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Pinto DS, George A, Johny J, Hoisala RV. Role of MRI in the evaluation of acute pyelonephritis in a high-risk population with renal dysfunction: a prospective study. Emerg Radiol 2023; 30:285-295. [PMID: 36959518 DOI: 10.1007/s10140-023-02122-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/06/2023] [Indexed: 03/25/2023]
Abstract
AIMS This study aims to evaluate the (a) accuracy of conventional and diffusion-weighted-imaging (DWI) sequences in the diagnosis of acute pyelonephritis and (b) minimum apparent diffusion coefficient (ADC) values for the diagnosis of acute pyelonephritis and the differentiation of renal abscesses from acute pyelonephritis. MATERIALS AND METHODS Ultrasound, conventional MRI sequences, and DWI were used to evaluate the kidneys in 68 patients suspected to have acute pyelonephritis. Multiple similar regions of interest (ROIs) were placed over the renal parenchyma with visually identifiable diffusion restriction, over the non-diffusion-restricted renal parenchyma of affected kidneys and over the normal kidneys. Corresponding minimum ADCs were noted for analysis. Pyelonephritis was confirmed based on clinical criteria, laboratory findings, and by resolution/development of known complications of pyelonephritis. RESULT DWI showed the highest sensitivity(100%), while DWI read with T2-weighted imaging (both being positive) showed the highest specificity(100%) for the diagnosis of acute pyelonephritis in our population with a high baseline creatinine. The minimum-ADC of the nephritic diffusion-restricted area in patients with confirmed pyelonephritis was significantly lower than the minimum-ADC in patients without pyelonephritis [(0.934 ± 0.220, mean ± SD) vs (1.804 ± 0.404) × 10-3 s/mm2] (p < 0.001). ROC cut-off of minimum-ADC for the diagnosis of acute pyelonephritis was 1.202 × 10-3 s/mm2 (area under curve 0.978). The minimum-ADC of the abscesses were significantly lower when compared to the minimum-ADC of the nephritic diffusion-restricted portion of the same kidney [(0.633 ± 0.248) vs (0.850 ± 0.191) × 10-3 s/mm2] (p < 0.001). CONCLUSION DWI is an excellent stand-alone imaging tool that can be combined with conventional sequences for the diagnosis of APN even in patients with high serum-creatinine or other contraindications to intravenous contrast. Further, ADC values can be used to differentiate between renal abscesses and uncomplicated pyelonephritis.
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Affiliation(s)
- Denver Steven Pinto
- Department of Radiology, St. John's Medical College, Koramangala, Bangalore, India.
- Division of Body Imaging, Jackson Memorial Hospital/ University of Miami, Miami, USA.
| | - Arun George
- Department of Radiology, St. John's Medical College, Koramangala, Bangalore, India
| | - Jovis Johny
- Department of Radiology, St. John's Medical College, Koramangala, Bangalore, India
| | - Ravi V Hoisala
- Department of Radiology, St. John's Medical College, Koramangala, Bangalore, India
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Bebars GM, Mostafa AN, Moness HM, Aziz RAA. Assessment of early kidney injury caused by asymptomatic bacteriuria in children with type 1 diabetes. BMC Pediatr 2022; 22:643. [PMCID: PMC9639256 DOI: 10.1186/s12887-022-03689-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Introduction
Infection is one of the most frequent causes of morbidity and mortality in diabetic patients. Some microorganisms become more virulent in a high glucose concentration. Diabetics are more likely to have asymptomatic and symptomatic bacteriuria. NGAL is secreted in high concentrations into the blood and urine within two hours of AKI.
Objectives
The aim of the study is early detection of UTI in type1diabetic children through screening of their urine samples, and measurement of NGAL urinary levels in cases with asymptomatic bacteriuria for early detection of AKI to prevent serious complications.
Patients and methods
One thousand twenty-two known diabetic children on regular follow up in endocrine outpatient clinic at Minia Children University hospital were screened for UTI. From them only 52 diabetic children were diagnosed as asymptomatic bacteriuria (group I), 52 diabetic children with normal urine analysis (group II) and 52 apparently healthy children, age and sex matched, served as controls (group III). CBC, Renal function test, HbA1c, hs- CRP, Albumin/creatinine ratio, urine examination, urine culture, GFR and urinary NGAL were done to all children.
Results
Thirty-seven females (71.2%) had asymptomatic bacteriuria, Hs CRP and urinary NGAL were significantly higher, while GFR was significantly lower in diabetic children with bacteriuria than the other two groups. For diabetic children with bacteriuria, (AUC) for NGAL was 1 with optimal cutoff value of > 44.1 (Sensitivity 100% and Specificity 100%) while AUC for hsCRP was 0.887 with optimal cutoff value of > 1 (Sensitivity 82.69% and Specificity 90.38%).
Conclusion
Routine urine analysis should be done for all diabetic children even if they are asymptomatic. NGAL and hsCRP are non-invasive methods that could detect early renal injury in these patients thus, early, and proper management of UTI should be started to prevent renal injury.
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Yano T, Takada T, Fujiishi R, Fujii K, Honjo H, Miyajima M, Takeshima T, Hayashi M, Miyashita J, Azuma T, Fukuhara S. Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus. Acta Radiol 2022; 63:268-277. [PMID: 33508952 DOI: 10.1177/0284185120988817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In older adults, the diagnosis of acute pyelonephritis is challenging because of non-specific symptoms and false-positive urine test results. Few studies have investigated the diagnostic performance of computed tomography (CT) signs. PURPOSE To evaluate the diagnostic performance of CT signs for acute pyelonephritis in older patients suspected of infection with unknown focus. MATERIAL AND METHODS This cross-sectional study was conducted between 2015 and 2018. Patients aged ≥65 years who underwent blood cultures, urine culture, and non-contrast or contrast-enhanced CT on admission were included. Cases with clinically presumable infection focus before CT were excluded. Two radiologists blinded to clinical information independently reviewed five CT signs: perirenal fat stranding; pelvicalyceal wall thickening and enhancement; renal enlargement; thickening of Gerota's fascia; and area(s) of decreased attenuation. The final diagnoses were made by a clinical expert panel. RESULTS Among 473 eligible patients, 61 were diagnosed with acute pyelonephritis. When the laterality of findings between the left and right kidneys were considered, the positive and negative likelihood ratios of perirenal fat stranding were 4.0 (95% confidence interval [CI] = 2.3-7.0) and 0.8 (95% CI = 0.7-0.9) in non-contrast CT, respectively. The other signs in non-contrast CT showed similar diagnostic performance with positive and negative likelihood ratios of 3.5-11.3 and 0.8-0.9, respectively. CONCLUSION CT signs can help physicians diagnose acute pyelonephritis in older patients suspected of infection with unknown focus.
