Aminoglycoside-induced Nephrotoxicity Research Articles

Aminoglycoside-Related Nephrotoxicity and Ototoxicity in Clinical Practice: A Review of Pathophysiological Mechanism and Treatment Options.

Aminoglycosides are a class of medications used to treat certain bacterial infections, specifically gram-negative aerobes. These drugs can be used alone as first-line treatments or in combination with other medications. There can be many different formulations of aminoglycosides including oral, inhalants, intravascular, intramuscular, or intraventricular. There are many distinctive types of aminoglycosides, and although they provide excellent coverage, they can have a wide variety of side effects. The most prevalent side effects of aminoglycosides are nephrotoxicity and ototoxicity. Aminoglycoside-induced nephrotoxicity is concerning because of the effects that abnormal creatinine levels can have on other drugs and the potential for neurotoxicity. Fortunately, changes in renal function are typically reversible. The kidney is affected by the drug's ability to enter the proximal tubule and cause a buildup of phospholipids in the lysosomes, inhibiting their function. Exposure to aminoglycosides in utero can result in permanent ototoxicity. The mechanism of ototoxicity is through the drug's ability to freely pass into hair cells and cause reactive oxygen species to damage the mitochondria, resulting in cell death. There is not a substantial amount of research regarding the prevention and treatment of adverse effects of aminoglycosides. Future research on the mediation or modulation of these pathophysiological processes would expand their usage in modern medicine.

A randomised controlled trial of rosuvastatin for the prevention of aminoglycoside-induced kidney toxicity in children with cystic fibrosis

The PROteKT study tested the hypothesis that rosuvastatin can inhibit aminoglycoside-induced nephrotoxicity in children with Cystic Fibrosis (CF). This open label, parallel group, randomised controlled trial recruited children and young people aged 6 to 18 years with CF at 13 paediatric CF treatment centres in the UK. Participants were randomised equally to either receive oral rosuvastatin (10 mg once daily) or no intervention (control) throughout clinically indicated treatment with intravenous tobramycin. The primary outcome was the difference between the groups in mean fold-change in urinary Kidney Injury Molecule-1 (KIM-1). Fifty (rosuvastatin n = 23, control n = 27) participants were recruited between May 2015 and January 2017. Primary outcome data was available for 88% (rosuvastatin n = 20, control n = 24). The estimated mean treatment difference in the geometric mean-fold change of normalised KIM-1 was 1.08 (95% CI 0.87–1.35, p = 0.48). In total there were 12 adverse reactions, all mild, reported by five participants randomised to rosuvastatin, and one serious adverse event in each group. Whilst no protective effect of rosuvastatin was seen, there was a lower than expected level of nephrotoxicity in the cohort. Therefore, we can neither confirm nor refute the hypothesis that rosuvastatin protects against aminoglycoside nephrotoxicity.

Development of a Novel Pharmaceutical Formula of Nanoparticle Lipid Carriers of Gentamicin/α-Tocopherol and In Vivo Assessment of the Antioxidant Protective Effect of α-Tocopherol in Gentamicin-Induced Nephrotoxicity

Gentamicin is a potent antibiotic with a nephrotoxicity drawback which limits its use. D-α-tocopherol polyethylene glycol succinate (α-tocopherol) is widely used as a surfactant and have potent antioxidant properties. This study aimed to assess the protective effect of α-tocopherol on gentamicin-induced nephrotoxicity by loading gentamicin on nanostructured lipid carriers (NLC). In vivo, the product was administered intravenously to three groups of rabbits (control, gentamicin and gentamicin/α-tocopherol NLC) for 10 consecutive days. Blood was collected on days 1, 5 and 10 to assess renal function. A significant difference in all plasma parameters related to kidney function were observed in the gentamicin group compared to the control by day 5 and 10, confirming the nephrotoxicity effect. On the other hand, the same parameter levels of the NLC group were significantly different compared to the gentamicin group, confirming the protective effect on kidney function. Gentamicin also caused significant decreases in plasma levels of glutathione sulfhydryl (GSH) and superoxide dismutase (SOD) activity. However, gentamicin-α-tocopherol NLC significantly elevates both plasma levels of GSH as well as SOD activity. The present work indicates that, loading of gentamicin on NLC by using α-tocopherol, is an innovative strategy to protect against aminoglycoside-induced nephrotoxicity due to its antioxidant activity.

