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Acute kidney injury with suspected pyonephrosis — MSRA MCQ

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HardNephrologyAcute kidney injury with suspected pyonephrosisMSRA

A 79-year-old man is assessed urgently in general practice. He has 24 hours of rigors, temperature 38.7°C, right-sided loin pain and markedly reduced urine output. For 6 months he has had progressive hesitancy, poor urinary stream and nocturia, but has not sought review. He has no history of renal stones. His usual creatinine is 102 micromol/L (eGFR 64 mL/min/1.73 m²). Today, creatinine is 218 micromol/L, potassium 5.2 mmol/L and bicarbonate 21 mmol/L. He is tachycardic at 112 bpm, BP is 104/62 mmHg, and there is right renal angle tenderness. Urine dipstick is positive for blood, protein, nitrites and leucocytes. What is the most appropriate immediate management plan?

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Correct answer: B — Arrange emergency hospital assessment for resuscitation and intravenous antibiotics, with immediate urinary tract ultrasound within 6 hours

This man has AKI, with creatinine more than doubling from baseline, alongside systemic infection and a credible obstructive history. The combination of fever/rigors, loin pain, pyuria and nitrituria, oliguria, AKI and progressive lower urinary tract symptoms should raise concern for infected upper-tract obstruction (pyonephrosis), rather than uncomplicated lower UTI or isolated acute urinary retention. NICE recommends immediate urinary tract ultrasound, performed within 6 hours, when pyonephrosis is suspected. He also requires emergency hospital care for sepsis management, intravenous antimicrobial treatment, fluid assessment/resuscitation and prompt urological intervention if obstruction is identified. A 24-hour ultrasound is appropriate where AKI has no identified cause or there is risk of obstruction without suspected pyonephrosis, but is too slow here. CT KUB may later be appropriate if stone disease remains a concern, but must not delay initial treatment or urgent ultrasound. Community catheterisation and oral antibiotics inadequately address possible upper-tract infection with AKI. Loop diuretics do not treat AKI and are reserved for fluid overload or oedema in selected circumstances.

Reference: NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations NICE NG148: Acute kidney injury: prevention, detection and management — Recommendations (Last updated 16 October 2024) — https://www.nice.org.uk/guidance/ng148/chapter/Recommendations