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Affiliation(s)
- Tetsuhiro Yano
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
- Graduate School of Medicine, Fukushima Medical University. Fukushima City, Fukushima, Japan
| | - Toshihiko Takada
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Ryuto Fujiishi
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
| | - Kotaro Fujii
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
| | - Hiroshi Honjo
- Department of Radiology, Shirakawa Kosei General Hospital, Shirakawa City, Fukushima, Japan
| | - Masayuki Miyajima
- Department of Radiology, Shirakawa Kosei General Hospital, Shirakawa City, Fukushima, Japan
| | - Taro Takeshima
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
| | - Michio Hayashi
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
| | - Jun Miyashita
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Teruhisa Azuma
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
| | - Shunichi Fukuhara
- Department of General Medicine, Shirakawa Satellite for Teaching and Research (STAR), Fukushima Medical University, Shirakawa City, Fukushima, Japan
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Anfigeno L, Sertorio F, Basso L, Fontana A, Bodria M, Pistorio A, Ghiggeri GM, Damasio MB. Diffusion-Weighted MRI in the Evaluation of Renal Parenchymal Involvement during Febrile Urinary Tract Infections in Children: Preliminary Data. J Clin Med 2021; 10:jcm10112239. [PMID: 34064114 PMCID: PMC8196731 DOI: 10.3390/jcm10112239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/03/2021] [Accepted: 05/14/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Urinary tract infection (UTI) is the most common infection in pediatric-age patients. Acute pyelonephritis (PNA) represents a worrying situation in pediatric patients due to the risk of sepsis and long-term cicatricial consequences. The purpose of this retrospective study is to evaluate the diagnostic role of DW-MRI in relation to clinical data, to understand if there are any clinical parameters useful in identifying which patients should undergo it. Methods: According to inclusion and exclusion criteria, we enrolled 51 patients ≤15 years old admitted to our Institute between September 2012 and April 2020 with a febrile UTI who underwent DW-MRI evaluation. Clinical, laboratory and imaging data were collected. Statistical analysis was performed. Results: 34 of 51 patients with an fUTI (66.7%) showed signs of acute parenchymal involvement at DW-MRI evaluation. In 27 of these 34 (79.4%), DW-MRI showed multiple areas of pyelonephritis. A statistically significant relationship (p = 0.0004) between older age at admission and pyelonephritis was demonstrated. No statistically significant relationship was found between the other clinical, anamnestic and laboratory parameters and the outcome of DWI. Only two ultrasound examinations allowed the identification of pathological areas on the renal parenchyma. Conclusions: From these preliminary investigations, we can say that selecting the patients with fUTI on whom to perform a DW-MRI is difficult. Nevertheless, thanks to the low cost, the very rare need for sedation and the accuracy in identifying pyelonephritic areas, the use of DW-MRI in patients with febrile UTI seems recommendable.
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Affiliation(s)
- Lorenzo Anfigeno
- Department of Health Sciences (DISSAL), Università degli Studi di Genova, 16132 Genova, Italy
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
- Correspondence:
| | - Fiammetta Sertorio
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Luca Basso
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Andrea Fontana
- Postgraduation School in Radiodiagnostics, Università degli Studi di Milano, 20122 Milan, Italy;
| | - Monica Bodria
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
| | - Angela Pistorio
- Epidemiology and Biostatistics Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy;
| | - Gian Marco Ghiggeri
- Nephrology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy;
| | - Maria Beatrice Damasio
- Radiology Department, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini, 16147 Genova, Italy; (F.S.); (L.B.); (M.B.); (M.B.D.)
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Diffusion-Weighted MRI in the Evaluation of Renal Parenchymal Involvement during Febrile Urinary Tract Infections in Children: Preliminary Data. J Clin Med 2021. [DOI: 10.3390/jcm10112239
expr 943224684 + 995609622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Background: Urinary tract infection (UTI) is the most common infection in pediatric-age patients. Acute pyelonephritis (PNA) represents a worrying situation in pediatric patients due to the risk of sepsis and long-term cicatricial consequences. The purpose of this retrospective study is to evaluate the diagnostic role of DW-MRI in relation to clinical data, to understand if there are any clinical parameters useful in identifying which patients should undergo it. Methods: According to inclusion and exclusion criteria, we enrolled 51 patients ≤15 years old admitted to our Institute between September 2012 and April 2020 with a febrile UTI who underwent DW-MRI evaluation. Clinical, laboratory and imaging data were collected. Statistical analysis was performed. Results: 34 of 51 patients with an fUTI (66.7%) showed signs of acute parenchymal involvement at DW-MRI evaluation. In 27 of these 34 (79.4%), DW-MRI showed multiple areas of pyelonephritis. A statistically significant relationship (p = 0.0004) between older age at admission and pyelonephritis was demonstrated. No statistically significant relationship was found between the other clinical, anamnestic and laboratory parameters and the outcome of DWI. Only two ultrasound examinations allowed the identification of pathological areas on the renal parenchyma. Conclusions: From these preliminary investigations, we can say that selecting the patients with fUTI on whom to perform a DW-MRI is difficult. Nevertheless, thanks to the low cost, the very rare need for sedation and the accuracy in identifying pyelonephritic areas, the use of DW-MRI in patients with febrile UTI seems recommendable.