Pentoxifylline May Restore Kanamycin-Induced Renal Damage in Rats

Background: Kidney damage can be caused by many factors, such as using certain drugs in high doses or over the longterm. The use of one such group of drugs, aminoglycosides, which act as Gram-negative antibacterial therapeutic agents,can lead to nephrotoxicity. It has been hypothesized that aminoglycoside-induced nephrotoxicity might be prevented byusing pentoxifylline, which has antioxidant and anti-inflammatory effects and improves microcirculation. The objectiveof this present research was to determine the protective effects of pentoxifylline on kanamycin-induced kidney damage.Materials, Methods & Results: Thirty-two male Wistar rats were divided into four groups as follows: control, pentoxifylline,kanamycin, and kanamycin + pentoxifylline. The control group received intraperitoneal (IP) injections of 0.5 mL normalsaline solution once a day (d) (SID) for 20 d; the pentoxifylline group received IP injections of 50 mg/kg pentoxifyllinetwice a day (BID) for 20 d, the kanamycin group received subcutaneous (SC) injections of 500 mg/kg kanamycin SID for20 d, and the kanamycin + pentoxifylline group received both SC injections of 500 mg/kg kanamycin SID and IP injectionsof 50 mg/kg pentoxifylline BID for 20 d. At the end of 20 d, blood samples were taken from the heart by cardiac punctureunder general anesthesia. After euthanizing the rats by cervical dislocation under anesthesia, the kidneys were immediatelyremoved, relative kidney weights were calculated, and routine pathologic evaluations were conducted. Hemogramparameters were measured using a blood cell count apparatus and serum biochemical parameters were measured usingan autoanalyzer. Kanamycin also caused (P < 0.05) tubular degeneration and tubular dilatation. Although pentoxifyllinesignificantly reduced the level of kanamycin-induced tubular degeneration (P < 0.05), it did not significantly reduce tubulardilatation. Increases in relative kidney weights (P < 0.05) and in interstitial mononuclear cell (MNC) infiltrates wereobserved in the kanamycin and kanamycin + pentoxifylline groups compared to those in the control and pentoxifyllinegroups. Statistically significant changes were determined in the levels of some hemogram and biochemical parameterswithin reference ranges (P < 0.05).Discussion: In this study, both tubular degeneration and dilatation were observed in the kanamycin group. Pentoxifyllineinhibited (P < 0.05) kanamycin-induced tubular degeneration and appeared to also reduce tubular dilatation, although thisreduction was not significant. Tubular necrosis, epithelial edema of proximal tubules, tubular fibrosis, and perivascularinflammation might also be observed in aminoglycoside-induced nephrotoxicity. In current research, pentoxifylline preventedtubular damage induced by kanamycin, but did not inhibit infiltration by MNCs. Pentoxifylline also amelioratedamikacin- or gentamycin-induced histopathologic changes, especially those associated with tubular structures. The protectiveeffects of pentoxifylline on kanamycin-induced tubular nephrotoxicity in this research might be a result of its stimulatingthe production of prostaglandin, a vasodilator, and of its improving microcirculation. Although the anti-inflammatoryeffects of pentoxifylline have been reported, these did not inhibit kanamycin-induced infiltration by interstitial MNCs inthe present study. These results could indicate that the anti-inflammatory effects of pentoxifylline are not obvious and/orare dose dependent. Statistically significantly changes were determined in the levels of some hemogram and biochemicalparameters in reference ranges. However, these changes were within the reference ranges for rats. These results suggestedthat kanamycin-induced tubular degeneration and dilatation might be prevented by administering pentoxifylline.

Urinary Biomarkers of Aminoglycoside-Induced Nephrotoxicity in Cystic Fibrosis: Kidney Injury Molecule-1 and Neutrophil Gelatinase-Associated Lipocalin

