Pyelonephrosis: More Than Just a Uti

Pyelonephrosis: More than just a UTI
By
Tanya A. Woods

A Paper

Submitted in partial fulfillment of the requirements for

NU 327-801Pathophysiological Bases of Nursing

University of South Alabama

College of Nursing

Fall 2010

Pyelonephrosis: More than just a UTI
Introduction
The purpose of this paper is to evaluate the pathophysiology of pyelonephrosis and to correlate that pathophysiology to the symptoms that accompany this disease process. This paper will also correlate the treatments and interventions which are appropriate for the nursing management and facilitation of wellness.
Defining Pyelonephrosis
Pyelonephrosis is a common result of ascending urinary tract infection and is evidenced by infection of the renal parenchyma and the renal calices (Sheffield & Cunningham, 2005). According to Sheu, Chen, Meng and Leu (2010), urinary tract infections (UTI)s are the leading cause of bacterial infection in infants and children. While many UTIs are relatively benign, a simple lower UTI or cystitis can quickly become more serious as it ascends the urinary tract to invade the structures of the kidneys. Sheffield and Cunningham (2005) noted that Escherichia coli are responsible for up to 80 percent of all urinary tract infections including pyelonephrosis. The bacterium’s virulence is related to its ability to colonize and invade the urinary epithelium through the adhesins p-fimbria and s-fimbria. These adhesions bind to the epithelial membranes and inhibit the host’s cells bactericidal response (Sheffield & Cuningham, 2005).
Predisposing factors which increase the likelihood of pyelonephrosis include diabetes, obesity, instrumentation, and obstructive conditions. Obstruction is the most common predisposing risk factor for urinary tract infections in adults and can be caused by urolithiaisis, pregnancy, and ureters or urethral stricture anomalies. However, Chishti, Maul, Nazario, Bennett, and Kiessling (2010) state that vesicular urethral reflux (VUR) accounts for 30-50 percent of all childhood UTIs and subsequent pyelonephrosis. Signs & Symptoms
In adults the symptoms of pyelonephrosis include: abrupt onset of fever, chills, anorexia, dysuria, frequency, and urgency with aching flank pain and intense costovertebral pain to percussion (Sheffield & Cunningham, 2005). However, children under five often have vague symptoms such as nonspecific malaise, fever, and abdominal pain (Chishti et al., 2010).
Complications
Early treatment is essential to prevent complications. Renal scaring occurs in up to 65 percent of all cases of pyelonephrosis and increases the risk of progressive kidney disease including renal insufficiency and failure. Pyelonephrosis is responsible for 10-24 percent of all childhood end stage renal failure requiring dialysis (Sheu et al., 2010). According to Duggal, Koury, and Kaur-Waraich (2010) emphysematous pyelonephritis has a high risk or mortality and occurs as a result of gas byproducts of bacteria within the hypoxic tissue of the renal medulla. The symptoms of emphysematous pyelonephritis include varying degrees of renal failure with metabolic acidosis, confusion, hyperglycemia, thrombocytopenia, and septic shock. Nursing Management
Many patients can be managed as outpatients if they are able to tolerate oral intake and have no evidence of serious underlying complications. Inpatient nursing management should focus on providing adequate hydration, antibiotics as ordered, and monitoring for complications such as decreased renal function and sepsis from emphysematous pyelonephrosis.
Fluid loss due to fever, emesis, and polyuria from the decreased ability to reabsorb sodium may require fluid boluses as aggressive fluid resuscitation can reduce secondary renal injury by 15 percent (Sheffield & Cunningham, 2005). Nurses should expect to administer IV antibiotics which provide empiric coverage; however when the results of urine culture and sensitivities are available, the antibiotic coverage should be chosen by the physician to provide specific coverage.
