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Highlights & Basics
- Chronic pyelonephritis is most commonly caused by chronic vesicoureteral reflux.
- Diagnosis is clinical and confirmed with imaging studies. Typically, a biopsy is not performed.
- There is no specific treatment, as damage is irreversible.
- May result in end-stage renal disease.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Chronic pyelonephritis: tubular damage, interstitial scarring, and fibrosis in chronic pyelonephritis
Medium-power microscopic view of dense polymorphonuclear infiltrates, showing chronic tubular atrophy, glomerulosclerosis, and surrounding areas of normal tubules and glomeruli
High-power view of polymorphonuclear cells in the renal tubules, showing damage to the tubules and red blood cell infiltration in the interstitial spaces
Xanthogranulomatous pyelonephritis: very low-power microscopic view showing extensive cellular infiltrate and granulomas. Note the marked destruction of the normal renal architecture
H&E stain: high-power view of granulomas found in xanthogranulomatous pyelonephritis
Very high-power view of xanthoma cells, which are lipid-filled macrophages
Citations
European Association of Urology. Urological infections. 2025 [internet publication].[Full Text]
Vourganti S, Agarwal PK, Bodner DR, et al. Ultrasonographic evaluation of renal infections. Radiol Clin North Am. 2006 Nov;44(6):763-75.[Abstract]
Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.[Abstract][Full Text]
American Urological Association. Management and screening of primary vesicoureteral reflux in children (2010, amended 2017). 2021 [internet publication].[Full Text]
1. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805.[Abstract][Full Text]
2. Ataei N, Madani A, Esfahani ST, et al. Screening for vesicoureteral reflux and renal scars in siblings of children with known reflux. Pediatr Nephrol. 2004 Oct;19(10):1127-31.[Abstract]
3. Dias CS, Silva JM, Diniz JS, et al. Risk factors for recurrent urinary tract infections in a cohort of patients with primary vesicoureteral reflux. Pediatr Infect Dis J. 2010 Feb;29(2):139-44.[Abstract]
4. Dick PT, Feldman W. Routine diagnostic imaging for childhood urinary tract infections: a systematic overview. J Pediatr. 1996 Jan;128(1):15-22.[Abstract]
5. Macedo CS, Riyuzo MC, Bastos HD. Renal scars in children with primary vesicoureteral reflux [in Portuguese]. J Pediatr (Rio J). 2003 Jul-Aug;79(4):355-62.[Abstract]
6. Wadie GM, Moriarty KP. The impact of vesicoureteral reflux treatment on the incidence of urinary tract infection. Pediatr Nephrol. 2012 Apr;27(4):529-38.[Abstract]
7. Marra G, Oppezzo C, Ardissino G, et al. Severe vesicoureteral reflux and chronic renal failure: a condition peculiar to male gender? Data from the ItalKid Project. J Pediatr. 2004 May;144(5):677-81.[Abstract]
8. Quinn FM, Dick AC, Corbally MT, et al. Xanthogranulomatous pyelonephritis in childhood. Arch Dis Child. 1999 Dec;81(6):483-6.[Abstract][Full Text]
9. Stoica I, O'Kelly F, McDermott MB, et al. Xanthogranulomatous pyelonephritis in a paediatric cohort (1963-2016): outcomes from a large single-center series. J Pediatr Urol. 2018 Apr;14(2):169.e1-169.e7.[Abstract]
10. Sangüesa Nebot C, Picó Aliaga S, Serrano Durbá A, et al. Xantogranulomatous pyeloneprhritis in children. Insights Imaging. 2018 Oct;9(5):643-51.[Abstract][Full Text]
11. Riccabona M, Fotter R. Urinary tract infection in infants and children: an update with special regard to the changing role of reflux. Eur Radiol. 2004 Mar;14 Suppl 4:L78-88.[Abstract]
12. Vachvanichsanong P. Urinary tract infection: one lingering effect of childhood kidney diseases - review of the literature. J Nephrol. 2007 Jan-Feb;20(1):21-8.[Abstract]
13. Wennerstrom M, Hansson S, Jodal U, et al. Primary and acquired renal scarring in boys and girls with urinary tract infection. J Pediatr. 2000 Jan;136(1):30-4.[Abstract]
14. Moreau JF, Grenier P, Grunfeld JP, et al. Renal clubbing and scarring in adults: a retrospective study of 110 cases. Urol Radiol. 1979-1980;1(3):129-36.[Abstract]
15. Guignard JP. Importance of vesico-ureteral reflux in the pathogenesis of chronic pyelonephritis [in French]. Schweiz Med Wochenschr. 1983 Feb 12;113(6):223-8.[Abstract]
16. Grainger RG, Longstaff AJ, Parsons MA. Xanthogranulomatous pyelonephritis: a reappraisal. Lancet. 1982 Jun 19;1(8286):1398-401.[Abstract]