Aminoglycosides are commonly used for the treatment of pulmonary exacerbations in patients with cystic fibrosis (CF). However, they are potentially nephrotoxic. This prospective observational cohort study aimed to investigate the potential validity of two urinary renal biomarkers, Kidney Injury Molecule-1 (KIM-1) and Neutrophil Gelatinase-associated Lipocalin (NGAL), in identifying aminoglycoside-induced nephrotoxicity in children with CF. Children and young adults up to 20 years of age with a confirmed diagnosis of CF were recruited from ten United Kingdom hospitals. Participants provided urine samples for measurement of KIM-1 and NGAL concentrations, at baseline, at regular outpatient appointments, and before, during and after exposure to clinically-indicated treatment with the aminoglycoside tobramycin. 37/158 patients recruited (23.4%) received at least one course of IV tobramycin during the study. The median peak fold-change during tobramycin exposure for KIM-1 was 2.28 (IQR 2.69) and 4.02 (IQR 7.29) for NGAL, in the absence of serum creatinine changes. Baseline KIM-1 was positively associated with cumulative courses of IV aminoglycosides (R2 = 0.11; β = 0.03; p < 0.0001). KIM-1, in particular, may be a useful, non-invasive, biomarker of acute and chronic proximal tubular injury associated with exposure to aminoglycosides in patients with CF, but its clinical utility needs to be further evaluated in prospective studies.

Repurposing Statins for Renal Protection: Is It a Class Effect?

There has been a great deal of excitement regarding the potential benefits of statins beyond their lipid-lowering effect, and repurposing them for other indications. In this commentary, we evaluate the role of statins in protecting the kidneys, with a focus on three areas: cardiac surgery, contrast-induced nephropathy, and aminoglycoside-induced nephrotoxicity.

O-37 Preventing aminoglycoside-induced nephrotoxicity using statins: an example of bench-to-bedside research

Background Megalin-mediated endocytosis is the prin-cipal pathway for the accumulation of aminoglycosides in proximal tubule epithelial cells,1 resulting in kidney toxicity. Activation of this pathway depends on intermediates derived from mevalonate, the product of 3-hydroxy-3-meth-ylglutaryl-coenzyme A (HMG-CoA) reduction, catalysed by HMG-CoA reductase.2 We hypothesised that inhibition of HMG-CoA reductase by statins would reduce uptake of aminoglycosides in the proximal tubule, leading to a re-duction in toxicity. This has previously been demonstrated in vitro.3 We tested this in two in vivo models. Methods Sprague Dawley rats, (n=4/group) received in-traperitoneal (IP) dosing with saline (control), gentamicin (200 mg/kg/day), rosuvastatin (40 mg/kg/day), or gentami-cin and rosuvastatin for 9 days. Nephrotoxicity was measured using urinary N-Acetyl-β-d-glucosaminidase (NAG) and kidney injury molecule-1 (kim-1) on urine samples collected within 24 hours after the final dose. Male Hartley guinea pigs (n=6/group) received IP dosing with saline (control), gentamicin (100 mg/kg/day), statin, or combined gentami-cin and statin (simvastatin or rosuvastatin, 0.4 to 40 mg/kg/day) for 9 days. Nephrotoxicity was measured using serum creatinine and blood urea nitrogen (BUN) on urine samples collected within 24 hours after the final dose. Results In rats co-administered rosuvastatin and gentami-cin, urinary concentrations of NAG and kim-1 were signifi-cantly lower than for gentamicin alone (p Conclusion Rosuvastatin inhibits gentamicin-induced nephrotoxicity in both rat and guinea pig models; in the latter, at therapeutic doses used in humans. This led to an RCT in children which has just completed recruitment. This bench-to-bedside translational research showcases the exciting area of drug repurposing with potential for signifi-cant patient benefit.

Morphological methods to evaluate protective agents against aminoglycoside-induced nephrotoxicity.

Implication for health policy/practice/research/medical education Since morphological evaluations of renal tissue are imperative in the search for treatments against aminoglycoside nephrotoxicity, this kind of studies must pay attention to preparative techniques, such as the most sensible staining method. In our opinion, all the affected compartments (tubules, interstitium and glomeruli) should be analyzed and finally, the assessments should be carried out by trained personnel using unbiased methods.

Chitosan Prevents Gentamicin-Induced Nephrotoxicity via a Carbonyl Stress-Dependent Pathway.

