Acute Pyelonephritis - Correlation of Clinical Parameter with Radiological Imaging Abnormalities

Leelavathi Venkatesh and Ramalingiah Karadakere Hanumegowda

Abstract

Introduction
Pyelonephritis (PN) is a suppurative infection of the kidney, most commonly due to bacterial infection and may be either acute or chronic.
Acute PN (APN) subdivided into uncomplicated and complicated. Severity of PN cannot be assessed by clinical or laboratorial parameters
alone, radiological imaging such as Ultrasound (USG) abdomen, Computed Tomography (CT) is required to know the nature, extent and
severity of disease and for planning interventions.

Aim
The aim of this study was to compare clinical and biochemical parameters with radiological findings (USG/CT) among patients diagnosed to
have PN.

Materials and Methods

The medical records of all patients admitted with PN at the Institute of Nephrourology, Bangalore from January 2016 to December 2016
were reviewed. Their clinical and biochemical parameter were compared with radiological findings. Statistical analysis was performed with
Statistical Package for the Social Sciences (SPSS) Version 15.0.

Results
There were 100 patients diagnosed with PN in the study period. Mean age of patient was 48.7 years and PN was common among females
(62%). Classical triad of PN was present in 87% of patients. Acute kidney injury was present in 47% of patients. Diabetes (69%) was the
most common comorbid condition. Positive urine culture was found in 24% of patients. USG abdomen was performed in all patients and it
was suggestive of APN in 66% cases. CT abdomen was available for 74% and it revealed PN in 70%, of patients. Among these
Emphysematous PN (EPN) was found in 4% and renal abscess in 3% of patients. In this study, USG findings of PN were correlated with
triad of PN symptoms and those who had PN for the first time.

Conclusion
In this study, majority of the patients presented with clinical triad of PN-fever, flank pain and dysuria. Urine culture was positive only in few
cases. USG was able to diagnose large number of PN cases except emphysematous change and renal abscess which was detected by CT. The
detection of PN was better with CT when compared to USG.

Keywords: Computed tomography, Diagnosis, Renal abscess

Introduction
APN is defined as a bacterial or fungal infection of the renal parenchyma and collecting system. The diagnosis is based on a combination of
clinical and laboratory findings. Clinical features include increased urinary frequency, dysuria, flank pain and a high-grade fever (>38.5°C)
with rigors. Laboratory findings include pyuria, white cell casts, and a positive urine culture. APN occurs as a result of bacterial invasion of
the renal parenchyma from ascending infection from the lower urinary tract. Haematogenous spread to the kidneys occurs less commonly.
APN is subdivided into uncomplicated and complicated. Complicated PN is associated with an abnormal urinary tract, obstruction, stones,
immunocompromised state, diabetes, pregnancy. The clinical spectrum of acute PN ranges from mild illness to pyonephrosis and
emphysematous PN with a fulminant course [1].

Patients with mild symptoms of APN can be managed in an outpatient setting. But, those presenting with life-threatening complications like
shock, septicaemia and multi-organ failure require hospitalization. Mortality due to APN varies from 1% to 12% [2].

The British Medical Research Council Bacteriuria Committee defined APN as a clinical syndrome of flank pain, costovertebral tenderness,
fever and laboratory findings of renal infection including leucocytosis, pyuria, haematuria, bacteriuria, positive urine culture and rarely
bacteraemia [3].

Pathologically, APN is defined as suppurative inflammation of the renal parenchyma and pyelocalyceal system distributed along one or more
medullary rays supporting an ascending route of infection [4]. Radiologically, on Contrast Enhanced Computed Tomography (CECT) scans,
it is seen as hypoenhancing regions with or without renal swelling and may be focal or diffused. APN includes all acute infection related to
parenchymal abnormalities without abscess diagnosed radiologically [5].

Severity of PN cannot be predicted with clinical or laboratorial parameters alone. Radiological images such as USG and CT are also
necessary to know the nature, extent and severity of disease and to plan intervention if required. CT abdomen will help detect calculi,
emphysematous change, parenchymal calcification, obstruction and inflammatory masses. Very few studies are available to correlate the
clinical severity of PN with radiological severity of the disease [2,3,6].

