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Acute Pyelonephritis

Variant: 1   Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US abdomen Usually Not Appropriate O
US color Doppler kidneys and bladder retroperitoneal Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
Fluoroscopy antegrade pyelography Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen and pelvis without IV contrast Usually Not Appropriate O
MRI abdomen without and with IV contrast Usually Not Appropriate O
MRI abdomen without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
MRU without IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
DMSA renal scan Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 2   Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢
US abdomen May Be Appropriate O
US color Doppler kidneys and bladder retroperitoneal May Be Appropriate O
MRI abdomen and pelvis without and with IV contrast May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen with IV contrast May Be Appropriate (Disagreement) ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
Fluoroscopy antegrade pyelography Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen without and with IV contrast Usually Not Appropriate O
MRI abdomen without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
MRU without IV contrast Usually Not Appropriate O
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
DMSA renal scan Usually Not Appropriate ☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 3   Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Appropriate ☢☢☢☢
US abdomen May Be Appropriate O
US color Doppler kidneys and bladder retroperitoneal May Be Appropriate O
MRI abdomen and pelvis without and with IV contrast May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen without and with IV contrast May Be Appropriate (Disagreement) ☢☢☢☢
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
Fluoroscopy antegrade pyelography Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen without and with IV contrast Usually Not Appropriate O
MRI abdomen without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
MRU without IV contrast Usually Not Appropriate O
CT abdomen with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
DMSA renal scan Usually Not Appropriate ☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 4   Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US abdomen May Be Appropriate (Disagreement) O
US color Doppler kidneys and bladder retroperitoneal May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
MRI abdomen without IV contrast May Be Appropriate O
MRU without IV contrast May Be Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
Fluoroscopy antegrade pyelography Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast Usually Not Appropriate O
MRI abdomen without and with IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
CT abdomen and pelvis with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without IV contrast Usually Not Appropriate ☢☢☢
CT abdomen with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
DMSA renal scan Usually Not Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast Usually Not Appropriate ☢☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Variant: 5   Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
Procedure Appropriateness Category Relative Radiation Level
US duplex Doppler kidney transplant Usually Appropriate O
CT abdomen and pelvis with IV contrast Usually Appropriate ☢☢☢
MRI abdomen and pelvis without and with IV contrast May Be Appropriate O
MRI abdomen and pelvis without IV contrast May Be Appropriate O
CT abdomen and pelvis without IV contrast May Be Appropriate ☢☢☢
CT abdomen and pelvis without and with IV contrast May Be Appropriate ☢☢☢☢
US abdomen Usually Not Appropriate O
US color Doppler kidneys and bladder retroperitoneal Usually Not Appropriate O
Fluoroscopy voiding cystourethrography Usually Not Appropriate ☢☢
Fluoroscopy antegrade pyelography Usually Not Appropriate ☢☢☢
Radiography abdomen and pelvis Usually Not Appropriate ☢☢☢
Radiography intravenous urography Usually Not Appropriate ☢☢☢
MRI abdomen without and with IV contrast Usually Not Appropriate O
MRI abdomen without IV contrast Usually Not Appropriate O
MRI pelvis without and with IV contrast Usually Not Appropriate O
MRI pelvis without IV contrast Usually Not Appropriate O
MRU without and with IV contrast Usually Not Appropriate O
MRU without IV contrast Usually Not Appropriate O
CT abdomen with IV contrast Usually Not Appropriate ☢☢☢
CT abdomen without IV contrast Usually Not Appropriate ☢☢☢
DMSA renal scan Usually Not Appropriate ☢☢☢
CT abdomen without and with IV contrast Usually Not Appropriate ☢☢☢☢
CTU without and with IV contrast Usually Not Appropriate ☢☢☢☢

Panel Members
Summary of Literature Review
Introduction/Background
Special Imaging Considerations
Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

