunnel and detrusor support. Open reimplantation surgery may be a primary treatment or may be performed as second-line therapy after endoscopic injection failure. Studies have reported no adverse effect on success rates, operation time, or complications when open reimplantation follows endospic injection treatment. [23]

Laparoscopic Ureteral Reimplantation

Robot-assisted laparoscopic extravesical ureteral reimplantation has been proposed as a minimally invasive alternative to open ureteral reimplantation for correcting primary vesicoureteral reflux in children. However, the current literature contains conflicting data regarding the safety and efficacy of this approach. In a multi-institutional review, a success rate of 87.9% was reported in a series of 260 patients who underwent robot-assisted laparoscopic extravesical ureteral reimplantation for primary vesicoureteral reflux. [24]

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Prevention

Progressive renal injury can be reduced by dietary protein restriction, while aggressive blood pressure control aids in slowing progression of renal failure. Angiotensin-converting enzyme (ACE) inhibitors are particularly beneficial in treating hypertension.

Careful follow-up and monitoring of renal function is beneficial. Vigorously treat a UTI or bacteriuria in a patient who is pregnant to prevent renal failure, preeclampsia, and abortions. [25]

Renal ultrasonography is recommended for siblings of patients with VUR. [26]  If an abnormality is found, then perform a voiding cystourethrogram (VCUG).

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