Hence, this study was done to compare clinical and biochemical parameters with radiological findings by USG and CT among patients
diagnosed to have PN.

Materials and Methods

Medical records of all patients diagnosed with APN admitted at Institute of Nephrourology Hospital Bengaluru, Karnataka, India, from
January 2016 to December 2016 were reviewed retrospectively. Patients demographic details, medical history, clinical, biochemical and
radiological imaging reports were reviewed.

All the patients diagnosed to have PN based on clinical and/or radiological findings were included in this study.

In this study, the diagnosis of PN was based on clinical and radiological criteria as explained below [2].

Clinical criteria were the presence of classical triad of PN i.e., fever with chills and rigor; presence of flank pain and pyuria, defined
as greater than 10 white blood cells per high-power field of centrifuged urine sample.

Radiological diagnosis of PN was made when USG/CT abdomen showed evidence of infection of renal parenchyma, in the form of
bulky kidney, compression of renal sinus, perinephric fat stranding, abscess and emphysematous changes.

EPN is necrotising infection with presence of gas in the renal parenchyma, collecting system or perinephric tissue. Based on CT
findings, EPN can be classified as: Class 1: Gas in the collecting system, Class 2: Gas in the renal parenchyma without extension to
the extrarenal space, Class 3A: Extension of gas or abscess to the perinephric space, Class 3B: Extension of gas or abscess to the
pararenal space and Class 4: Bilateral EPN or solitary kidney with EPN [7].

Hypotension is defined as a systolic blood pressure of <100 mmHg.

Acute renal failure was defined as 25% decrease in Glomerular Filtration Rate (GFR) from baseline, according to Acute Dialysis
Quality Initiative (ADQI) group.

GFR is calculated based on the Modification of Diet in Renal Disease (MDRD) study equation.

Statistical analysis
Statistical analysis was performed with SPSS Version 15.0. Descriptive studies were performed for the cohort. Fischer Exact test were
performed for significance. The p value of <0.05 was considered to be significant.

Results
All patient records fulfilling the inclusion criteria were included for analysis. The study includes 100 patient records. Mean age of patient
were 48.7 years (range 15 – 85), majority of them were more than 40 years (70) with female (62) preponderance. Among them, three females
nd
were in 2nd trimester of their pregnancy. Classical triad of PN was present in 87 of patients. Renal function was normal in 21 patients. Acute
kidney injury secondary to PN was present in 47 patients. PN was present in 32 chronic kidney disease patients. Risk factors and
comorbidities are represented in [Table/Fig-1]. Diabetes (69) was the most common comorbid condition. Recurrent PN was documented in
16 patients. History of renal calculi was noted in 9 patients.

[Table/Fig-1]:
Demographics and comorbidities of patients.

Biochemical Findings
Lecucocytosis was present in 68 patients and thrombocytopenia was found in 16 patients. Pyuria was present in 87 patients. Microscopic
hematuria was present in 21 patients. Positive urine culture was found only in 24 patients. Majority of them had E coli infection, followed by
Enterococcus, Klebsiella and Candida. None of the patient had positive blood culture. [Table/Fig-2]

[Table/Fig-2]:
Biochemical parameters.

Imaging Parameters
Renal USG [Table/Figure 3] was performed at the time of admission among all patients. It was suggestive of APN in 66 cases, unilateral PN
was seen in 40 and bilateral in 26 patients. Other USG findings include - 17 with dilated pelvicalyceal system, 11 had increased echogenicity,
three had renal calculi, two showed cyst and one had benign prostatic hypertrophy.

[Table/Fig-3]:
Imaging parameter.

CT abdomen reports were available for 74 patients, it revealed unilateral PN in 33 and bilateral in 30 patients [Table/Fig-3]. Three patients
were diagnosed to have renal abscess [Table/Fig-4]. Evidence of emphysematous PN was present four of patients [Table/Fig-5]. Dilated
pelvicalyceal system noted in three patients and renal calculi was noted in 15 patients.

