Skip to main content

Clinical utility of FDG PET/CT in acute complicated pyelonephritis—results from an observational study

European Journal of Nuclear Medicine and Molecular Imaging volume 45, pages 462–470 (2018)Cite this article

Abstract

Background

Acute complicated pyelonephritis (ACP) is an upper urinary tract infection associated with coexisting urinary tract abnormalities or medical conditions that could predispose to serious outcomes or treatment failures. Although CT and magnetic resonance imaging (MRI) are frequently used in patients with ACP, the clinical value of 18F–fluorodeoxyglucose positron emission tomography and computed tomography (FDG PET/CT) has not been systematically investigated. This single-center retrospective study was designed to evaluate the potential usefulness of FDG PET/CT in patients with ACP.

Methods

Thirty-one adult patients with ACP who underwent FDG PET/CT were examined. FDG PET/CT imaging characteristics, including tracer uptake patterns, kidney volumes, and extrarenal imaging findings, were reviewed in combination with clinical data and conventional imaging results.

Results

Of the 31 patients, 19 (61%) showed focal FDG uptake. The remaining 12 study participants showed a diffuse FDG uptake pattern. After volumetric approximation, the affected kidneys were found to be significantly enlarged. Patients who showed a focal uptake pattern had a higher frequency of abscess formation requiring drainage. ACP patients showing diffuse tracer uptake patterns had a more benign clinical course. Seven patients had suspected extrarenal coinfections, and FDG PET/CT successfully confirmed the clinical suspicion in five cases. FDG PET/CT was as sensitive as CT in identifying the six patients (19%) who developed abscesses. Notably, FDG PET/CT findings caused a modification to the initial antibiotic regimen in nine patients (29%).

Conclusions

FDG PET/CT may be clinically useful in the assessment of patients with ACP who have a progressive disease course.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2

References

  1. Grabe M, Bartoletti R, Bjerklund Johansen TE, et al. EAU guidelines on urological infections. European Association of Urology. 2015. Available online: http://uroweb.org/guideline/urological-infections.

  2. Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician. 2005;71(5):933–42.

    PubMed  Google Scholar 

  3. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis. 2007;45(3):273–80.

    Article  PubMed  Google Scholar 

  4. Schaeffer AJ, Nicolle LE. Urinary tract infections in older men. N Engl J Med. 2016;374(22):2192.

    Article  PubMed  Google Scholar 

  5. Gupta K, Trautner BW. Urinary tract infections, pyelonephritis, and prostatitis. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J, editors. Harrison’s principles of internal medicine, 19e. New York, NY: McGraw-Hill; 2015.

    Google Scholar 

  6. Gupta K, Hooton TM, Naber KG, Wullt B, Colgan R, Miller LG, et al. Infectious Diseases Society of America.; European Society for Microbiology and Infectious Diseases.. 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;52(5):e103–20.

    Article  PubMed  Google Scholar 

  7. National Guideline Clearinghouse (NGC). Guideline summary: ACR Appropriateness Criteria® acute pyelonephritis. In: National Guideline Clearinghouse (NGC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ). 2012. [cited 2017 Jan 03]. Available: https://www.guideline.gov.

  8. Pohl HG, Belman AB. The “top-down” approach to the evaluation of children with febrile urinary tract infection. Adv Urol. 2009;2009:783409. https://doi.org/10.1155/2009/783409.

    Article  PubMed Central  Google Scholar 

  9. Boellaard R, Delgado-Bolton R, Oyen WJ, et al. FDG PET/CT: EANM procedure guidelines for tumour imaging: version 2.0. Eur J Nucl Med Mol Imaging. 2015;42:328–54.

    CAS  Article  PubMed  Google Scholar 

  10. Vaidyanathan S, Patel CN, Scarsbrook AF, et al. FDG PET/CT in infection and inflammation—current and emerging clinical applications. Clin Radiol. 2015;70:787–800.

    CAS  Article  PubMed  Google Scholar 

  11. Jamar F, Buscombe J, Chiti A, et al. EANM/SNMMI guideline for FDG use in inflammation and infection. J Nucl Med. 2013;54:647–58.