Aminoglycosides are widely used to treat infections; however, their applications are limited by nephrotoxicity. With the increase of antibiotic resistance, the use of aminoglycosides is inevitable. Low-molecular-weight chitosan (LMWC) has shown renal protective effects in dialysis patients. However, no study has evaluated LMWC for preventing aminoglycoside-induced nephrotoxicity or determined the mechanisms underlying the renal protective effects. In this study, LMWC (165 or 825 mg/kg/day) or metformin (100 mg/kg/day) was orally administered for 13 days to rats with nephropathy induced by gentamicin (GM), a kind of aminoglycoside (150 mg/kg/day i.p. for 6 days). Both LMCW doses improved renal function. Serum creatinine levels improved in rats treated with 165 and 825 mg/kg/day LMWC (from 2.14 ± 0.74 mg/dL to 1.26 ± 0.46 mg/dL and 0.69 ± 0.12 mg/dL, resp., P < 0.05). Blood urea nitrogen levels were also improved in these rats (from 73.73 ± 21.13 mg/dL to 58.70 ± 22.71 mg/dL and 28.82 ± 3.84 mg/dL, resp., P < 0.05). Additionally, renal tissue morphology improved after LMWC treatment, and accumulation of renal methylglyoxal, a damage factor associated with carbonyl stress, was reversed. These results show that LMWC prevents GM-induced renal toxicity via a carbonyl stress-dependent pathway.

Renoprotective effect of red ginseng in gentamicin-induced acute kidney injury

Aminoglycoside-induced nephrotoxicity is one of the prevalent causes of acute kidney injury (AKI). Oxidative stress-mediated apoptosis of renal tubular cells is known to be a major mechanism of renal injury. Red ginseng extract (RGE) has been reported to possess antioxidant and immune-modulatory activities. We investigated the effect of RGE on gentamicin (GM)-induced apoptosis and oxidative stress in cultured renal tubular cells and animal model of GM-induced AKI. GM induced the generation of reactive oxygen species (ROS) with an increase in NADPH oxidase (NOX) activity and mitochondrial oxidation in NRK-52E cells that were ameliorated with RGE. GM-induced apoptosis of NRK-52E cells, which was associated with an increased expression of mitochondrial Bax, cytosolic cytochrome c, and cleaved caspase-9 and -3, along with a decrease in bcl-2 expression, was also blocked by RGE. In an animal model of GM-induced AKI, RGE treatment significantly attenuated renal dysfunction, cell apoptosis, and tubular damage. RGE ameliorated ROS production in rats with GM-induced AKI, as demonstrated by an increase in the reduced form of glutathione in renal cortex and a decrease in urinary excretion of 8-hydroxy-2′-deoxyguanosine. Our results suggest that RGE protects the kidney from GM-induced AKI via the mechanism of modulation of oxidative stress.

Aminoglycoside-Induced Nephrotoxicity

Aminoglycosides are among the oldest antibiotics available to treat serious infections caused by primarily, Gram-negative bacteria. The most commonly utilized parenteral agents in this class include gentamicin, tobramycin and amikacin. Aminoglycosides are concentration-dependent, bactericidal agents that undergo active transport into the cell where they inhibit protein synthesis on the 30S subunit of the bacterial ribosome. As the use of aminoglycosides became more widespread, the toxic effects of these agents, most notably ototoxicity and nephrotoxicity, became more apparent. When other, safer, antimicrobial agents became available, the use of aminoglycosides sharply declined. The development of multi-drug resistance among bacteria has now lead clinicians to reexamine the role of the aminoglycosides in the treatment of serious infections. This review will revisit the mechanism and risk factors for the development of aminoglycoside-induced nephrotoxicity, as well as strategies to prevent patients from developing nephrotoxicity.

Aminoglycoside-Induced Nephrotoxicity—A Focus on Monitoring

The use of aminoglycoside (AG) antibiotics has declined over the past 15 years primarily due to comparable potency of other antimicrobials and the nephrotoxicity potential of AG drugs. However, resurgence in the use of AG antimicrobials is occurring due to multidrug-resistant gram-negative nosocomial infections. Multidrug-resistant Pseudomonas and Acinetobacter isolates as well as extended-spectrum beta-lactamase–producing Enterobacteriaceae continue to force clinicians to consider AG therapy for nosocomial infections in hospitalized patients and enterococcal endocarditis. Additionally, AGs are still indicated in the treatment of pulmonary exacerbations of cystic fibrosis. Along with the use of AG antibiotics is the associated renal insufficiency complication. This review discusses the mechanism for AG-induced nephrotoxicity. Patient- and drug-related risk factors are discussed to help identify patients at increased risk. The issue of serum-level monitoring is discussed relative to the development of nephrotoxicity.