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Singh N, Zabbarova I, Ikeda Y, Maranchie J, Chermansky C, Foley L, Hitchens TK, Yoshimura N, Kanai A, Kaufman J, Tyagi P. Virtual measurements of paracellular permeability and chronic inflammation via color coded pixel-wise T 1 mapping. Am J Physiol Renal Physiol 2020; 319:F506-F514. [PMID: 32715761 DOI: 10.1152/ajprenal.00025.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
To assess whether quantitative T1 relaxometry can measure permeability, chronic inflammation and mural thickening of mouse bladder wall. Adult female C57BL6 mice unexposed to radiation (controls) or 40 wk postirradiation of 10 Gy were scanned at 9.4 T before and after instillation (0.1 mL) of aqueous, novel contrast mixture (NCM) containing 4 mM gadobutrol and 5 mM ferumoxytol. Rapid acquisition with refocused echo (RARE) sequence was used with variable repetition times (TR). Pixel-wise maps of T1 relaxation times for the segmented bladder wall layers were generated from voxel-wise, nonlinear least square data fitting of TR-dependent signal intensity acquired with TR array of 0.4-10 s followed by the histology of harvested bladder. Significant differences between precontrast and postcontrast T1 (ΔT1) were noted in urothelium and lamina propria of both groups but only in detrusor of irradiated group (P < 0.001; 2-way ANOVA). Nearly twofold higher gadobutrol permeability (550 ± 73 vs. 294 ± 160 μM; P < 0.01) derived as per 1/ΔT1 = r1. [C] in urothelium of irradiated group. Inflammation and bladder wall thickening (0.75 ± 0. vs. 0.44 ± 0.08 mm; P < 0.001) predicted by MRI was subsequently confirmed by histology and altered expression of CD45 and zonula occludens-1 (ZO-1) relative to controls. NCM enhanced MRI relies on the retention of large molecular weight ferumoxytol in lumen for negative contrast, while permeation of the non-ionic, small molecular weight gadobutrol through ZO-1 generates positive contrast in bladder wall for virtual measurement of paracellular permeability and assessment of chronic inflammation in thin and distensible bladder wall, which is also defined by its variable shape and location within pelvis.
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Affiliation(s)
- Nishant Singh
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Irina Zabbarova
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Youko Ikeda
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jodi Maranchie
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Lesley Foley
- Advanced Imaging Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - T Kevin Hitchens
- Advanced Imaging Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Naoki Yoshimura
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anthony Kanai
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Pradeep Tyagi
- Department of Urology, University of Pittsburgh, Pittsburgh, Pennsylvania
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Khoo KSM, Lim ZY, Chai CY, Mahadevan M, Kuan WS. Management of acute pyelonephritis in the emergency department observation unit. Singapore Med J 2020; 62:287-295. [PMID: 32147739 DOI: 10.11622/smedj.2020020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION This study aimed to assess the effectiveness of the emergency department observation unit (EDOU) for patients with acute pyelonephritis in a Singapore tertiary academic medical centre. METHODS We reviewed the clinical records of consecutive patients who presented with pyelonephritis between 1 July 2012 and 31 October 2014 to collect information on demographics, symptoms, signs, laboratory and radiological results, treatment, and clinical outcomes. RESULTS Of 459 emergency department (ED) patients who were identified as having pyelonephritis, 164 (35.7%) were managed in the EDOU. Successful management in the EDOU was achieved in 100 (61.0%) patients. Escherichia coli was the predominant (64.6%) micro-organism in urine cultures and was positive in 106 patients. Patients diagnosed with acute pyelonephritis who were successfully managed in the EDOU had a lower incidence of nausea (32.0% vs. 60.9%, p < 0.001) and vomiting (15.0% vs. 50.0%, p < 0.001) compared to those who were not successful. CONCLUSION EDOU is useful for both observation and treatment of patients with acute pyelonephritis. Urine cultures are sufficient for the identification of the culprit micro-organism. Patients who present with prominent symptoms of vomiting should have routine administration of antiemetics, while consideration for second-line antiemetics is recommended for those with persistent symptoms.
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Affiliation(s)
| | - Zhen Yu Lim
- Department of Medicine, National University Hospital, National University Health System, Singapore
| | - Chew Yian Chai
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Malcolm Mahadevan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Win Sen Kuan
- Emergency Medicine Department, National University Hospital, National University Health System, Singapore.,Department of Surgery, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Udare A, Abreu-Gomez J, Krishna S, McInnes M, Siegelman E, Schieda N. Imaging Manifestations of Acute and Chronic Renal Infection That Mimics Malignancy: How to Make the Diagnosis Using Computed Tomography and Magnetic Resonance Imaging. Can Assoc Radiol J 2019; 70:424-433. [PMID: 31537315 DOI: 10.1016/j.carj.2019.07.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To review the computed tomography and magnetic resonance imaging manifestations of acute and chronic renal infections that may mimic malignancy and to provide useful tips to establish an imaging diagnosis. CONCLUSION Acute and chronic bacterial pyelonephritis are usually readily diagnosed clinically and on imaging when the diagnosis is suspected based upon clinical presentation. When unsuspected, focal, extensive or mass-like, acute and chronic bacterial pyelonephritis may mimic infiltrative tumours such as urothelial cell carcinoma (UCC), lymphoma, and metastatic disease. Infection may be suspected when patients are young and otherwise healthy when there is marked associated perinephric changes and in the absence of metastatic adenopathy or disease elsewhere in the abdomen and pelvis. Renal abscesses, from bacterial or atypical microbial agents, can appear as complex cystic renal masses mimicking cystic renal cell carcinoma. Associated inflammatory changes in and around the kidney and local invasion favour infection. Emphysematous pyelonephritis can mimic necrotic or fistulizing tumour; however, infection is more likely and should always be considered first. Xanthogranulomatous pyelonephritis can mimic malignancy when focal or multifocal and in cases without associated renal calculi. Malacoplakia is an inflammatory process that may mimic malignancy and should be considered in patients with chronic infection. Bacillus Calmette-Guerin (BCG)-induced pyelonephritis is rare but can mimic renal malignancy and should be considered in patients presenting with a renal mass when being treated with BCG for urinary bladder UCC.
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Affiliation(s)
- Amar Udare
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jorge Abreu-Gomez
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Satheesh Krishna
- Joint Department of Medical Imaging, Toronto General Hospital, The University of Toronto, Toronto, Ontario, Canada
| | - Matthew McInnes
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Evan Siegelman
- Department of Radiology, The Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicola Schieda
- Department of Medical Imaging, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada.