    Article  PubMed  Google Scholar 

  12. Tseng JR, Chen KY, Lee MH, Huang CT, Wen YH, Yen TC. Potential usefulness of FDG PET/CT in patients with sepsis of unknown origin. PLoS One. 2013;8:e66132.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  13. Lucaj R, Achong DM. Concurrent diffuse pyelonephritis and prostatitis: discordant findings on sequential FDG PET/CT and 67Ga SPECT/CT imaging. Clin Nucl Med. 2017;42(1):73–5.

    Article  PubMed  Google Scholar 

  14. Morelle M, Jaillard A, Bellevre D, Collet G, Petyt G. 18F-FDG PET/CT in renal infections: evidence of acute pyelonephritis in a horseshoe kidney. Clin Nucl Med. 2017;42(2):112–3.

    Article  PubMed  Google Scholar 

  15. McCammack KC, Hawkes NC, Silverman ED, Paz DA. PET/CT appearance of acute pyelonephritis. Clin Nucl Med. 2013;38(7):e299–301.

    Article  PubMed  Google Scholar 

  16. Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its complications. Part 1: diagnosis and classification of diabetes mellitus provisional report of a WHO consultation. Diabet Med. 1998;15:539–53.

    CAS  Article  PubMed  Google Scholar 

  17. National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis. 2002; 39 (2 suppl 1):S1–S266.

  18. Puech P, Lagard D, Leroy C, Dracon M, Biserte J, LemaÃŽtre L. Imaging in urinary tract infections in adults. J Radiol. 2004;2(pt 2):220–40.

    Article  Google Scholar 

  19. Browne RF, Zwirewich C, Torreggiani WC. Imaging of urinary tract infection in the adult. Eur Radiol. 2004;14(Suppl 3):E168–83.

    PubMed  Google Scholar 

  20. Gorospe L, Jover-Díaz R, Vicente-Bártulos A. Spectrum of PET-CT pelvic pitfalls in patients with gynecologic malignancies. Abdom Imaging. 2012;37(6):1041–65.

    Article  PubMed  Google Scholar 

  21. Shreve PD, Anzai Y, Wahl RL. Pitfalls in oncologic diagnosis with FDG PET imaging: physiologic and benign variants. Radiographics. 1999;19(1):61–77. quiz 150-1.

    CAS  Article  PubMed  Google Scholar 

  22. Kochhar R, Brown RK, Wong CO, Dunnick NR, Frey KA, Manoharan P. Role of FDG PET/CT in imaging of renal lesions. J Med Imaging Radiat Oncol. 2010;54(4):347–57.

    CAS  Article  PubMed  Google Scholar 

  23. Lantinga MA, Drenth JP, Gevers TJ. Diagnostic criteria in renal and hepatic cyst infection. Nephrol Dial Transplant. 2015;30(5):744–51.

    CAS  Article  PubMed  Google Scholar 

  24. Guler S, Cimen S, Hurton S, Molinari M. Diagnosis and treatment modalities of symptomatic polycystic kidney disease. In: Li X, editor. Polycystic kidney disease [Internet]. Brisbane (AU): Codon Publications; 2015. Chapter 4.

    Google Scholar 

  25. Akers SR, Werner TJ, Rubello D, Alavi A, Cheng G. FDG uptake and clearance in patients with compromised renal function. Nucl Med Commun. 2016;37(8):825–32.

    CAS  Article  PubMed  Google Scholar 

  26. Piccoli GB, Colla L, Burdese M, Marcuccio C, Mezza E, Maass J, et al. Development of kidney scars after acute uncomplicated pyelonephritis: relationship with clinical, laboratory and imaging data at diagnosis. World J Urol. 2006;24:66–73.

    CAS  Article  PubMed  Google Scholar 

  27. Lim SK, Ng FC. Acute pyelonephritis and renal abscesses in adults—correlating clinical parameters with radiological (computer tomography) severity. Ann Acad Med Singap. 2011;40(9):407–13.

    PubMed  Google Scholar 

  28. Das CJ, Ahmad Z, Sharma S, Gupta AK. Multimodality imaging of renal inflammatory lesions. World J Radiol. 2014;6(11):865–73.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Kim SH, Kim YW, Lee HJ. Serious acute pyelonephritis: a predictive score for evaluation of deterioration of treatment based on clinical and radiologic findings using CT. Acta Radiol. 2012;53(2):233–8.

