Kidney Infection: Backention and Treatment

The urinary tract is made up of a pair of kidneys, which make urine by filtering the waste products from the blood. Thin tubes known as ureters stem from each kidney and drain the urine into the bladder, which stores the urine until it is excreted out of the body through another tube called a urethra.

Often times, infection-causing bacteria find their way into the urinary tract through the genitals, moving upstream from the urethra to the bladder and traveling up the ureters to infect the kidneys.

At its nascent stages when the infection is restricted to the bladder, the condition is referred to as cystitis. This is a relatively common urinary tract infection and is not associated with any serious damage apart from making urination quite painful and discomforting.

However, if not treated properly, cystitis can progress into a more serious condition as the bacteria multiply and migrate further to infect one or both the kidneys. Although such a kidney infection is relatively easy to cure if caught early, delayed or negligent treatment can cause the bacteria to spread to your bloodstream and cause life-threatening complications. Moreover, the risk of permanent kidney damage also increases.

Some kidney infections can develop without a bladder infection and are due to a problem within the kidney itself. As an example, people with kidney stones or an abnormality of the kidney are more susceptible to kidney infections.

Note: Consult a doctor for proper diagnosis and treatment of this condition. Use home remedies just as an adjunct treatment. Discuss with your doctor before taking any herbal supplements as some herbs and spices can interact with medications.

Types of Kidney Infection

Acute kidney infection refers to a relatively non-threatening form of pyelonephritis wherein the problem resolves completely when adequately treated. However, the condition is said to be chronic if the disease-causing bacteria continue to persist despite the prescribed treatment. As a result, the infection keeps recurring. This kind of sustained damage can severely compromise your kidney function.

Chronic pyelonephritis can even lead to the release of bacteria into the bloodstream, paving the way for subsequent infections in the opposite kidney or elsewhere in the body.

This long-standing condition is usually rooted in certain underlying abnormalities, such as a structural blockage in the urinary tract, large kidney stones that persist, and vesicoureteral reflux, a condition that causes small amounts of urine to flow backward from the bladder into the kidneys or cysts in the kidney.

Although chronic pyelonephritis is comparatively uncommon, most cases are reported in children and people with urinary blockages.

Causes of a Kidney Infection

  • Bacteria that usually reside in the gut area have easy access into the urinary tract through the anus or vagina. Once these pathogens enter the urethra, they proliferate and spread, eventually gaining entry into the kidneys through the ureters. The most common culprit is Escherichia coli, which is responsible for about 90 percent of cases of pyelonephritis among people who are not hospitalized or living in a nursing home.
  • Any physical obstruction to the flow of urine on account of structural deformities, kidney stone, or benign prostatic hyperplasia (enlarged prostate gland). Another common precipitating factor for pyelonephritis is a condition called vesicoureteral reflux, which causes the backflow of urine from the bladder into the ureters and thereby to the kidneys.
  • About 5 percent of pyelonephritis cases can be traced back to infections that are carried through the bloodstream to the kidneys from another part of the body. For instance, a staphylococcal skin infection can breach the skin to make its way to your blood and eventually spread to the kidneys through the bloodstream.
  • Even more rarely, you might contract a kidney infection in the aftermath of a kidney surgery.

Symptoms of a Kidney Infection

It takes between a few hours to a day for the symptoms of acute pyelonephritis to manifest. Some of the most commonly reported indicators of a probable kidney infection include:

  • Running a fever of over 99.9 F
  • Shivering or chills
  • Dull to severe pain and tenderness on either side of the lower back
  • General feeling of being unwell
  • Vomiting
  • Diarrhea

Children with acute pyelonephritis may also exhibit additional symptoms, such as:

  • Low levels of energy resulting in constant lethargy
  • Irritability
  • Poor appetite and/or vomiting
  • Abdominal pain
  • Jaundiced appearance characterized by yellowing of the skin and the whites of the eyes
  • Blood in the urine
  • Foul-smelling urine
  • Tendency to wet the bed

Around one in three people with acute pyelonephritis will also have symptoms of a lower urinary tract infection (cystitis). These can include:

  • Dysuria or a stinging or burning sensation when urinating
  • Increasingly persistent and frequent need to urinate
  • Pressing urge to urinate even if you pass very little or no urine
  • Passing urine that is cloudy or dark colored
  • Passing urine that may have a strong, unpleasant smell
  • Blood or pus in your urine

Children with long-standing pyelonephritis can exhibit signs and symptoms of poor growth and failure to thrive.