[Table/Fig-4]:
Renal abscess. a) USG image of left kidney showing a well-definedhypoechoic lesion with internal debris in mid-lower pole, not taking
vascularity on color Dop-pler study; b & c) Plain and contrast enhanced CT images of the same patient showing ...

[Table/Fig-5]:
Emphysematous pyelonephritis. a) Axial and b) Coronal, Plain CT images show enlarged right kidney with multiple pockets of air seen
in both renal calyces and parenchyma. Perinephric fat stranding noted.

USG findings of PN were significantly associated with triad of PN symptoms, and those who had PN for the first time [Table/Fig-6, 7]. CT
was helpful in detecting PN with complications, but there was no significant association between CT and clinical and biochemical parameters
like duration of fever, leucocytosis, pyuria, septic shock and renal impairment.

[Table/Fig-6]:
Comparison of ultrasound (USG) findings with triad of pylenophritis I (PN).

[Table/Fig-7]:
Comparison of ultrasound (USG) findings with history pylenophritis I (PN).

Treatment
All patients were treated with appropriate antibiotics and supportive therapy. Majority of them responded to the treatment without any
mortality. Intervention in the form of Double J stenting was done in 12 patients and one patient required percutaneous nephrostomy for renal
abscess. Dialysis dependent state occurred in 7 (27%) out of 32 patients with chronic kidney disease.

Discussion
The objective of this study was to compare clinical and biochemical parameters with radiological findings (USG/CT) among patients
diagnosed to have PN.

Mean age of our patient in this study was 48.7 years, majority of them were above 40 years. In Dhamotharan VN et al., study, majority were
in the age group of 51-60 years [8]. Mean age of patient was 57.4 years in a study done by Kumar S et al., [9] and the mean age was 37 years
in a study done by Rollino C et al., [10]. The prevalence of PN was more common among females and this finding was similar to Kumar S et
al., [9] and Rollino C et al., study [10]. This could be explained because of the presence of short urethra among female. In this study, the
mean duration of symptoms prior to hospitalisation was 8.9 days and it was 18 days in kumar S et al., study [9]. Mean length of
hospitalisation was 6.8 days in present study and 11 days in a study by Rollino C et al., [10].

Classical triad of PN was present in 87 patients in this study which was higher than that found by Dhamotharan VM et al(35%) [8]. Renal
dysfunction was present in 79 patients, of these 47 had acute kidney injury and 32 had chronic kidney disease. Study by Kumar S et al.,
found the renal dysfunction among 93% patients [9]. Microscopic haematuria was seen in 21% in this study, whereas it was 7% in
Dhamotharan VM et al., group [8]. Urine cultures were positive in 24% of patients in present study, it was positive in 88.5% of patients in
Kumar S et al., study [9]. Gram-negative bacilli, Escherichia coli were the most frequently isolated organism. Low yield of urine culture may
be due to prior use of antibiotics or presence of atypical organisms which requires special culture media.

Diabetes mellitus was the most common comorbidity in our patients (69) which was similar to the findings by Dhamotharan VM et al., [8].
Diabetics are more prone to infection because of diabetic cystopathy, alteration of bacteria-host interaction and defective neutrophil
bactericidal activity, impaired phagocytosis and chemotaxis[11-13]. Geerling SE et al., stated an increased adherence of Escherichia coli to
diabetic uroepithelial cells and this was due to higher levels of glycosylated haemoglobin (HbA1c)[12]. Due to impaired production of
cytokines, the Escherichia coli infection does not cause symptomatic urinary tract infection (UTI) in diabetic.

Nephrolithiasis had been reported to be a risk factor for PN. In this study 9% of patients had renal calculi on CT. Studies have found that
renal stones act as nidus for bacteria so are associated with treatment failure for uncomplicated PN[13,14].

In this study, EPN was found in 4 patients on CT, all were in Class 2 based on classification proposed by Huang JJ and Tseng CC [7]. Three
out of these four patients were diabetic. Patients improved after antibiotic therapy alone for two weeks.