Entry of aminoglycosides into renal tubular epithelial cells via endocytosis-dependent and endocytosis-independent pathways

Aminoglycoside antibiotics such as gentamicin and amikacin are well recognized as a clinically important antibiotic class because of their reliable efficacy and low cost. However, the clinical use of aminoglycosides is limited by their nephrotoxicity and ototoxicity. Nephrotoxicity is induced mainly due to high accumulation of the antibiotics in renal proximal tubular cells. Therefore, a lot of studies on characterization of the renal transport system for aminoglycosides so far reported involved various in-vivo and in-vitro techniques. Early studies revealed that aminoglycosides are taken up through adsorptive endocytosis in renal epithelial cells. Subsequently, it was found that megalin, a multiligand endocytic receptor abundantly expressed on the apical side of renal proximal tubular cells, can bind aminoglycosides and that megalin-mediated endocytosis plays a crucial role in renal accumulation of aminoglycosides. Therefore, megalin has been suggested to be a promising molecular target for the prevention of aminoglycoside-induced nephrotoxicity. On the other hand, recently, some reports have indicated that aminoglycosides are transported via a pathway that does not require endocytosis, such as non-selective cation channel-mediated entry, in cultured renal tubular cells as well as cochlear outer hair cells. In this commentary article, we review the cellular transport of aminoglycosides in renal epithelial cells, focusing on endocytosis-dependent and -independent pathways.

Gentamicin Induced Neurodegenrative Changes in Auditory Cortex of Adult Albino Rats

Background: Aminoglycoside-induced nephrotoxicity and ototoxicity is a major clinical problem. Aminoglycosides have good activity against many multi-drug resistant Gram-negative bacilli and are therefore important for treating serious infections due to these organisms in adults and children including neonates. Gentamicin, due to it cost effectiveness has been used in most of the trials as compared to other aminoglycosides. Most studies documented the peripheral toxicities of gentamicin without any concern of central neurotoxicity. Objective: To observe Gentamicin induced neurodegenerative changes in auditory cortex of adult albino rats. Methods: It was an experimental study. Twenty rats were randomly divided in two groups; Group I (Experimental: n = 10) received intramuscular injection of Gentamicin for twenty-one days and Group II (Control: n =10) received normal saline intramuscularly. Histological preparations were done on sections obtained from the area around lateral sulcus of rat cortex. The photomicrographs of the relevant stained sections were taken with the aid of a light microscope. Results: Light microscopic examination of the auditory cortex sections obtained from gentamicin injected rats (Group I) revealed severe neurodegenerative changes as compared to the rats in (Group II). Conclusion: Exposure of rats to Gentamicin for three weeks showed severe neurodegenerative changes.

Mechanism-Based Urinary Biomarkers to Identify the Potential for Aminoglycoside-Induced Nephrotoxicity in Premature Neonates: A Proof-of-Concept Study

Premature infants are frequently exposed to aminoglycoside antibiotics. Novel urinary biomarkers may provide a non-invasive means for the early identification of aminoglycoside-related proximal tubule renal toxicity, to enable adjustment of treatment and identification of infants at risk of long-term renal impairment. In this proof-of-concept study, urine samples were collected from 41 premature neonates (≤32 weeks gestation) at least once per week, and daily during courses of gentamicin, and for 3 days afterwards. Significant increases were observed in the three urinary biomarkers measured (Kidney Injury Molecule-1 (KIM-1), Neutrophil Gelatinase-associated Lipocalin (NGAL), and N-acetyl-β-D-glucosaminidase (NAG)) during treatment with multiple courses of gentamicin. When adjusted for potential confounders, the treatment effect of gentamicin remained significant only for KIM-1 (mean difference from not treated, 1.35 ng/mg urinary creatinine; 95% CI 0.05–2.65). Our study shows that (a) it is possible to collect serial urine samples from premature neonates, and that (b) proximal tubule specific urinary biomarkers can act as indicators of aminoglycoside-associated nephrotoxicity in this age group. Further studies to investigate the clinical utility of novel urinary biomarkers in comparison to serum creatinine need to be undertaken.

