Assessment of renal perfusion in purulent-destructive pyelonephritis

Introduction. The problem of assessing renal perfusion is especially relevant in purulent-destructive forms of pyelonephritis, since parenchymal infection is accompanied by foci of ischemia and necrosis. Visualization of perfusion allows you to identify such foci of reduced blood flow and diagnose complications in a timely manner. In recent years, new imaging techniques (e.g., CT perfusion, contrast-enhanced ultrasound, diffusion-weighted MRI) have emerged that have the potential to improve diagnostic accuracy.

Objective. To analyze modern methods for assessing renal perfusion in pyelonephritis and to formulate guidelines for clinical practice.

Material & methods. The review was carried out in accordance with the PRISMA rules. A systematic search of publications for the last 10 years (2013 – 2023) was carried out with the inclusion of key classical works for completeness of the analysis. The literature search was carried out in the international databases PubMed, Scopus, Web of Science, Cochrane Library, as well as in the Russian resources eLibrary and RSCI.

Outcomes. Contrast-enhanced CT (CECT) firmly occupies a leading position in a complicated course due to the combination of high sensitivity and informative value in relation to complications. The sensitivity of CT in the detection of parenchymal changes is about 80–90%, and the diagnostic accuracy is close to 90 – 95% in purulentdestructive forms. The ultrasound method, despite all its attractiveness (no harm, the possibility of performing it at the patient's bedside), is significantly inferior in sensitivity. Nevertheless, modern improvements in ultrasound technology radically increase the informative value of ultrasound. Some studies demonstrate results of CEUS comparable to CT (95 – 100% sensitivity). DMSA-scintigraphy is still the «gold standard» for scientific research on pyelonephritis in children. MRI has proven to be an excellent tool for diagnosing pyelonephritis in patients with contraindications to CT. PET/CT cannot be recommended for routine use in pyelonephritis, but the review shows its niche effectiveness in complex cases — when functional criteria for infection activity or a search for a latent focus are required.

Conclusion. Modern imaging methods make it possible to assess in detail the kidney perfusion in purulent pyelonephritis, significantly increasing the accuracy of diagnosis. The introduction of innovative technologies (CEUS, CT perfusion, functional MRI) opens new opportunities for early detection of complications and individualization of treatment, which ultimately improves the prognosis and contributes to the preservation of renal function in patients with this serious infection.

1. Herness J, Buttolph A, Hammer NC. Acute Pyelonephritis in Adults: Rapid Evidence Review. Am Fam Physician. 2020;102(3):173-180. PMID: 32735433

2. Björgvinsson E, Majd M, Eggli KD. Diagnosis of acute pyelonephritis in children: comparison of sonography and 99mTc-DMSA scintigraphy. AJR Am J Roentgenol. 1991;157(3):539-543. DOI: 10.2214/ajr.157.3.1651644

3. Granata A, Andrulli S, Fiorini F, Basile A, Logias F, Figuera M, Sicurezza E, Gallieni M, Fiore CE. Diagnosis of acute pyelonephritis by contrastenhanced ultrasonography in kidney transplant patients. Nephrol Dial Transplant. 2011;26(2):715-720. DOI: 10.1093/ndt/gfq417

4. Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics. 2008;28(1):255-277; quiz 327-328. DOI: 10.1148/rg.281075171

5. Gaillard F, Fahrenhorst-Jones T, Molinari A. Acute pyelonephritis. Reference article. Radiopaedia.org (Accessed on 24 Dec 2024) https://doi.org/10.53347/rID-9953.

6. Ha SK, Seo JK, Kim SJ, Park SH, Park CH, Lee HY, Han DS, Kim KW. Acute pyelonephritis focusing on perfusion defects on contrast enhanced computerized tomography (CT) scans and its clinical outcome. Korean J Intern Med. 1997;12(2):122-127. DOI: 10.3904/kjim.1997.12.2.122

7. Rathod SB, Kumbhar SS, Nanivadekar A, Aman K. Role of diffusionweighted MRI in acute pyelonephritis: a prospective study. Acta Radiol. 2015;56(2):244-249. DOI: 10.1177/0284185114520862

8. Kurbatov D.G., Dubsky S.A., Khudyashov S.A. Radiation research methods in the diagnosis of acute pyelonephritis. Medical Dental Institute Bulletin. 2017;(3):18-23. (In Russian). eLIBRARY ID: 32268675; EDN: YLNONY

9. Arkhipov E.V., Sigitova O.N., Bogdanova A.R. Current recommendations for the diagnosis and treatment of pyelonephritis and evidence-based medicine. Bulletin of Modern Clinical Medicine. 2015;8(6):115-120. (In Russian). eLIBRARY ID: 25007481; ЕDN: VBGFDX

10. Lacy ME, Sidhu N, Miller J. When does acute pyelonephritis require imaging? Cleve Clin J Med. 2019;86(8):515-517. DOI: 10.3949/ccjm.86a.18096

11. Ananiev V.A., Pavlov V.N., Pushkarev A.M., Lubyansky V.G. Results of organ-preserving treatment of acute purulent pyelonephritis. Urologiia. 2024;(6):37-44. (In Russian). DOI: 10.18565/urology.2024.6.37-44

12. Moghrabi S, Abdlkadir AS, Al-Hajaj N, Gnanasegaran G, Kumar R, Syed G, Bozkurt MF, Shukri S, Obeidat S, Khalaf A, Shahait M, Al-Nabhani K, Al-Ibraheem A. A New Era for PET/CT: Applications in NonTumorous Renal Pathologies. J Clin Med. 2024;13(16):4632. DOI: 10.3390/jcm13164632

13. Wan CH, Tseng JR, Lee MH, Yang LY, Yen TC. Clinical utility of FDG PET/ CT in acute complicated pyelonephritis-results from an observational study. Eur J Nucl Med Mol Imaging. 2018;45(3):462-470. DOI: 10.1007/s00259-017-3835-9

14. Boccatonda A, Stupia R, Serra C. Ultrasound, contrast-enhanced ultrasound and pyelonephritis: A narrative review. World J Nephrol. 2024;13(3):98300. DOI: 10.5527/wjn.v13.i3.98300

15. Dacher JN, Pfister C, Monroc M, Eurin D, LeDosseur P. Power Doppler sonographic pattern of acute pyelonephritis in children: comparison with CT. AJR Am J Roentgenol. 1996;166(6):1451-1455. DOI: 10.2214/ajr.166.6.8633462

16. Jung HJ, Choi MH, Pai KS, Kim HG. Diagnostic performance of contrastenhanced ultrasound for acute pyelonephritis in children. Sci Rep. 2020;10(1):10715. DOI: 10.1038/s41598-020-67713-z.

17. Sarikaya I, Sarikaya A. Current Status of Radionuclide Renal Cortical Imaging in Pyelonephritis. J Nucl Med Technol. 2019;47(4):309-312. DOI: 10.2967/jnmt.119.227942

18. Lukiyanchenko А.B., Medvedeva B.М., Kolobanova E.S., Romanova К.A., Magamedova S.S. The Potentials and Role of Diffusion-Weighted Magnetic Resonance Imaging in Evaluating the Efficiency of Antitumor Treatment of Patients with Breast Liver Metastasis. Journal of radiology and nuclear medicine. 2019;100(5):286-292. (In Russian). DOI: 10.20862/0042-4676-2019-100-5-286-292