Special considerations include carefully monitor patients for orthostatic hypotension and the risk for falls and monitoring pregnant women for the onset of contractions which result from endotoxins release and from dehydration (Sheffield & Cunningham, 2005). Finally, patient teaching is critical to ensure that patients understand the importance of completing their prescribed antibiotic therapy even when they begin to feel better.
Laboratory test and diagnostic procedures Nurses should anticipate that the physician will order a urinalysis with culture and sensitivity. A urine sample should be obtained prior to administration of antibiotics, as even one dose can inhibit the ability to obtain a valid culture. The urine culture will be considered diagnostic with the presence of leukocyte esterase, urinary nitrates, and when under microscopic examination there are greater than five white blood cells per high power resolution field and when any bacteria is noted upon the field (Chishti et al., 2010). According to the Mayo Clinic (2010), creatinine clearance and blood urea nitrogen (BUN) are often ordered to evaluate renal clearance of the byproducts of metabolism, urea, and nitrogen. Serum creatinine (normal level less than 1.3mg/dL) is increased with renal failure. BUN (normal value 6-24) is elevated in renal injury. Lactate Dehydrogenase (normal value 122-222 U/L) is an enzyme which is often elevated in pyelonephrosis. A complete blood cell count will be evaluated for increased in white blood cell counts. A normal value for WBC is between 4300-10800 cmm and will be evaluated during bacterial infection (Mayo Clinic, 2010). Computed tomography (CT) scans can be done with or without contrast and shows structural changes to the kidneys and related urinary structures. However, renal ultrasound is a non-invasive means of determining if calculi are present within the ureters. An important advantage of ultrasound is that it does not require dye which is can cause further damage to the kidneys (Allison, & Lev-Toaff, 2010). Micturating cystourethorgraphy (MCUG) tests for vesicoueteral reflux. A small catheter is placed in the bladder and a dye is introduced then fluoroscopic images are obtained during voiding (Sheu et al.,2010). Tc-dimercaptosuccinic acid renal scan (DMSA) is a test which uses injected isotope to evaluate the reuptake of the dye to evaluate the level of injury to the kidneys. Areas which do not pick up the isotope indicate areas of injury (Sheu et al.,2010).
Conclusion
Urinary tract infections are more than an annoyance. They demand evaluation and prompt treatment to prevent the ascension of the bacteria and the development of pyelonephritis. When pyelonephrosis develops the use of supportive therapy and antibiotics are needed to prevent subsequent sequela and assist the patient to return to a state of wellness. References
Allison, S., & Lev-Toaff, A. (2010). Acute pelvic pain: What we have learned from the ER. Ultrasound Quarterly, 26, 2100-218. doi:10.1097/ RUQ.0b013e3181fe0e21
Chishti, A., Maul, E., Nazario, R., Bennett, J., & Kiessling, S. (2010). A guideline for the inpatient care of children with pyelonephritis. Annals of Saudi Medicine, 30, 341-349. doi:10.4103/0256-4947.68549.
Duggal, A., Koury, G., & Kaur- Waraich, K. (2010). Medical therapy in emphysematous pyelonephritis. Infectious Diseases in Clinical Practice, 1-2. Retrieved from Ovid SR database. (00019048-900000000-99790.)
Mayo Clinic. (2010). Mayo Medical Laboratories. Retrieved from http://www.mayomedicallaboratories.com/test-catalog/ search.php?search_type=disease&search=Pyelonephritis
Sheffield, J., & Cunningham, G. (2005). Urinary tract infection in women. Obstetrics and Gynecology, 106, 1085-1092. doi:10.1097/ 01.AOG.0000185257.52328.a2
Sheu, J.-N., Chen, S.-M., Meng, M.-H., & Leu, K.-H. (2010). The role of serum and urine interleukin-8 on acute pyelonephritis and subsequent renal scarring in children. . Pediatric Infectious Disease Journal, 28, 885-890. doi:10.1097/INF.0b013e3181a39e23

References: Allison, S., & Lev-Toaff, A. (2010). Acute pelvic pain: What we have learned from the ER Duggal, A., Koury, G., & Kaur- Waraich, K. (2010). Medical therapy in emphysematous pyelonephritis 1-2. Retrieved from Ovid SR database. (00019048-900000000-99790.) Mayo Clinic Sheffield, J., & Cunningham, G. (2005). Urinary tract infection in women. Obstetrics and Gynecology, 106, 1085-1092