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Tanizaki R, Ichikawa S, Takemura Y. Clinical impact of perinephric fat stranding detected on computed tomography in patients with acute pyelonephritis: a retrospective observational study. Eur J Clin Microbiol Infect Dis 2019; 38:2185-2192. [PMID: 31372906 DOI: 10.1007/s10096-019-03662-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Accepted: 07/24/2019] [Indexed: 11/26/2022]
Abstract
Perinephric fat stranding (PFS) is often detected on computed tomography (CT) in patients with acute pyelonephritis (APN). However, its clinical impact remains unclear. This study aimed to evaluate the clinical impact of PFS detected on CT in patients with APN. This retrospective observational study included patients with APN who underwent CT (median age, 79.5 years). Patients were classified into PFS (patients with PFS observed on CT) and non-PFS (patients without PFS observed on CT) groups, which were further classified into bacteraemia and non-bacteraemia groups. Clinical findings between the groups were compared. Among 194 patients who underwent CT, 111 (57.2%) patients demonstrated PFS. The rate of bacteraemia was significantly higher in the PFS group than in the non-PFS group (55.2 vs. 23.1%, p < 0.001). CT findings other than PFS were not associated with bacteraemia. The median peak body temperature was significantly higher in the PFS group than in the non-PFS group (38.8 vs. 38.5 °C, p < 0.001); however, the duration of fever and in-hospital mortality rates were not significantly different between the groups. Concordance between blood and urine culture results was observed in 75.0% of the patients; the presence of PFS was not different between patients with concordant and discordant results, regardless of the pre-treatment antibiotic used. Our findings suggest that the presence of PFS in patients with APN predicts bacteraemia; thus, clinicians should consider obtaining blood cultures if PFS is found on CT in patients with APN, even if the patients had received antibiotics prior to admission.
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Affiliation(s)
- Ryutaro Tanizaki
- Department of Community Medicine, Nabari, Mie University School of Medicine, Tsu, Mie, Japan.
- General Internal Medicine and Family Medicine, Nabari City Hospital, Nabari, Mie, Japan.
- Department of Internal Medicine, Ise Municipal General Hospital, Ise, Mie, Japan.
| | - Shuhei Ichikawa
- Department of Community Medicine, Nabari, Mie University School of Medicine, Tsu, Mie, Japan
| | - Yousuke Takemura
- Department of Family Medicine, Mie University School of Medicine and Graduate School of Medicine, Tsu, Mie, Japan
- Department of Family Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
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Jeon DH, Jang HN, Cho HS, Lee TW, Bae E, Chang SH, Park DJ. Incidence, risk factors, and clinical outcomes of acute kidney injury associated with acute pyelonephritis in patients attending a tertiary care referral center. Ren Fail 2019; 41:204-210. [PMID: 30942133 PMCID: PMC6450601 DOI: 10.1080/0886022x.2019.1591995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Acute kidney injury (AKI) associated with acute pyelonephritis (APN) rarely has been reported. The aim of this study was to evaluate the incidence and risk factors of AKI associated with APN. We retrospectively reviewed the medical records of 403 patients over 18-year old age hospitalized for APN management from October 2009 to September 2014 in tertiary care referral center. Demographic data, clinical symptoms and signs, and laboratory findings were gathered from the medical records and analyzed. The mean age of patients was 57 years and APN commonly occurred in female (87.6%). AKI occurred in 253 patients (62.8%). As per the RIFLE classification, renal injury was graded as ‘Risk’ (62.1%), ‘Injury’ (26.5%), and ‘Failure’ (11.4%). AKI patients were more likely a male gender and had complicated APN. The AKI group had a significantly higher tendency to present with shock. The prevalence of underlying chronic kidney disease (CKD) was significantly higher in the AKI group. There was no difference in mortality between the AKI and non-AKI groups. Multivariate analysis revealed that age over 65 (OR 1.93, 95% CI 1.18–3.13, p= .008), complicated (OR 2.13, 95% CI 1.35–3.34, p= .001) and bilateral APN (OR 1.71, 95% CI 1.01–2.88, p= .045), and initial shock (OR 2.44, 95% CI 1.05–5.71, p= .039) were independent risk factors for the occurrence of AKI in patients with APN. Physicians should attempt to prevent, detect, and manage AKI associated with APN in patients with above conditions.
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Affiliation(s)
- Dae-Hong Jeon
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , Republic of Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , Republic of Korea
| | - Ha Nee Jang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Hyun Seop Cho
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , Republic of Korea
| | - Tae Won Lee
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , Republic of Korea
| | - Eunjin Bae
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , Republic of Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , Republic of Korea
| | - Se-Ho Chang
- a Department of Internal Medicine , Gyeongsang National University Hospital , Jinju , Republic of Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , Republic of Korea.,d Institute of Health Science, Gyeongsang National University , Jinju , Republic of Korea
| | - Dong Jun Park
- b Department of Internal Medicine , Changwon Gyeongsang National University Hospital , Changwon , Republic of Korea.,c Department of Internal Medicine, College of Medicine , Gyeongsang National University , Jinju , Republic of Korea.,d Institute of Health Science, Gyeongsang National University , Jinju , Republic of Korea
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Guvvala SL, Sakam S, Stokes MB, Uday K. Bilateral acute non-obstructive pyelonephritis presenting as acute kidney injury requiring haemodialysis. BMJ Case Rep 2019; 12:12/2/e227996. [PMID: 30796082 DOI: 10.1136/bcr-2018-227996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A 54-year-old female patient with hypothyroidism and diabetes mellitus type 2 was brought to emergency room by the family members for acute change in mental status. The laboratory evaluation demonstrated findings consistent with acute renal failure (normal renal function 3 months prior to presentation). She was initiated on hemodialysis due to lack of improvement in renal function. Urine culture done prior to initiation of antibiotics was positive for Escherichia coli, which was later confirmed by renal biopsy. Extensive workup for the cause of renal failure including for connective tissue disease, plasmacytoma, obstruction was negative. She was treated with 6 week course of antibiotics with eventual recovery of her renal function in 4 months.
