Clinical Investigation

Kidney International (1989) 35, 696–703; doi:10.1038/ki.1989.41

Frequency of development of early cortical scarring in acute primary pyelonephritis

Alain Meyrier, Marie-Claude Condamin, Marc Fernet, Agnès Labigne-Roussel, Pierre Simon, Patrice Callard, Muriel Rainfray, Marc Soilleux and Arlette Groc

Service de Néphrologie, Service de Radiologie, and Laboratoire de Bactériologie, Hôpital Avicenne, Bobigny; Service des Entérobactéries & INSERM U199, Institut Pasteur, Paris; Service de Néphrologie, Hôpital La Bauchee, Saint-Brieuc; and Laboratoire d'Anatomo-pathologie, Hôpital Jean-Verdier, Bondy, France

Correspondence: Alain Meyrier MD, Department of Nephrology, Hôpital Avicenne, 125, route de Stalingrad, F-93009 Bobigny, France.

Received 17 May 1988; Revised 23 September 1988.

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Abstract

Frequency of development of early cortical scarring in acute primary pyelonephritis. Fifty-five cases of primary (that is, without urinary tract abnormalities), acute pyelonephritis (PN) were studied by computed tpmodensitometry (CT). There were 48 women and 7 men. All were febrile and 16 had positive blood cultures. In 7 cases, (4 diabetics and 3 malnourished alcoholics) PN was painless, diagnosis was delayed and lesions were severe. Two diabetics underwent emergency nephrectomy for sepsis. Conventional radiological techniques (IVP and ultrasonography) were poorly informative. In contrast, initial CT abnormalities were visible in 44 patients. They consisted of triangular or round hypodense images, diffuse hypodensity in a grossly swollen kidney, and/or abscesses. Hypodense images were presumably due to acute focal ischemia. Renal histology was available in five patients. It showed acute interstitial nephritis with leukocyte infiltrates, edema and hemorrhagic streaks. Pyelonephritis was due to E. coli in 48 cases (87.5%). In 27 cases E. coli isolates were studied by genotypic assays which detect the three most frequent (pap, afa and sfa) of the four opérons known to encode adhesin. In all cases, at least one of these genotypic markers of uropathogenicity was found. In 27 cases, repeat CT was done shortly after treatment. It showed healing in only 12. Early cortical scar formation was visible in 2. Final evaluation in 27 cases with adequate follow-up showed that (in addition to the 2 patients who had been nephrectomized), in only 17 of 27 (63%) had the kidneys recovered a normal appearance. In two cases one kidney had undergone atrophy; renal biopsy showed subacute-chronic interstitial nephritis. Cortical scars were visible in eight other cases. Our data do not substantiate the common opinion that, in the absence of urinary tract abnormalities, acute PN entails little risk of renal insult. On the contrary, we show that such acute primary renal infection, due to uropathogenic E. coli strains encoding a pap or afa adhesin often leads to early cortical scarring and may occasionally progress to unilateral renal atrophy.

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