Classical triad of symptoms to diagnose PN is not specific and sensitive. Studies have shown CT was better in detecting PN in the form of
parenchymal abnormalities like perinephric stranding, bulky kidney, decreased or delayed cortical enhancement (on contrast), inflammatory
masses, kidney enlargement or gas formation [15,16]. Majd M et al reported a sensitivity of 86.8% and specificity of 87.5% of CT in
diagnosing APN, compared with 74.3% and 56.7% for USG [17].

In our study, USG abdomen was able to detect PN in 66/100 patients, while CT detected in 70/74 of patients, including renal abscess in three
patients, emphysematous PN in four patients which was missed in USG. CT was found to reduce the risk of missing renal abscesses by about
37 times compared with USG [18].

There are few studies that correlate the clinical and biochemical parameters with CT diagnosed APN for identification of severity of disease
[2,19-22]. Only two studies have shown good correlation of CT findings with clinical severity [2, 21].

Limitation
The limitation of the study were that it is based on review of hospital records, CT reports were not available for 26 patients and CT did not
show any significant association with clinical and biochemical parameters. Prospective studies with simultaneous comparison of USG and
CT findings in patients with PN will help decide better mode of diagnosis.

Conclusion
From our study, it was found that diabetics are at higher risk of developing PN. Early diagnosis helps prevent complications. Majority of PN
patients respond to antibiotics when diagnosed early.

Notes

Financial or Other Competing Interests

None.

Article information
J Clin Diagn Res. 2017 Jun; 11(6): TC15–TC18.
Published online 2017 Jun 1. doi: 10.7860/JCDR/2017/27247.10033
PMCID: PMC5535453
PMID: 28764263

Leelavathi Venkatesh 1 and Ramalingiah Karadakere Hanumegowda2

1 Assistant Professor, Department of Nephrology, Institute of Nephrourology, Bengaluru, Karnataka, India.

2 Associate Professor, Department of Radiology, Institute of Nephrourology, Bengaluru, Karnataka, India.

Corresponding author.
NAME, ADDRESS, E-MAIL ID OF THE CORRESPONDING AUTHOR: Dr. Leelavathi Venkatesh, Door No. 39, 1st Cross, Nagappa Block, M.K.K. Road, Srirampuram Post,
Bengaluru-560021, Karnataka, India. E-mail: Leelavathi.v@[Link]

Received 2017 Feb 6; Revisions requested 2017 Feb 21; Accepted 2017 Apr 19.

Copyright © 2017 Journal of Clinical and Diagnostic Research

This article has been cited by other articles in PMC.

Articles from Journal of Clinical and Diagnostic Research : JCDR are provided here courtesy of JCDR Research & Publications Private Limited

References
[1] Stunell H, Buckley O, Feeney J, Geoghegan T, Browne RFJ, Torreggiani WC. Imaging of acute pyelonephritis in the adult. EurRadiol. 2007;17:1820–
28. [PubMed] [Google Scholar]
[2] Lim SK, Ng FC. Acute pyelonephritis and renal abscesses in adults—correlating clinical parameters with radiological (computer tomography) severity.
Ann Acad Med Singapore. 2011;40:407–13. [PubMed] [Google Scholar]

[3] British Medical Research Council Bacteriuria Committee. Recommended terminology of urinary tract infection. Br Med J. 1979;2:717–19.
[PMC free article] [PubMed] [Google Scholar]

[4] Hill GS. Uropathology. New York: Churchill-Livingstone; 1989. [Google Scholar]

[5] Talner LB, Davidson AJ, Lebowitz RL, Dalla Palma L, Goldman SM. Acute pyelonephritis: can we agree on terminology? Radiology. 1994;192:297–
305. [PubMed] [Google Scholar]

[6] Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographic. 2008;28:255–76. [PubMed] [Google Scholar]

[7] Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med.
2000;160(6):797–805. [PubMed] [Google Scholar]