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Affiliation(s)
- Suvarna L Guvvala
- Department of Internal Medicine, Paul L Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Sailaja Sakam
- Department of Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, New York, USA
| | - Michael B Stokes
- Department of Pathology, Columbia University Medical Center, New York, New York, USA
| | - Kalpana Uday
- Division of Nephrology, Department of Internal Medicine, Bronx-Lebanon Hospital Center, Bronx, New York, USA
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12
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Umesha L, Shivaprasad SM, Rajiv EN, Kumar MMS, Leelavathy V, Sreedhara CG, Niranjan MR. Acute Pyelonephritis: A Single-center Experience. Indian J Nephrol 2018; 28:454-461. [PMID: 30647500 PMCID: PMC6309380 DOI: 10.4103/ijn.ijn_219_16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Acute pyelonephritis (APN), although a common clinical entity, still not much is known about the clinical profile in the Indian scenario. We prospectively collected clinical, biochemical, and radiological data of patients hospitalized with a diagnosis of APN from March 2014 to June 2016. A total of 296 cases were included in the study. Mean age was 53.85 ± 9.78 years. Male to females ratio was 1.93:1. Among the risk factors recognized for complicated pyelonephritis (PN), diabetes mellitus (DM) (54.4%) was the most common factor followed by renal calculi (14.4%), benign prostatic hyperplasia (6.7%), immunocompromised state (3.3%), stricture urethra and meatal stenosis (3.3%), and neurogenic bladder (2%). Urinary culture was negative in 153 (51.7%) and positive in 143 patient (48.3%). Most common organism isolated was Escherichia coli (29.7%), followed by Klebsiella pneumoniae (5.4%), pseudomonas (5.4%), Enterococcus (4.4%), and Proteus in 10 (3.4%). Serum creatinine of more than 1.5 mg/dl at admission was seen in 96.3% patients; 40% of them had underlying chronic kidney disease with DM being the most common. Multiorgan dysfunction either at admission or during the course in hospital stay was seen in 31.8% patients. Twelve (2%) had emphysematous PN. Six patients had Class II, 4 had Class III, 1 with Class I, and another with Class IV. A total of 18 deaths were noted (6.1%). Hemoglobin <10 g/dl, serum creatinine at admission >1.5 mg/dl, HbA1c% >10%, and immunosuppression had statistically significant association with the development of multiorgan dysfunction on univariate analysis, but on multivariate analysis, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance. Even with attributable risk of mortality, only hemoglobin, HbA1c%, and immunosuppression reached statistical significance on multivariate analysis. HbA1c% adds to the predictive parameters to recognize at-risk patients to intensify the treatment and avoid complications.
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Affiliation(s)
- L Umesha
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - S M Shivaprasad
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - E N Rajiv
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - M M Satish Kumar
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - V Leelavathy
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - C G Sreedhara
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
| | - M R Niranjan
- Department of Nephrology, Institute of Nephro Urology, Victoria Hospital Campus, Bengaluru, Karnataka, India
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Cruz J, Figueiredo F, Matos AP, Duarte S, Guerra A, Ramalho M. Infectious and Inflammatory Diseases of the Urinary Tract: Role of MR Imaging. Magn Reson Imaging Clin N Am 2018; 27:59-75. [PMID: 30466913 DOI: 10.1016/j.mric.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Urinary tract infection (UTI) is among the most common of bacterial infections. Imaging studies are only required in cases of complicated UTIs. Ultrasound remains the first-line imaging method; however, CT is the gold standard for evaluation of UTIs. MR imaging's improved contrast resolution and absence of ionizing radiation may recommend its use for assessment of lower UTIs. Furthermore, MR imaging performs with diagnostic accuracy at least similar to CT in complicated UTIs, except for the identification of calculi and emphysematous pyelonephritis. In this article, the role of MR imaging for the evaluation of infectious and inflammatory disease processes of the urinary tract is reviewed.
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Affiliation(s)
- João Cruz
- Department of Radiology, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267 Almada, Portugal; Department of Radiology, Hospital da Luz, Estrada Nacional 10, km 37, Setúbal 2900-722, Portugal
| | - Filipa Figueiredo
- Department of Radiology, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267 Almada, Portugal
| | - António P Matos
- Department of Radiology, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267 Almada, Portugal
| | - Sérgio Duarte
- Department of Radiology, Hospital da Luz, Estrada Nacional 10, km 37, Setúbal 2900-722, Portugal
| | - Adalgisa Guerra
- Department of Radiology, Hospital da Luz, Avenida Lusíada, 100, Lisbon 1500-650, Portugal
| | - Miguel Ramalho
- Department of Radiology, Hospital Garcia de Orta, Av. Torrado da Silva, 2805-267 Almada, Portugal; Department of Radiology, Hospital da Luz, Estrada Nacional 10, km 37, Setúbal 2900-722, Portugal.
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14
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Attini R, Kooij I, Montersino B, Fassio F, Gerbino M, Biolcati M, Versino E, Todros T, Piccoli GB. Reflux nephropathy and the risk of preeclampsia and of other adverse pregnancy-related outcomes: a systematic review and meta-analysis of case series and reports in the new millennium. J Nephrol 2018; 31:833-846. [PMID: 30066252 DOI: 10.1007/s40620-018-0515-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/12/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Reflux nephropathy is a common urinary tract malformation, and a substantial cause of morbidity in women of childbearing age. While recent studies provide further new information on pregnancy-related outcomes, their results are heterogeneous and a systematic meta-analysis may help the interpretation. The aim of this review was to analyze pregnancy-related outcomes in the recent literature on reflux nephropathy (2000-2016), to perfect the estimation of risks, and to identify specific research needs. METHODS We searched Medline, EMBASE and the Cochrane review databases for the period 2000-2016 (PROSPERO registration no. 42016042713). SELECTION CRITERIA all case series and case reports dealing with reflux nephropathy and reporting on at least one pregnancy outcome. Data were extracted from eligible case series (≥ 6 cases). For the outcomes preeclampsia (PE), pregnancy-induced hypertension (PIH), preterm birth, and newborns small for gestational age, we employed as a control group the low-risk pregnancies from a multicenter database including 1418 live-born singletons. Case reports were analyzed narratively. RESULTS The search retrieved 2507 papers, of which 7 case series and 4 case reports were retained. The series report on 434 women with 879 pregnancies; no study reported controls. Compared to the low-risk controls, the meta-analysis showed an increased risk of PIH (odds ratio, OR 5.55; confidence interval, CI 3.56-8.66), PE (OR 6.04; CI 2.41-15.13), and all hypertensive disorders combined (OR 10.43; CI 6.90-15.75). No difference was observed in preterm delivery and caesarean sections. A higher incidence of stillbirth was reported in one paper. Conversely, the 4 case reports (on 10 pregnancies) alert us to a potentially severe complication, hydro(uretero)nephrosis with or without infection. CONCLUSION Reflux nephropathy is associated with an increased risk of PIH and PE, but not of preterm delivery, suggesting the occurrence of late 'maternal' PE. The finding of a higher incidence of stillbirths in one series requires further analysis. Strict follow-up of these women is needed, in particular in late pregnancy stages, to avoid and manage in particular hypertensive pregnancy complications.
