1. Acute pyelonephritis.

2. Pyonephrosis and paranephritis.

3. Tuberculosis of kidneys.

Question: what is acute pyelonephritis?

It is a sudden inflammation of both the parenchyma and the pelvis of the kidney (either one kidney or both)

Question: what is the classification of pyelonephritis?

1. Primary and secondary pyelonephritis

In primary pyelonephritis; there is no dysfunction of urine outflow

In secondary pyelonephritis; there is dysfunction of urine outflow due to urolithiasis, tumors, iatrogenic factors (catheterization) etc.

2. Unilateral and bilateral pyelonephritis

3. Acute and chronic

4. Serous and purulent

5. By the mode of bacteria pathway there are differed

1. hematogenous spread

2. ascending spread

3. urogenic

4. Urolithiasis or infected urinary stones

5. tuberculosis of the kidneys;

6. By the course, age, stage of the organism there are differed:

1. pyelonephritis of newborn;

2. pyelonephritis of the aged (old) patients;

3. pyelonephritis of the pregnant women;

4. Pyelonephritis in diabetes mellitus patients.

Question: what is the etiology of pyelonephritis?

Primary pyelonephritis is caused by the following bacteria:

1. E. coli (most common cause)

2. Staphylococcus species (saprophyticus or fecalis)

3. Proteus

4. Klebsiella

5. Pseudomonas

6. Enterococci

Secondary pyelonephritis is due to the following

1. Urolithiasis

2. Tumors of urinary tract

3. Immunocompromised patients (HIV, diabetes, malignancy)

4. Iatrogenic causes (catheterization)

5. Pregnancy due to; Mechanical pressure of pregnant uterus on ureters, neurohumoral changes, asymptomatic bactriuria.

6. Urinary tract infections (cystitis, urethritis etc.)

Question: what is the pathogenesis of pyelonephritis?

1. Bacteria gets to the kidneys through hematogenous or ascending way (through the urethra, bladder, ureter and to renal pelvis and kidney)

2. An inflammatory process begins resulting to the signs and symptoms such as lumbar pain, fever, chills etc.

Question: what is the clinical manifestation (signs and symptoms) of pyelonephritis?

The triad of pyelonephritis is (lumbar/flank pain, fever and chills)

1. Lumbar or flank pain

2. Fever more than 38⁰C

3. Chills/shaking

4. Abdominal pain

5. Nausea and vomiting

6. Sweating (diaphoresis)

7. Fatigue

8. Mental confusion

9. Gross hematuria

10. Dysuria

11. Urine Urgency

12. Nocturia

13. Positive Pasternesky sign during physical examination

Question: what is the diagnostic principle of pyelonephritis?

1. Complete blood count: shows leukocytosis, high ESR

2. Urinalysis: shows cloudy fluid with heavy pyuria, bacteriuria, mild proteinuria, and often microscopic or gross hematuria.

3. CT scan/MRI of abdomen may show:

1. alterations in renal parenchymal perfusion

2. renal abscesses,

3. perinephric fluid

4. inflammatory masses

5. obstruction (renal calculi, tumor)

6. MRI can evaluate renal vasculature abnormalities

4. abdominal ultrasound

1. Renal abscesses,

2. stones

5. Plain abdominal X-ray may show renal stones

6. Excretory urography may show

1. Enlarged kidneys

2. Renal stones

3. Deformation of renal calices

7. Cystoscopy may show hemorrhage from the ureters

8. Chromocystoscopy should be used in pregnant women and those who are allergic to contrast used in IVP

9. Retrograde cystogram can show vesicoureteral reflux, stones tumors etc.

Question: what is the differential diagnosis of pyelonephritis?

