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Acute pyelonephritis in adults. Should we adopt the pediatric guidelines?
Binyamin B Neeman1, Ilan Kafka1, Ariel Mamber1
1Department of Urology & Pediatric Urology, Shaare Zedek Medical Center, Faculty of Medical Science, Hebrew University, Jerusalem, Israel.
Insights
Vesicoureteral reflux (VUR) is common in adults after their first pyelonephritis episode. Investigation for VUR is recommended, especially with kidney damage indicators, to guide treatment decisions.
Area of Science:
- Urology
- Nephrology
- Diagnostic Imaging
Background:
- Guidelines are lacking for cystography in adults with a first-time pyelonephritis episode.
- Vesicoureteral reflux (VUR) is a known condition, but its incidence and management in adults post-pyelonephritis require further clarification.
Purpose of the Study:
- To determine the incidence of VUR in adult patients hospitalized for their first episode of pyelonephritis.
- To provide recommendations for VUR investigation in this patient population.
Main Methods:
- A retrospective review of adult patients diagnosed with acute pyelonephritis between 2006 and 2022.
- Patients without prior urological history were advised to undergo Voiding Cystourethrography (VCUG) or Contrast Enhanced Voiding Urosonography (CEVUS) post-discharge.
Main Results:
- 76 adult patients (mean age 31.73 years) were identified; 63% had right-sided pyelonephritis.
- VUR was detected in 14 (60%) of the 23 patients who completed VCUG/CEVUS.
- Reflux grades ranged from I to IV, with significant renal function impairment noted in affected kidneys.
Conclusions:
- Adults experiencing a first episode of pyelonephritis exhibit a high incidence of VUR.
- VUR investigation should be considered in these patients, particularly if signs of nephronia, abscess, scarring, atrophy, or hydronephrosis are present.
Purpose:
There are no guidelines, what recommend pro or against cystography for identification of VUR for adults who suffer from first episode of pyelonephritis. The aim of this study was to look at incidence of VUR in adults with first episode of pyelonephritis, and to highlight recommendations for possible reflux investigation in these patients.
Methods:
We have performed retrospective review of all patients who admitted at our department over the last decade with the working diagnosis of acute pyelonephritis. Following discharge from the department, individuals with no pre-existing urological history were advised to undergo a VCUG or CEVUS.
Results:
We have identified 76 patients (62 females and 14 males) with an average age of 31.73 years who were hospitalized in our departments between 2006 and 2022. Forty-eight (63%) presented with right pyelonephritis, 26(34%) with left, and 2(3%) had bilateral disease. Of those, 23(30%) patients returned for clinical follow-up after completion of VCUG/CEVUS. Reflux was demonstrated in 14(60%) patients comprising 18 renal refluxing units (RRU). Six had grade IV reflux, 4 grade III, 4 grade II, and 4 grade I respectively. DMSA demonstrated 27.2 ± 11.9% relative function of the reflux kidney. Of those VUR patients, 9(64%) underwent endoscopic correction, 1(7%) refused surgery, and 4(29%) are under clinical follow-up.
Conclusions:
Our data demonstrate high incidence of VUR in adult patients with acute pyelonephritis patients, therefore VUR investigation at least should be considered in adult patients even after first episode of pyelonephritis, especially in cases where there is evidence of nephronia, abscess, kidney scars, atrophic kidney, or hydronephrosis.
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