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Affiliation(s)
- Rossella Attini
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Isabelle Kooij
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
- Nephrologie, Centre Hospitalier Le Mans, 194 Avenue Roubillard, 72000, Le Mans, France
| | - Benedetta Montersino
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Federica Fassio
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Martina Gerbino
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Marilisa Biolcati
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Elisabetta Versino
- Epidemiologia, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Turin, Italy
| | - Tullia Todros
- Unità Materno-Fetale, Dipartimento di Chirurgia, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Turin, Italy.
- Nephrologie, Centre Hospitalier Le Mans, 194 Avenue Roubillard, 72000, Le Mans, France.
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15
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Cabiddu G, Spotti D, Gernone G, Santoro D, Moroni G, Gregorini G, Giacchino F, Attini R, Limardo M, Gammaro L, Todros T, Piccoli GB. A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology. J Nephrol 2018; 31:665-681. [PMID: 29949013 PMCID: PMC6182355 DOI: 10.1007/s40620-018-0499-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/30/2018] [Indexed: 12/15/2022]
Abstract
Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes “normal” or “good” kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1–2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage “non-ideal” situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial “third element”.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica Limardo
- Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | | | - Tullia Todros
- Department of Surgery, Università di Torino, Turin, Italy
| | - Giorgina Barbara Piccoli
- Department of Clinical and Biological Sciences, Università di Torino, Turin, Italy. .,Centre Hospitalier Le Mans, Le Mans, France.
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16
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Guet-Revillet H, Tomini E, Emirian A, Join-Lambert O, Lécuyer H, Zahar JR, Jullien V. Piperacillin/tazobactam as an alternative antibiotic therapy to carbapenems in the treatment of urinary tract infections due to extended-spectrum β-lactamase-producing Enterobacteriaceae: an in silico pharmacokinetic study. Int J Antimicrob Agents 2017; 49:62-66. [DOI: 10.1016/j.ijantimicag.2016.09.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 09/09/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022]
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17
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Cabiddu G, Castellino S, Gernone G, Santoro D, Moroni G, Giannattasio M, Gregorini G, Giacchino F, Attini R, Loi V, Limardo M, Gammaro L, Todros T, Piccoli GB. A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy. J Nephrol 2016; 29:277-303. [PMID: 26988973 PMCID: PMC5487839 DOI: 10.1007/s40620-016-0285-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 02/08/2016] [Indexed: 01/09/2023]
Abstract
Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.
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Affiliation(s)
| | | | | | | | - Gabriella Moroni
- Nephrology, Fondazione Ca' Granda Ospedale Maggiore, Milano, Italy
| | | | | | | | - Rossella Attini
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Valentina Loi
- Nephrology, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | - Monica Limardo
- Nephrology, Azienda Ospedaliera della Provincia di Lecco, Lecco, Italy
| | - Linda Gammaro
- Nephrology, Ospedale Fracastoro, San Bonifacio, Italy
| | - Tullia Todros
- Obstetrics, Department of Surgery, University of Torino, Torino, Italy
| | - Giorgina Barbara Piccoli
- Nephrology, ASOU San Luigi, Department of Clinical and Biological Sciences, University of Torino, Torino, Italy.
- Nephrologie, Centre Hospitalier du Mans, Le Mans, France.
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Narchi H, Marah M, Khan AA, Al-Amri A, Al-Shibli A. Renal tract abnormalities missed in a historical cohort of young children with UTI if the NICE and AAP imaging guidelines were applied. J Pediatr Urol 2015; 11:252.e1-7. [PMID: 25979215 DOI: 10.1016/j.jpurol.2015.03.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 03/09/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE In a historical cohort of children with a urinary tract infection (UTI) who had already undergone all the imaging procedures, the aim was to determine renal tract abnormalities which would have been missed had we implemented the new guidelines from the National Institute for Health and Care Excellence in the United Kingdom (NICE) or the American Academy of Pediatrics (AAP). MATERIAL AND METHODS After a UTI episode, forty-three children (28 females, 65%) aged between 2 months and 2 years presenting at two general hospitals with a febrile UTI before 2008 underwent all the recommended imaging studies predating the new guidelines. Hydronephrosis was defined and graded according to the Society for Fetal Urology (SFU) classification. Hydronephrosis grade II (mild pelvicalyceal dilatation), grade III (moderate dilatation), and grade IV (gross dilatation with thinning of the renal cortex), duplication, vesicoureteral reflux (VUR) grade II and above, renal scarring and reduced renal uptake (<45%) on technetium-99m-labeled dimercaptosuccinic acid (DMSA) scintigraphy were considered significant abnormalities. We calculated the proportion of abnormalities which would have been missed had the new guidelines been used instead. RESULTS The median of age was 7.6 months (mean 8.7, range 2-24 months), with the majority (n = 37, 86%) being under 1 year of age. Ultrasound (US) showed hydronephrosis in 14 (32%), all grade II. A voiding cystourethrogram (VCUG) was performed in all and showed VUR ≥ grade II in 16 (37%), including eight children (19%) where it was bilateral. DMSA scan showed scarring in 25 children (58%) of whom 11 (26%) had bilateral scars. Reduced differential renal uptake was present in 10 children (23%). Of the 29 children with normal US, 18 (62%) had renal scarring and nine (31%) had VUR ≥ grade II. The NICE guidelines would have missed 63% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, 44% of the children with renal scarring, and 20% of the children with decreased renal uptake, including some children with bilateral renal scarring and with decreased renal uptake. The AAP guidelines would have missed 56% of the children with VUR ≥ grade II, including a high proportion of grades IV and V VUR, and all children with renal scarring as well as those with decreased renal uptake. CONCLUSION The prevalence of renal tract abnormalities missed by the new guidelines is high. They should be used with full awareness of their limitations.