  • There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

OR

  • There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).
Discussion of Procedures by Variant
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
A. CT Abdomen and Pelvis
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
B. CT Abdomen
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
C. CTU
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
D. DMSA Renal Scan
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
E. Fluoroscopy Antegrade Pyelography
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
F. Fluoroscopy Voiding Cystourethrography
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
G. MRI Abdomen and Pelvis
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
H. MRI Abdomen
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
I. MRU
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
J. Radiography Abdomen and Pelvis
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
K. Radiography Intravenous Urography
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
L. US Abdomen
Variant 1: Suspected acute pyelonephritis. First-time presentation. Uncomplicated patient (eg, no history of pyelonephritis, diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
M. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
A. CT Abdomen and Pelvis
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
B. CT Abdomen
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
C. CTU
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
D. DMSA Renal Scan
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
E. Fluoroscopy Antegrade Pyelography
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
F. Fluoroscopy Voiding Cystourethrography
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
G. MRI Abdomen and Pelvis
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
H. MRI Abdomen
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
I. MRU
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
J. Radiography Abdomen and Pelvis
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
K. Radiography Intravenous Urography
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
L. US Abdomen
Variant 2: Suspected acute pyelonephritis. Complicated patient (eg, recurrent pyelonephritis, diabetes, immune compromise, advanced age, vesicoureteral reflux, or lack of response to initial therapy). Initial imaging.
M. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
A. CT Abdomen and Pelvis
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
B. CT Abdomen
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
C. CTU
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
D. DMSA Renal Scan
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
E. Fluoroscopy Antegrade Pyelography
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
F. Fluoroscopy Voiding Cystourethrography
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
G. MRI Abdomen and Pelvis
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
H. MRI Abdomen
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
I. MRU
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
J. Radiography Abdomen and Pelvis
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
K. Radiography Intravenous Urography
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
L. US Abdomen
Variant 3: Suspected acute pyelonephritis. History of renal stones or renal obstruction. Initial imaging.
M. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
A. CT Abdomen and Pelvis
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
B. CT Abdomen
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
C. CTU
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
D. DMSA Renal Scan
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
E. Fluoroscopy Antegrade Pyelography
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
F. Fluoroscopy Voiding Cystourethrography
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
G. MRI Abdomen and Pelvis
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
H. MRI Abdomen
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
I. MRU
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
J. Radiography Abdomen and Pelvis
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
K. Radiography Intravenous Urography
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
L. US Abdomen
Variant 4: Suspected acute pyelonephritis. Pregnant female with no other complications (eg, no history of diabetes, immune compromise, history of stones or renal obstruction, prior renal surgery, vesicoureteral reflux, or lack of response to therapy). Initial imaging.
M. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
A. CT Abdomen and Pelvis
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
B. CT Abdomen
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
C. CTU
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
D. DMSA Renal Scan
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
E. Fluoroscopy Antegrade Pyelography
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
F. Fluoroscopy Voiding Cystourethrography
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
G. MRI Abdomen and Pelvis
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
H. MRI Abdomen
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
I. MRI Pelvis
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
J. MRU
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
K. Radiography Abdomen and Pelvis
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
L. Radiography Intravenous Urography
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
M. US Abdomen
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
N. US Color Doppler Kidneys and Bladder Retroperitoneal
Variant 5: Suspected acute pyelonephritis. History of pelvic renal transplant with native kidneys in situ and no other complications (eg, no history of pyelonephritis, diabetes, history of stones or renal obstruction, prior renal surgery, advanced age, vesicoureteral reflux, lack of response to therapy, or pregnancy). Initial imaging.
O. US Duplex Doppler Kidney Transplant
Summary of Recommendations
Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Safety Considerations in Pregnant Patients

Imaging of the pregnant patient can be challenging, particularly with respect to minimizing radiation exposure and risk. For further information and guidance, see the following ACR documents:

·        ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI)

·        ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation

·        ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound

·        ACR Manual on Contrast Media

·        ACR Manual on MR Safety

Appropriateness Category Names and Definitions

Appropriateness Category Name

Appropriateness Rating

Appropriateness Category Definition

Usually Appropriate

7, 8, or 9

The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.

May Be Appropriate

4, 5, or 6

The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.

May Be Appropriate (Disagreement)

5

The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.

Usually Not Appropriate

1, 2, or 3

The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.
Relative Radiation Level Information
References
1. Johnson JR, Russo TA. Acute Pyelonephritis in Adults. N Engl J Med 2018;378:48-59.
2. Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 2007;45:273-80.
3. Stamm WE, Hooton TM, Johnson JR, et al. Urinary tract infections: from pathogenesis to treatment. J Infect Dis 1989;159:400-6.
4. Talan DA, Takhar SS, Krishnadasan A, et al. Fluoroquinolone-Resistant and Extended-Spectrum beta-Lactamase-Producing Escherichia coli Infections in Patients with Pyelonephritis, United States(1). Emerg Infect Dis 2016;22:1594-603.
5. Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005;142:20-7.
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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked.  Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.