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4.
UTIs IN RENAL INSUFFICIENCY, TRANSPLANT RECIPIENTS, DIABETES
MELLITUS AND IMMUNOSUPPRESSION
4.1 SUMMARY
What are the acute
effects of a UTI on the kidney and do the lesions become chronic?
In acute pyelonephritis very dramatic changes can occur with focal reduction in perfusion on imaging and corresponding renal tubular dysfunction. However, if in the adult the kidney is normal beforehand, chronic renal damage is most unlikely. In diabetes mellitus, occasionally overwhelming infection can predispose to pyogenic infection with intra-renal perinephric abscess formation and, very rarely, a specific form of infective interstitial nephritis. Papillary necrosis is a common consequence of pyelonephritis in diabetics.
Arguably, diabetic patients are susceptible to the rapid progression of parenchymal infection, and the clearance of asymptomatic bacteriuria should be attempted and then re-infection prevented with long-term antibiotics.
Does chronic renal disease progress more quickly as a result of infection and do particular renal diseases predispose to a UTI?
There are several factors of general potential importance predisposing to infection in uraemia, including loss of several urinary defence mechanisms and a degree of immunosuppression. Typically adult polycystic kidney disease (APCKD), gross VUR and end-stage obstructive uropathy will harbour infective foci or promote ascending infection, but not invariably so. Clearly, a severe UTI with accompanying bacteraemia can hasten the progression of renal failure, but there is little evidence that vigorous treatment of lesser degrees of infection or prophylaxis will slow renal functional impairment once it is established.
VUR and a UTI in end-stage chronic renal failure
Bilateral nephro-ureterectomy should only be carried out as a last resort.
Obstruction and a UTI
As in all other situations, the combination of obstruction and infection is dangerous and should be treated vigorously. Obstruction may be covert and require specific diagnostic tests, e.g. video urodynamics, upper tract pressure flow studies.
APCKD
Acute pyelonephritis, infected cysts (presenting as recurrent bacteraemia or 'local sepsis') should be treated with high-dose systemic fluoroquinolones. A long course should be given and followed by prophylaxis. Bilateral nephrectomy is used as a last resort.
Calculi and UTI
For patients without renal impairment (i.e. stone clearance), where possible minimize antibiotic treatment if the calculus cannot be removed. Nephrectomy is a last resort, but even residual renal function may be of vital importance.
The need to correct uropathy or remove a potential focus of infection in a diseased end-stage kidney is more pressing in a patient enlisted for renal transplantation. Even so, the results of nephrectomy for scarred or hydronephrotic kidney in the hope of curing infection may be disappointing.
There is a tendency for certain antibiotics to be removed at dialysis.
Are immunosuppressed patients prone to UTIs? Are UTIs a significant cause of graft failure?
Immunosuppression has secondary importance, although if extreme it will promote at least persistent bacteriuria, which may become symptomatic. In the context of renal transplantation, UTIs are very common, but immunosuppression is only one of many factors that are mainly classified as 'surgical'.