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Affiliation(s)
- Hassib Narchi
- Department of Pediatrics, College of Medicine & Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates.
| | - Muhaned Marah
- Department of Pediatrics, Al Ain Hospital, Al Ain, United Arab Emirates
| | - Asad Aziz Khan
- Department of Pediatrics, Al Ain Hospital, Al Ain, United Arab Emirates
| | - Abdulla Al-Amri
- Department of Pediatrics, Tawam Hospital, Al Ain, United Arab Emirates
| | - Amar Al-Shibli
- Department of Pediatrics, Tawam Hospital, Al Ain, United Arab Emirates
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Piccoli GB, Grassi G, Cabiddu G, Nazha M, Roggero S, Capizzi I, De Pascale A, Priola AM, Di Vico C, Maxia S, Loi V, Asunis AM, Pani A, Veltri A. Diabetic Kidney Disease: A Syndrome Rather Than a Single Disease. Rev Diabet Stud 2015; 12:87-109. [PMID: 26676663 PMCID: PMC5397985 DOI: 10.1900/rds.2015.12.87] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 04/15/2015] [Accepted: 04/22/2015] [Indexed: 12/13/2022] Open
Abstract
The term "diabetic kidney" has recently been proposed to encompass the various lesions, involving all kidney structures that characterize protean kidney damage in patients with diabetes. While glomerular diseases may follow the stepwise progression that was described several decades ago, the tenet that proteinuria identifies diabetic nephropathy is disputed today and should be limited to glomerular lesions. Improvements in glycemic control may have contributed to a decrease in the prevalence of glomerular lesions, initially described as hallmarks of diabetic nephropathy, and revealed other types of renal damage, mainly related to vasculature and interstitium, and these types usually present with little or no proteinuria. Whilst glomerular damage is the hallmark of microvascular lesions, ischemic nephropathies, renal infarction, and cholesterol emboli syndrome are the result of macrovascular involvement, and the presence of underlying renal damage sets the stage for acute infections and drug-induced kidney injuries. Impairment of the phagocytic response can cause severe and unusual forms of acute and chronic pyelonephritis. It is thus concluded that screening for albuminuria, which is useful for detecting "glomerular diabetic nephropathy", does not identify all potential nephropathies in diabetes patients. As diabetes is a risk factor for all forms of kidney disease, diagnosis in diabetic patients should include the same combination of biochemical, clinical, and imaging tests as employed in non-diabetic subjects, but with the specific consideration that chronic kidney disease (CKD) may develop more rapidly and severely in diabetic patients.
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Affiliation(s)
- Giorgina B. Piccoli
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Giorgio Grassi
- SCDU Endocrinologia, Diabetologia e Metabolismo, Citta della Salute e della Scienza Torino, Italy
| | | | - Marta Nazha
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Simona Roggero
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Irene Capizzi
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | - Agostino De Pascale
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
| | - Adriano M. Priola
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
| | - Cristina Di Vico
- SS Nefrologia, SCDU Urologia, San Luigi Gonzaga Hospital, Department of Clinical and Biological Sciences, University of Torino, Italy
| | | | | | - Anna M. Asunis
- SCD Anatomia Patologica, Brotzu Hospital, Cagliari, Italy
| | | | - Andrea Veltri
- SCDU Radiologia, san Luigi Gonzaga Hospital, Department of Oncology, University of Torino, Italy
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20
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Sim JH, Yim HE, Choi BM, Lee JH, Yoo KH. Plasma neutrophil gelatinase-associated lipocalin predicts acute pyelonephritis in children with urinary tract infections. Pediatr Res 2015; 78:48-55. [PMID: 25790277 DOI: 10.1038/pr.2015.59] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/22/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND The identification of acute pyelonephritis (APN) is still a challenge. METHODS Patients admitted for their first urinary tract infection (UTI) were enrolled. Plasma neutrophil gelatinase-associated lipocalin (NGAL) levels were measured at admittance and after treatment. Laboratory, clinical, and imaging results were compared between children with and without APN. RESULTS A total of 123 patients were enrolled (53 APN and 70 lower UTI). After adjusting for age and gender, plasma NGAL levels were higher in the APN group than in the lower UTI group (233 (129-496) ng/ml vs. 71 (50.8-110) ng/ml, P < 0.001). NGAL levels were correlated with the serum levels of leukocytes, C-reactive protein, and creatinine, as well as fever duration (P < 0.05). Multivariable analysis revealed that log-transformed plasma NGAL was an independent predictor of APN (P < 0.05). Receiver operating curve analysis showed a good diagnostic profile of NGAL for identifying APN (area under the curve 0.864) with a best cut-off value of 102.5 ng/ml. The NGAL levels in both two groups decreased after treatment compared to levels before treatment (P < 0.001). CONCLUSION Plasma NGAL can be a sensitive predictor for identifying APN and monitoring the treatment response of pediatric UTI.
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Affiliation(s)
- Ji Hyun Sim
- Department of Pediatrics, College of Medicine, Korea University, Seoul, South Korea
| | - Hyung Eun Yim
- Department of Pediatrics, College of Medicine, Korea University, Seoul, South Korea
| | - Byung Min Choi
- Department of Pediatrics, College of Medicine, Korea University, Seoul, South Korea
| | - Jee Hyun Lee
- Department of Pediatrics, College of Medicine, Korea University, Seoul, South Korea
| | - Kee Hwan Yoo
- Department of Pediatrics, College of Medicine, Korea University, Seoul, South Korea
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21
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Hsiao PJ, Lin CC, Chen YL, Chan JS. Massive Inguinoscrotal Hernia Associated with Acute Renal Failure Complicated Acute Pyelonephritis. JOURNAL OF MEDICAL SCIENCES 2015. [DOI: 10.4103/1011-4564.173007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Kumar S, Ramachandran R, Mete U, Mittal T, Dutta P, Kumar V, Rathi M, Jha V, Gupta KL, Sakhuja V, Kohli HS. Acute pyelonephritis in diabetes mellitus: Single center experience. Indian J Nephrol 2014; 24:367-71. [PMID: 25484530 PMCID: PMC4244716 DOI: 10.4103/0971-4065.135347] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Diabetes mellitus is a common cause of pyelonephritis. Both emphysematous pyelonephritis (EPN) and non-EPN (NEPN) are associated with poor outcome. This study was aimed at analyzing the clinical features, microbiological profile, prognostic factors, and treatment outcome of pyelonephritis in diabetic patients. A total of 105 diabetic patients with pyelonephritis were admitted from July 2010 to June 2012. Patients were treated with appropriate antibiotics and percutaneous drainage (PCD) as indicated. Nephrectomy was carried out in patients of EPN who were refractory to conservative measures. NEPN and EPN were seen in 79 (75.2%) and 26 (24.7%) patients, respectively. Escherichia coli was the most common organism. Pyelonephritis was associated with renal abscess and papillary necrosis in 13 (12.4%) and 4 (3.8%) patients with EPN and NEPN, respectively. Worsening of renal functions were seen in 92 and 93% of patients with EPN and NEPN, respectively. Class 1 EPN was seen in 2 (7.7%), Class II in 8 (30.7%), IIIa in 7 (27%), IIIb in 5 (19.3), and IV in 4 (15.4%) patients. Antibiotics alone were sufficient in 38.5% of EPN versus 62% in NEPN; additional PCD was required in 42.3% in EPN and 21.4% in NEPN. Nephrectomy was required in 5 (19.2%) EPN patients with Class IIIB or IV. A total of 13 patients (12.4%) expired, 4 (15.4%) in EPN, and 9 (11.4%) in NEPN group. Patients with EPN had a higher incidence of shock (6% vs. 0; P < 0.05) and poorly controlled blood sugar (26% vs. 50%; P < 0.05) compared with NEPN. Presence of shock and altered sensorium were associated with poor outcome in patients with EPN. Diabetics with pyelonephritis have severe disease. Patients of EPN have poorer treatment outcome compared with those with NEPN. However, there is no difference in the mortality, but a greater need of nephrectomy in EPN compared with NEPN patients. Presence of shock and altered sensorium at presentation were poor prognostic factors in EPN.
