Acute pyelonephritis remains common and continues to have significant morbidity in certain groups of

patients.

Epidemiology
The incidence of acute pyelonephritis parallels that of lower urinary tract infections: approximately five
times more common in females with a sharp increase following puberty 6.

Clinical presentation
Clinical presentation is fairly specific and classical in most cases, consisting of rapid onset of high fevers
and flank pain and tenderness. In many instances less specific or non-urinary symptoms and signs may
also be present which may lead to clinical confusion 1.
White cells and bacteria are usually present in the urine, and blood tests reveal the expected changes:
increased WCC (WBC), CRP and/or ESR. In severe cases, sepsis may be present.

Pathology
The most commonly implicated organisms are from the gastrointestinal tract 5:

E. coli (most common)

Klebsiella spp.

Proteus spp.

Enterobacter spp.

Pseudomonas spp.

Haemophilus influenzae

Infection gains access to the upper urinary tract by passing retrograde up the ureter from the bladder,
facilitated by virulence factors which allow bacteria to adhere to the urothelium (e.g. adhesin P) and inhibit
ureteric peristalsis (endotoxins) 1,5. The infection then passes into the collecting tubules and results in an
interstitial nephritis, with resulting alterations in renal filtration and blood flow in the affected region.
Localised ischaemia secondary to inflammatory changes results in altered imaging and may eventually
lead to necrosis and scar 2.
Rarely, the kidney may be seeded haematogeneously, in which case renal abscesses develop rather than
pyelonephritis. These abscesses usually develop peripherally.

Radiographic features
In many instances, imaging is not required. Situations in which imaging is indicated include:

exclude obstructed kidney

high-risk patients: diabetics, elderly, immunocompromised

those with a mixed clinical picture

previous renal pathology

Abdominal radiograph / KUB

Radiography has a limited role to play, especially if patients are likely to go on to CT. Radiographs may
demonstrate obstructing urinary tract calculi and occasionally demonstrate gas within the collecting system
(emphysematous pyelonephritis).

Ultrasound
Ultrasound is insensitive to the changes of acute pyelonephritis, with most patients having 'normal' scans.
Abnormalities are identified in only ~25% of cases 1. Possible features include:

particulate matter/debris in the collecting system

reduced areas of cortical vascularity by using power Doppler

gas bubbles (emphysematous pyelonephritis)

abnormal echogenicity of the renal parenchyma

o

focal/segmental hypoechoic regions

mass like change

Ultrasound is, however, useful in assessing for local complications such as hydronephrosis, renal
abscess formation, renal infarction, perinephric collections, and thus may guide management.

CT
CT is a sensitive modality for evaluation of the renal tract, able to assess for renal calculi, gas, perfusion
defects, collections and obstruction. Unfortunately, it does have a significant radiation burden and should
be used sparingly, especially in young patients.
There is usually no need for a three or four phase CT IVP (CT urography). A single 45-90 second postcontrast scan usually suffices, although clinical acumen may be necessary to choose the best contrast
phase 1,3. For example, if renal colic is suspected then a non-contrast scan is often required to assess for
renal calculi. If renal ischaemia is suspected than an arterial scan (15-25 seconds) is ideal to assess
perfusion 3.

Non-contrast CT

often the kidneys appear normal

affected parts of the kidney may appear swollen and of lower attenuation

renal calculi or gas within the collecting system may be evident

Postcontrast CT

one or more focal wedge-like regions will appear swollen and demonstrate reduced enhancement
compared with the normal portions of the kidney

the periphery of the cortex is also affected, helpful in distinguishing so-called acute pyelonephritis
from a renal infarct (which tends to spare the periphery, the so-called 'rim sign')

if imaged during the excretory phase, a striated nephrogram may also be visible 3-4.

If for some reason the kidney is imaged again within 3-6 hours, persistent enhancement of the affected
regions may be evident due to slow flow of contrast through involved tubules 1,3.

MRI
MRI is usually reserved for patients who are pregnant, and findings mirror those seen on CT. The kidney
demonstrates wedge-shaped regions of altered signal:

T1: affected region(s) appear hypointense compared with the normal kidney parenchyma

T2: hyperintense compared to normal kidney parenchyma

T1 C+: reduced enhancement

A fast inversion recovery sequence obtained after contrast administration has been shown to be particularly
effective in outlining affected regions which appear hyperintense compared to the low signal parenchyma.

The contrast is thought to represent a combination of local oedema and decreased T2 signal due to
gadolinium in the perfused 'normal' portions 2.

Nuclear medicine
Technetium-99m dimercaptosuccinic acid (DMSA) demonstrates a similar reduction in renal perfusion and
function, which one or more patchy scintigraphy defects in the outline of the kidneys 2.

Treatment and prognosis

Most patients respond rapidly to appropriate antibiotic therapy, and often no imaging whatsoever is
required.
Even when imaging has been obtained, unless patients do not respond clinically, no follow-up imaging is
usually required, and it is important to note that imaging changes can take up to five months to resolve 1.
The presence of an upper urinary tract infection in the presence of obstruction can threaten the viability of
the kidney and a percutaneous nephrostomy is usually required on an emergency basis.

Complications
Complications include 2:

renal abscess

renal infarction, necrosis and scarring

chronic renal impairment

hypertension

Differential diagnosis
General imaging differential considerations include:

renal infarction
o

typically spares the peripheral aspect of the cortex, e.g. cortical rim sign
other causes of interstitial nephritis

sarcoidosis

drug-induced
renal lymphoma (has multiple presentations and can mimic pyelonephritis)

Practical points

CT is the most sensitive modality for diagnosis and assessment of complications

CT portal venous phase demonstrating areas of reduced enhancement compared with the normal
portions of the kidney is the key for diagnosis
striated nephrogram on CT excretory phase
evidence of obstruction in the setting of pyelonephritis/sepsis characterises an urgency
requiring percutaneous nephrostomy