    Article  PubMed  Google Scholar 

  30. Erdi YE, Mawlawi O, Larson SM, et al. Segmentation of lung lesion volume by adaptive positron emission tomography image thresholding. Cancer. 1997;80(suppl):2505–9.

    CAS  Article  PubMed  Google Scholar 

  31. Breau RH, Clark E, Bruner B, Cervini P, Atwell T, Knoll G, et al. A simple method to estimate renal volume from computed tomography. Can Urol Assoc J. 2013;7(5–6):189–92.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Craig WD, Wagner BJ, Travis MD. Pyelonephritis: radiologic-pathologic review. Radiographics. 2008;28(1):255–77. quiz 327-8.

    Article  PubMed  Google Scholar 

  33. Stunell H, Buckley O, Feeney J, Geoghegan T, Browne RF, Torreggiani WC. Imaging of acute pyelonephritis in the adult. Eur Radiol. 2007;17(7):1820–8.

    CAS  Article  PubMed  Google Scholar 

  34. Tseng JR, Lin CW, Chen SH, Yen TH, Lin PY, Lee MH, et al. Clinical usefulness of 18F-FDG PET/CT for the detection of infections of unknown origin in patients undergoing maintenance hemodialysis. J Nucl Med. 2015;56(5):681–7.

    Article  PubMed  Google Scholar 

  35. Sun Y, Yu H, Ma J, Lu P. The role of 18F-FDG PET/CT integrated imaging in distinguishing malignant from benign pleural effusion. PLoS One. 2016;11(8):e0161764.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The authors acknowledge the statistical assistance of the Clinical Trial Center, Linkou, Taiwan (founded by the Ministry of Health and Welfare of Taiwan; grant MOHW106-TDU-B-212-113005).

Funding

No funding was received for this study.

Author information

Author notes

  1. Chih-Hsing Wan and Jing-Ren Tseng contributed equally to this work.

Affiliations

  1. Department of Nuclear Medicine, Mackay Memorial Hospital at Taipei, No. 92, Section 2, Zhong-shan North road, Zhong-shan District, Taipei, Taiwan, Republic of China

    Chih-Hsing Wan

  2. Department of Nuclear Medicine and Center for Advanced Molecular Imaging and Translation, Chang Gung Memorial Hospital at Linkou, No. 5, Fu-Hsing ST., Kwei-Shan, Taoyuan, Taiwan, Republic of China

    Jing-Ren Tseng & Tzu-Chen Yen

  3. Department of Medical Imaging and Radiological Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China

    Jing-Ren Tseng & Tzu-Chen Yen

  4. Division of Infectious Diseases, Department of Internal Medicine, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China

    Ming-Hsun Lee

  5. Biostatistics Unit, Clinical Trial Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan, Republic of China

    Lan-Yan Yang

Authors
  1. Chih-Hsing Wan
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jing-Ren Tseng
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Ming-Hsun Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lan-Yan Yang
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Tzu-Chen Yen
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Tzu-Chen Yen.

Ethics declarations

Institutional Review Board of the Chang Gung Memorial Hospital (CGMH) at Linkou.

Conflict of interest

None.

Ethical approval

This retrospective study was performed in accordance with the 1964 Declaration of Helsinki and was approved by the Institutional Review Board of the Chang Gung Memorial Hospital (CGMH) at Linkou (Number: 104-7091C).

Informed consent

Informed consent was waived for all patients included in this retrospective study.

Additional information

Chi-Hsing Wan and Jing-Ren Tseng are the first authors.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Wan, CH., Tseng, JR., Lee, MH. et al. Clinical utility of FDG PET/CT in acute complicated pyelonephritis—results from an observational study. Eur J Nucl Med Mol Imaging 45, 462–470 (2018). https://doi.org/10.1007/s00259-017-3835-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00259-017-3835-9

Keywords

  • FDG PET/CT
  • Acute complicated pyelonephritis
  • Coinfection
  • Progressive disease course