17. Mokabberi R, Ravakhah K. Emphysematous urinary tract infections: diagnosis, treatment and survival (case review series). Am J Med Sci. 2007 Feb;333(2):111-6.[Abstract]
18. Rubenstein JN, Schaeffer AJ. Managing complicated urinary tract infections: the urologic view. Infect Dis Clin North Am. 2003 Jun;17(2):333-51.[Abstract]
19. Tseng CC, Wu JJ, Wang MC, et al. Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis. 2005 Sep;46(3):432-9.[Abstract]
20. Ransley PG, Risdon RA. The pathogenesis of reflux nephropathy. Contrib Nephrol. 1979;16:90-7.[Abstract]
21. Shaikh N, Ewing AL, Bhatnagar S, et al. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. 2010 Dec;126(6):1084-91.[Abstract]
22. Kincaid-Smith P, Becker G. Reflux nephropathy and chronic atrophic pyelonephritis: a review. J Infect Dis. 1978 Dec;138(6):774-80.[Abstract]
23. Hodson CJ, Maling TM, McManamon PJ, et al. The pathogenesis of reflux nephropathy (chronic atrophic pyelonephritis). Br J Radiol. 1975;suppl 13:1-26.[Abstract]
24. Skoog SJ, Peters CA, Arant BS, Jr., et al. Pediatric vesicoureteral reflux guidelines panel summary report: clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis. J Urol. 2010 Sep;184(3):1145-51.[Abstract]
25. Alan C, Atas S, Tunc B. Xanthogranulomatous pyelonephritis with psoas abscess: 2 cases and review of the literature. Int Urol Nephrol. 2004;36(4):489-93.[Abstract]
26. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368-77.[Abstract][Full Text]
27. Babich T, Eliakim-Raz N, Turjeman A, et al. Risk factors for hospital readmission following complicated urinary tract infection. Sci Rep. 2021 Mar 25;11(1):6926.[Abstract][Full Text]
28. Stevens LA, Coresh J, Feldman HI, et al. Evaluation of the modification of diet in renal disease study equation in a large diverse population. J Am Soc Nephrol. 2007 Oct;18(10):2749-57.[Abstract][Full Text]
29. European Association of Urology. Urological infections. 2025 [internet publication].[Full Text]
30. Ozeki S, Kawamura T, Nishino Y, et al. Clinical evaluation of nitrite test for the detection of bacteriuria [in Japanese]. Hinyokika Kiyo. 1997 Dec;43(12):861-5.[Abstract]
31. Yang WJ, Cho IR, Seong do H, et al. Clinical implication of serum C-reactive protein in patients with uncomplicated acute pyelonephritis as marker of prolonged hospitalization and recurrence. Urology. 2009 Jan;73(1):19-22.[Abstract]
32. Kljucevsek D, Kljucevsek T, Kersnik LT, et al. Catheter-free methods for vesicoureteric reflux detection: our experience and a critical appraisal of existing data. Pediatr Nephrol. 2010 Jul;25(7):1201-6.[Abstract]
33. Stoller ML, Kogan BA. Sensitivity of 99mtechnetium-dimercaptosuccinic acid for the diagnosis of chronic pyelonephritis: clinical and theoretical considerations. J Urol. 1986 Jul;25(7):977-80.[Abstract]
34. Loffroy R, Guiu B, Wafta J, et al. Xanthogranulomatous pyelonephritis in adults: clinical and radiological findings in diffuse and focal forms. Clin Radiol. 2007 Sep;62(9):884-90.[Abstract]
35. Vourganti S, Agarwal PK, Bodner DR, et al. Ultrasonographic evaluation of renal infections. Radiol Clin North Am. 2006 Nov;44(6):763-75.[Abstract]
36. Dwivedi US, Goyal NK, Saxena V, et al. Xanthogranulomatous pyelonephritis: our experience with review of published reports. ANZ J Surg. 2006 Nov;76(11):1007-9.[Abstract]
37. Kondo T, Okuda H, Suzuki M, et al. A case of emphysematous pyelonephritis improved with conservative therapy - indication for conservative therapy [in Japanese]. Hinyokika Kiyo. 2000 May;46(5):335-8.[Abstract]
38. Evanoff GV, Thompson CS, Foley R, et al. Spectrum of gas within the kidney. Emphysematous pyelonephritis and emphysematous pyelitis. Am J Med. 1987 Jul;83(1):149-54.[Abstract]
39. Naseri M. Association of nocturnal enuresis with vesicoureteral reflux and renal cortical damage. Nephrourol Mon. 2012 Spring;4(2):448-53.[Abstract][Full Text]
40. Afgan F, Mumtaz S, Ather MH. Preoperative diagnosis of xanthogranulomatous pyelonephritis. Urol J. 2007 Summer;4(3):169-73.[Abstract][Full Text]
41. Cardenas DD, Hooton TM. Urinary tract infection in persons with spinal cord injury. Arch Phys Med Rehabil. 1995 Mar;76(3):272-80.[Abstract][Full Text]
42. Miller JM, Binnicker MJ, Campbell S, et al. Guide to utilization of the microbiology laboratory for diagnosis of infectious diseases: 2024 update by the Infectious Diseases Society of America (IDSA) and the American Society for Microbiology (ASM). Clin Infect Dis. 5 Mar 2024 [Epub ahead of print].[Abstract][Full Text]