1. Pancreatitis (Elevated serum amylase and normal results of urinalysis allow differentiation)

2. Basal pneumonia (pleuritic nature of the pain and the chest x-ray usually allow differentiation)

3. Acute intraabdominal disease (acute appendicitis, cholecystitis, and diverticulitis)

4. Pelvic inflammatory disease (PID)

5. Renal abscess and perinephric abscess (Radiographic studies often are necessary to confirm the specific diagnosis)

6. Tuberculosis of the urinary tract (intravesical signs- Yellow raised nodules surrounded by a halo of hyperemia, "golf-hole" (gaping) ureteral orifice, Mycobacterium tuberculosis in urine or blood culture, contracted bladder)

Question: what is the principle of treatment of pyelonephritis?

1. Hospitalization with complete bed rest

2. Antibiotic therapy: administer an aminoglycoside (amikacin, gentamicin, or tobramycin) plus ampicillin intrave­nously in full dosage

3. Antipyretic and analgesics (ibuprofen, naproxen, piroxicam etc.)

4. Disintoxication therapy (intravenous fluids such as normal saline, ringer’s lactate)

5. Surgery in case of the following: renal carbuncle, perinepheric abscess, large calculi

6. Treatment of purulent pyelonephritis involves decapsulation and nephrostomy

7. Treatment of secondary acute pyelonephritis is aimed at removing the cause

Question: name the possible complications of pyelonephritis

1. Acute kidney failure

2. Infection around the kidney (perinephric abscess)

3. Sepsis

4. pyonephrosis

5. Shock

Question: what is pyonephrosis?

It is a suppurative destruction (pus formation) of the renal parenchyma, with total or almost complete loss of kidney function.

Question: what is the etiology of pyonephrosis?

Spread of infection may be hematogenous or ascending way

1. Infected Hydronephrosis

2. Pyelonephritis

3. Tuberculosis

4. Risk factors for pyonephrosis include

1. immunosuppression due to medications (eg, steroids), disease (eg, diabetes mellitus, acquired immunodeficiency syndrome [AIDS]),

2. Any anatomic urinary tract obstruction (eg, stones, tumors, ureteropelvic junction obstruction, pelvic kidney, horseshoe kidney).

Question: what are the clinical findings (signs and symptoms) of pyonephrosis?

1. fever,

2. chills,

3. flank pain,

4. Abdominal pains

5. Nausea and vomiting

6. Fatigue/ malaise

7. Intensive pyuria

8. Intravesical signs: Pus discharge from the ureteral openings.

Question: what is the principle of diagnosis of pyonephrosis?

1. CBC: high leukocytosis and ESR

2. Urinalysis: pyuria, heavy bacteriuria

3. Cystoscopy: : Pus discharge from the ureteral openings

4. Retrograde pyelography: Dilatation of hollow system with unequal contours.

5. CT scan/ MRI:

1. thickening of the renal pelvic wall

2. dilatation and obstruction of the collecting system

3. enlarged kidney

6. Ultrasound:

1. dilatation of the pelvi-calyceal system

2. echogenic collecting system debris - considered the most reliable sign

3. fluid-fluid levels within the collecting system

4. incomplete (dirty) echoes of collecting system gas can be occasionally seen

Question: what is the differential diagnosis of pyonephrosis?

1. Hydronephrosis (normal urinalysis, apyretic, intoxication signs absent)

2. Pyelonephritis (hematuria,)

3. Tuberculosis of the urinary tract (intravesical signs- Yellow raised nodules surrounded by a halo of hyperemia, "golf-hole" (gaping) ureteral orifice, Mycobacterium tuberculosis in urine or blood culture, contracted bladder)

Question: treatment of pyonephrosis?

1. percutaneous nephrostomy to drain the infected collecting system

2. Nephrectomy if the functioning of the other kidney is normal

3. Intravenous Antibiotics

Question: what is perinephric abscess?

It is a collection of suppurative material in the perinephric space (between the renal capsule and the perirenal (Gerota's) fascia)

Paranephric abscess is a chronic suppurative process outside the renal (Gerota) fascia

Question: what is the etiology of perinephric abscess?

1. Most result from rupture of an intrarenal abscess into the perinephric space; the causative organisms are usually

1. coliform bacteria

2. Pseudomonas,

3. less often staphylococci and obligate anaerobes

Question: what is the clinical presentation of perinephric abscess?