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Affiliation(s)
- S Kumar
- Department of Nephrology, PGIMER, Chandigarh, India
| | | | - U Mete
- Department of Urology, PGIMER, Chandigarh, India
| | - T Mittal
- Department of Nephrology, PGIMER, Chandigarh, India
| | - P Dutta
- Department of Endocrinology, PGIMER, Chandigarh, India
| | - V Kumar
- Department of Nephrology, PGIMER, Chandigarh, India
| | - M Rathi
- Department of Nephrology, PGIMER, Chandigarh, India
| | - V Jha
- Department of Nephrology, PGIMER, Chandigarh, India
| | - K L Gupta
- Department of Nephrology, PGIMER, Chandigarh, India
| | - V Sakhuja
- Department of Nephrology, PGIMER, Chandigarh, India
| | - H S Kohli
- Department of Nephrology, PGIMER, Chandigarh, India
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Piccoli GB, Priola AM, Vigotti FN, Guzzo G, Veltri A. Renal infarction versus pyelonephritis in a woman presenting with fever and flank pain. Am J Kidney Dis 2014; 64:311-4. [PMID: 24767880 DOI: 10.1053/j.ajkd.2014.02.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 02/07/2014] [Indexed: 11/11/2022]
Abstract
Patients with fever, flank pain, and dysuria frequently are encountered in the emergency department. Acute pyelonephritis is the most likely diagnosis; however, its clinical and radiologic presentation consistently overlap with that of acute renal infarction. Ultrasound is unable to distinguish early infarction from nonabscessed acute pyelonephritis. Hence, computed tomography or magnetic resonance imaging are needed. We report the case of a 68-year-old woman who presented with fever, flank pain, and dysuria, along with respiratory distress and tachycardia. Elevated values for inflammatory indexes suggested a diagnosis of acute pyelonephritis, and subsequent contrast-enhanced computed tomography showed hypodense wedge-shaped areas in both kidneys. However, the presence of a thin rim of capsular enhancement (cortical rim sign), the absence of perirenal inflammatory changes, and the location of the lesions apart from defined calyces suggested the alternative diagnosis of renal infarction. The underlying cause was not identified until an episode of acute dyspnea revealed paroxysmal arrhythmia. Our case demonstrates that a thorough knowledge of the imaging findings of renal infarction and acute pyelonephritis is essential to correctly making the diagnosis.
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Affiliation(s)
- Giorgina B Piccoli
- SS Nefrologia, Department of Medical and Biological Sciences, ASOU san Luigi Gonzaga, University of Turin, Turin, Italy.
| | - Adriano M Priola
- SCDU Radiologia, Department of Oncology, ASOU san Luigi Gonzaga, University of Turin, Turin, Italy
| | - Federica N Vigotti
- SS Nefrologia, Department of Medical and Biological Sciences, ASOU san Luigi Gonzaga, University of Turin, Turin, Italy
| | - Gabriella Guzzo
- SS Nefrologia, Department of Medical and Biological Sciences, ASOU san Luigi Gonzaga, University of Turin, Turin, Italy
| | - Andrea Veltri
- SCDU Radiologia, Department of Oncology, ASOU san Luigi Gonzaga, University of Turin, Turin, Italy
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24
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Lee YJ, Cho S, Kim SR. Unilateral and bilateral acute pyelonephritis: differences in clinical presentation, progress and outcome. Postgrad Med J 2013; 90:80-5. [DOI: 10.1136/postgradmedj-2013-131935] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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25
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Diffusion–Weighted Imaging and Apparent Diffusion Coefficient Values Versus Contrast–Enhanced MR Imaging in the Identification and Characterisation of Acute Pyelonephritis. Eur Radiol 2013; 23:3501-8. [DOI: 10.1007/s00330-013-2951-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Revised: 05/27/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
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26
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De Pascale A, Piccoli GB, Priola SM, Rognone D, Consiglio V, Garetto I, Rizzo L, Veltri A. Diffusion-weighted magnetic resonance imaging: new perspectives in the diagnostic pathway of non-complicated acute pyelonephritis. Eur Radiol 2013; 23:3077-86. [DOI: 10.1007/s00330-013-2906-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 04/22/2013] [Accepted: 05/02/2013] [Indexed: 12/01/2022]
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27
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Kwon S, Jin S, Choi W, Kim S. Analysis of Kidney Computed Tomographic Findings in Patients with Acute Pyelonephritis and Septic Shock. Korean J Crit Care Med 2013. [DOI: 10.4266/kjccm.2013.28.4.272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Soonseong Kwon
- Department of Emergency Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sangchan Jin
- Department of Emergency Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Wooik Choi
- Department of Emergency Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
| | - Sungjin Kim
- Department of Emergency Medicine, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Korea
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28
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Piccoli GB, Ferraresi M, Aroasio E, Gonella S, De Pascale A, Veltri A. The search for perfect biomarkers in acute kidney damage: the case of NGAL, from AKI to acute pyelonephritis: back to the clinic? Nephrol Dial Transplant 2012; 27:3665-6. [DOI: 10.1093/ndt/gfs331] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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