Measurement of the urinary biomarker KIM-1 identifies the potential for aminoglycoside-induced nephrotoxicity in premature neonates

Measurement of the urinary biomarker KIM-1 identifies the potential for aminoglycoside-induced nephrotoxicity in premature neonates

Urinary KIM-1 as a Biomarker of Aminoglycoside-Induced Nephrotoxicity in Premature Neonates

Urinary KIM-1 as a Biomarker of Aminoglycoside-Induced Nephrotoxicity in Premature Neonates

Aminoglycoside-induced nephrotoxicity studied by proton magnetic resonance spectroscopy of urine

Acute kidney injury is a relatively common complication of aminoglycoside therapy that affects 10-20% of patients receiving antibiotics of this class. Although the vast majority of patients do recover, the presence of certain risk factors may alter the clinical presentation and result in permanent renal damage. Thus, aminoglycoside-induced nephrotoxicity is a major concern and early diagnosis is critical. The aim of the present study was to characterize the early stages of aminoglycoside-induced nephrotoxicity using proton nuclear magnetic resonance ((1)H NMR) spectroscopy of urine. We studied 19 previously healthy patients who were hospitalized in our clinic due to bacterial infections. Combined antibiotic treatment with amikacin (1 g once daily) and a beta-lactam antibiotic was instituted in all patients. Urine and blood samples were collected before and after 5 days of aminoglycoside treatment. (1)H NMR spectroscopic data showed increased amounts of alanine and lactic acid (+138 and +255% compared to baseline values, respectively) and decreased hippurate (-50%) after aminoglycoside treatment. In addition, fractional excretions of sodium, magnesium and calcium were significantly increased (+271, +295 and +60%, respectively). These findings indicate that aminoglycosides can affect nephron tubules through two unrelated mechanisms that produce a partial 'Fanconi-like syndrome' and a 'Bartter-like syndrome'. However, because none of the study participants developed renal failure, these alterations are probably reversible and should not be used as sensitive or specific indicators of impending renal insufficiency. Our study findings confirm that aminoglycosides can induce both proximal and distal renal tubular dysfunction. However, it remains unclear whether the early functional changes detected by (1)H NMR spectroscopy in patients treated with aminoglycosides are of prognostic value.

CLIMP-63 is a gentamicin-binding protein that is involved in drug-induced cytotoxicity

Aminoglycoside-induced nephrotoxicity and ototoxicity is a major clinical problem. To understand how aminoglycosides, including gentamicin, induce cytotoxicity in the kidney proximal tubule and the inner ear, we identified gentamicin-binding proteins (GBPs) from mouse kidney cells by pulling down GBPs with gentamicin–agarose conjugates and mass spectrometric analysis. Among several GBPs specific to kidney proximal tubule cells, cytoskeleton-linking membrane protein of 63 kDa (CLIMP-63) was the only protein localized in the endoplasmic reticulum, and was co-localized with gentamicin-Texas Red (GTTR) conjugate after cells were treated with GTTR for 1 h. In western blots, kidney proximal tubule cells and cochlear cells, but not kidney distal tubule cells, exhibited a dithiothreitol (DTT)-resistant dimer band of CLIMP-63. Gentamicin treatment increased the presence of DTT-resistant CLIMP-63 dimers in both kidney proximal (KPT11) and distal (KDT3) tubule cells. Transfection of wild-type and mutant CLIMP-63 into 293T cells showed that the gentamicin-dependent dimerization requires CLIMP-63 palmitoylation. CLIMP-63 siRNA transfection enhanced cellular resistance to gentamicin-induced toxicity, which involves apoptosis, in KPT11 cells. Thus, the dimerization of CLIMP-63 is likely an early step in aminoglycoside-induced cytotoxicity in the kidney and cochlea. Gentamicin also enhanced the binding between CLIMP-63 and 14-3-3 proteins, and we also identified that 14-3-3 proteins are involved in gentamicin-induced cytotoxicity, likely by binding to CLIMP-63.

A guideline for the inpatient care of children with pyelonephritis

BACKGROUND AND OBJECTIVES:Febrile urinary tract infections and pyelonephritis are common in children and frequently lead to hospitalization for management, especially in the child who appears toxic. The American Academy of Pediatrics (AAP) practice parameter on the diagnosis, treatment and evaluation of the initial urinary tract infection in febrile infants and young children provides experience and evidence-based guidelines for the practitioner caring for children between the ages of 2 months to 2 years. No established guideline exists for older children and the AAP guideline does not specifically focus on inpatient care.METHODS:We conducted a comprehensive review of recently published literature and practice guidelines to develop a consensus on the inpatient diagnosis and management of children with pyelonephritis.RESULTS:Eight recommendations are proposed for the diagnosis and management, including revised guidelines for the imaging studies postpyelonephritis on the basis of current best evidence.CONCLUSION:Proper diagnosis of pyelonephritis, timely initiation of appropriate therapy and identification of children at risk for renal injury will help to reduce immediate as well as long-term complications due to chronic kidney disease.