43. Kirsch AJ, Grattan-Smith JD, Molitierno JA Jr. The role of magnetic resonance imaging in pediatric urology. Curr Opin Urol. 2006 Jul;16(4):283-90.[Abstract]
44. Kass EJ, Kernen KM, Carey JM. Paediatric urinary tract infection and the necessity of complete urological imaging. BJU Int. 2000 Jul;86(1):94-6.[Abstract]
45. American College of Radiology; American College of Nuclear Medicine; Society for Pediatric Radiology. ACR-ACNM-SPR practice parameter for the performance of renal scintigraphy. 2022 [internet publication].[Full Text]
46. Garin EH, Olavarria F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. 2006 Mar;117(3):626-32.[Abstract]
47. Xie L, Tapiero S, Flores AR, et al. Long-term antibiotic treatment prior to laparoscopic nephrectomy for xanthogranulomatous pyelonephritis improves postoperative outcomes: results from a multicenter study. J Urol. 2021 Mar;205(3):820-5.[Abstract]
48. Artiles-Medina A, Laso-García I, Lorca-Álvaro J, et al. Xanthogranulomatous pyelonephritis: a focus on microbiological and antibiotic resistance profiles. BMC Urol. 2021 Apr 7;21(1):56.[Abstract][Full Text]
49. Rusu A, Munteanu AC, Arbănași EM, et al. Overview of side-effects of antibacterial fluoroquinolones: new drugs versus old drugs, a step forward in the safety profile? Pharmaceutics. 2023 Mar 1;15(3):804.[Abstract][Full Text]
50. Dhillon S. Meropenem/vaborbactam: a review in complicated urinary tract infections. Drugs. 2018 Aug;78(12):1259-70.[Abstract][Full Text]
51. Wagenlehner FME, Cloutier DJ, Komirenko AS, et al. Once-daily plazomicin for complicated urinary tract infections. N Engl J Med. 2019 Feb 21;380(8):729-40.[Abstract][Full Text]
52. Tamma PD, Heil EL, Justo JA, et al. Infectious Diseases Society of America 2024 guidance on the treatment of antimicrobial-resistant gram-negative infections. Clin Infect Dis. 2024 Aug 7:ciae403.[Abstract][Full Text]
53. Harley F, Wei G, O'Callaghan M, et al. Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases. BJU Int. 2023 Apr;131(4):395-407.[Abstract][Full Text]
54. Kelly C, Anderson S, Looney A, et al. Nephrectomy for xanthogranulomatous pyelonephritis-a not-so-simple solution. Ir J Med Sci. 2024 Apr;193(2):1055-60.[Abstract][Full Text]
55. Heuer JG, Sharma GR, Zhang T, et al. Effects of hyperglycemia and insulin therapy on outcome in a hyperglycemic septic model of critical illness. J Trauma. 2006 Apr;60(4):865-72.[Abstract]
56. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc. 2004 Aug;79(8):992-1000.[Abstract]
57. Somani BK, Nabi G, Thorpe P, et al; ABACUS Research Group. Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review. J Urol. 2008 May;179(5):1844-9.[Abstract]
58. Nelson Z, Aslan AT, Beahm NP, et al. Guidelines for the prevention, diagnosis, and management of urinary tract infections in pediatrics and adults: a WikiGuidelines Group consensus statement. JAMA Netw Open. 2024 Nov 4;7(11):e2444495.[Abstract][Full Text]
59. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2011 Mar 1;52(5):e103-20.[Abstract][Full Text]
60. Soo Park B, Lee SJ, Wha Kim Y, et al. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. Scand J Urol Nephrol. 2006;40(4):332-8.[Abstract]
61. Kaye KS, Belley A, Barth P, et al. Effect of cefepime/enmetazobactam vs piperacillin/tazobactam on clinical cure and microbiological eradication in patients with complicated urinary tract infection or acute pyelonephritis: a randomized clinical trial. JAMA. 2022 Oct 4;328(13):1304-14.[Abstract][Full Text]
62. Bailey RR. End-stage reflux nephropathy. Nephron. 1981;27(6):302-6.[Abstract]
63. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024 Apr;105(4S):S117-314.[Full Text]
64. Kidney Disease: Improving Global Outcomes (KDIGO) CKD-MBD Work Group. KDIGO 2017 clinical practice guideline update for the diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD). Jul 2017 [internet publication].[Full Text]
65. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008 Nov;122(5):1064-71.[Abstract]
66. American Urological Association. Management and screening of primary vesicoureteral reflux in children (2010, amended 2017). 2021 [internet publication].[Full Text]
67. National Institute for Health and Care Excellence. Urinary tract infection in under 16s: diagnosis and management. Jul 2022 [internet publication].[Full Text]
68. Kanaan N, Cooper S, Landau D, et al. Patterns of damage observed on dimercaptosuccinic acid kidney scans and future risk of urinary tract infections or reduced kidney function. Pediatr Nephrol. 2025 Apr 28.[Abstract][Full Text]
