Acute kidney injury from pyelonephritis in an elderly man: case report

Abstract

Pyelonephritis is rarely considered in the differential diagnosis of acute kidney injury. Acute non-obstructed bacterial pyelonephritis is an infrequent and rarely considered cause of rapidly progressive acute kidney injury. A diagnostic challenge thus develops as it is difficult to clinically differentiate acute kidney injury secondary to ischemic or toxic acute tubular necrosis or papillary necrosis versus acute interstitial nephritis secondary to drugs or infectious pyelonephritis. We describe a case of acute kidney injury due to suppurative pyelonephritis in an elderly immunocompetent man who presented with dysuria, vomiting, and fever and later found to have histologic and radiologic proven pyelonephritis as the cause of acute kidney injury in the absence of hypotension, nephrotoxic agents, non-steroidal analgesics, immunosuppression, urinary tract obstruction, or other structural anomalies. The patient was managed with antimicrobial therapy, hemodialysis, and a short course of corticosteroids.

Persistent Aseptic Pyelonephritis After Acute Bacterial Pyelonephritis: Possible Role of Corticosteroids

“… 1 In some of these latter, renal dysfunction persists despite appropriate antiinfectious treatment and urine sterilization. 2 , 3 , 4 Some authors suggest the use of corticosteroids to treat inflammatory tubulointerstitial nephritis (TIN) triggered by the infection. 2 , 3 , 4 Nevertheless, this approach is not validated by any evidence-based study and therefore not mentioned in any guideline.…”

Acute Non-Obstructive Bilateral Pyelonephritis With Acute Kidney Injury Requiring Hemodialysis

“…Pyelonephritis is most commonly reported in women [1], but men have a higher mortality rate [8]. Common presiding factors for pyelonephritis include prolonged use of indwelling catheters, renal stones, pregnancy, and chronic use of medications such as non-steroidal analgesics, or immunosuppressive agents [9]. It is possible that this patient's HIV status may have contributed to the development of AKI secondary to pyelonephritis.…”

“…Typically, imaging is not a routine step in the diagnosis of pyelonephritis, but it can be utilized when there is no improvement seen within 72 hours of initiating appropriate antibiotic therapy. Antibiotic susceptibility testing is commonly used when determining the sensitivity of the causative organism, and earlier utilization of an appropriate antibiotic generally has a better patient outcome [9].…”

Bilateral acute non-obstructive pyelonephritis presenting as acute kidney injury requiring haemodialysis

“…The common predisposing factors for APN include the presence of an indwelling catheter, use of immunosuppressive agents, pregnancy, renal stones, solitary kidney or non-steroidal analgesic use 9. The pathogenesis of acute renal failure in pyelonephritis include disruption of tubular function by interstitial inflammation, interstitial oedema, tubular obstruction by cellular debris and intrarenal vasoconstriction 5 10.…”

“…The imaging has not been routinely considered except in cases of non-improvement within first 72 hours despite appropriate antibiotic therapy. Prompt diagnosis with appropriate antibiotic use had a favourable prognosis in adults with acute pyelonephritis 9…”