[8] Dhamotharan VM, Ramadurai S, Gopalan S, Arthur P. Study of the clinical profile of patients with CT proven acute pyelonephritis in a tertiary care
hospital. Med. Res. Chron. 2016;3(1):64–68. [Google Scholar]

[9] Kumar S, Ramachandran R, Mete U, Mittal T, Dutta P, Kumar V, et al. Acute pyelonephritis in diabetes mellitus: Single center experience. Indian J
Nephrol. 2014 Nov-Dec;24(6):367–71. [PMC free article] [PubMed] [Google Scholar]

[10] Rollino C, Beltrame G, Ferro M, Quattrocchio G, Sandrone M, Quarello F. Acute pyelonephritis in adults: a case series of 223 patients. Nephrol Dial
Transplant. 2012;27:3488–93. [PubMed] [Google Scholar]

[11] Repine JE, Clawson CC, Goetz FC. Bactericidal function of neutrophils from patients with acute bacteria infections and from diabetes. J Infect Dis.
1980;142:869–75. [PubMed] [Google Scholar]

[12] Geerlings SE, Meiland R, van Lith EC, Brouwer EC, Gaastra W, Hoepelman AI. Adherence of type 1-fimbriated Escherichia coli to uroepithelial
cells: more in diabetic women than in control subjects. Diabetes Care. 2002;25:1405–09. [PubMed] [Google Scholar]

[13] Pertel PE, Haverstock D. Risk factors for a poor outcome after therapy for acute pyelonephritis. BJU Int. 2006;98:141–47. [PubMed] [Google Scholar]

[14] Efstathiou SP, Pefanis AV, Tsioulos DI, Zacharos ID, Tsiakou AG, Mitromaras AG, et al. Acute pyelonephritis in adults: prediction of mortality and
failure of treatment. Arch Intern Med. 2003;163:1206–12. [PubMed] [Google Scholar]

[15] Kawashima A, Sandler CM, Ernst RD, Goldman SM, Raval B, Fishman EK. Renal inflammatory disease: the current role of CT. Crit Rev Diagn
Imaging. 1997;38:369–415. [PubMed] [Google Scholar]

[16] Goldman SM, Fishman EK. Upper urinary tract infection: the current role of CT, ultrasound and MRI. Semin Ultrasound CT MR. 1991;12:335–60.
[PubMed] [Google Scholar]

[17] Majd M, Blask ARN, Markle BM, Rana ES, Pohl HG, Park JS, et al. Acute pyelonephritis: comparison of diagnosis with 99 m-Tc DMSA, SPECT,
spiral CT, MR imaging and power Doppler US in and experimental pig model. Radiology. 2001;218:101–08. [PubMed] [Google Scholar]

[18] Stojadinovic M, Micic S, Milovanovic D. Ultrasonographic and computed tomography findings in renal suppurations: performance indicators and
risks for diagnostic failure. UrolInt. 2008;80:389–97. [PubMed] [Google Scholar]

[19] Rollino C, Boero R, Ferro M, Anglesio A, Vaudano GP, Cametti A, et al. Acute pyelonephritis: analysis of 52 cases. Ren Fail. 2002;24:601–08.
[PubMed] [Google Scholar]

[20] Piccoli GB, Colla L, Burdese M, Marcuccio C, Mezza E, Maass J, et al. Development of kidney scars after acute uncomplicated pyelonephritis:
relationship with clinical, laboratory and imaging data at diagnosis. World J Urol. 2006;24:66–73. [PubMed] [Google Scholar]

[21] Huang JJ, Sung JM, Chen KW, Ruaan MK, Shu GH, Chuang YC, et al. Acute bacterial nephritis: A clinic radiologic correlation based on Computed
Tomography. Am J Med. 1992;93:289–98. [PubMed] [Google Scholar]

[22] Ha SK, Seo JK, Kim SJ, Park SH, Park CH, Lee HY, et al. Acute pyelonephritis focusing on perfusion defects on contrast enhanced computerized
tomography. The Korean Journal of Internal Medicine. 1997 Jun;12(2) [PMC free article] [PubMed] [Google Scholar]