Risk Factors of a Kidney Infection

Some people run a higher risk of developing kidney infections than others due to the following factors:

  • People who suffer from a bladder infection are naturally susceptible to a potential escalation of their condition to the kidneys.
  • Kidney infections tend to be more prevalent among women than men due to the shorter length of their urethras. Many a time, bacteria can spread from the vaginal or anal openings to the urethra and then advance upwards in the urinary tract. Because the urethra is more closely located to the vagina and anus in women than it is in men, women show a greater likelihood of picking up such infections.
  • People with structural defects in their urinary tract may find it harder to pass urine and are therefore at an increased risk for infection.
  • People whose urinary tract is obstructed by the presence of uterine fibroids, benign prostatic hyperplasia, and kidney stones also belong to the high-risk category.
  • Pregnant women are also increasingly vulnerable to this infection as their burgeoning uterus can end up squeezing the ureters. As a result, the flow of urine is restricted, increasing the tendency to develop bacterial infections.
  • People with weakened immunity due to diseases such as diabetes or HIV or on account of certain drugs such as immunosuppressants have a greater predisposition for this disease.
  • Some people fail to pick up on the symptoms of an ongoing bladder infection due to preexisting nerve or spinal cord damage that renders them unable to feel the pain associated with this condition. A bladder infection that is not treated in a timely and proper fashion can lead to a subsequent kidney infection.
  • The bacteria can easily find their way into the urinary tract through a catheter that is used to drain urine from the bladder.
  • People who suffer from vesicoureteral reflux (VUR), a condition characterized by the backward flow of urine from the bladder towards the kidneys, are also susceptible.
  • People who have structural kidney problems such as polycystic kidney or kidney stones are at high risk of kidney infection.

Diagnosing a Kidney Infection

Given that the symptoms of a kidney infection can apply to certain other problems in the pelvis and abdomen, your doctor will have to conduct a thorough evaluation to reach a conclusive diagnosis.

To that end, your health care provider may use the following tests:

  • He/she will take a comprehensive overview of your medical history and inquire about your symptoms.
  • This will be followed by a general physical exam, wherein your doctor will examine your abdomen to check for pain or tenderness. Appropriate urine and blood tests will be done to evaluate for infection.
  • The doctor will order a urinalysis to check your urine for possible traces of bacterial infection. A urine culture will help the doctor determine the best antibiotic to use for eradicating the growth of bacteria.
  • A blood culture will help rule out the potential spread of infection to your bloodstream.
  • Although a CT scan does not figure as a standard test to diagnose kidney infections, it can help delineate possible blockages in the urinary tract that might be at the root of the problem.
  • Similarly, an ultrasound can guide treatment strategies by displaying probable obstructions in the form of stones or other things that block the urinary tract.
  • A voiding cystourethrogram (VCUG) is an x-ray image of the bladder and urethra taken while the bladder is full and during urination. It uses a contrast dye. This test can show problems in the urethra and bladder.
  • Men may be advised to go through a more comprehensive digital rectal examination (DRE) to look for signs of an enlarged prostate that may be blocking the neck of the bladder.
  • Dimercaptosuccinic acid (DMSA) scintigraphy is another imaging tool that is used to determine signs of kidney infection, scarring, and damage. The procedure entails the injection of a radioactive material through a vein in the arm which travels to the kidneys. Specially designed cameras and computers are used to generate images, tracking the movement of this material as it passes through the kidneys to see if they are working properly.

Your doctor will also look for problems that can cause kidney infection, such as kidney stones and birth defects. Your treatment will be based on a clear diagnosis of the problem.

Treatment for Pyelonephritis

The first line of treatment for pyelonephritis involves a doctor-prescribed course of antibiotics to eliminate the bacteria. The choice of drug will depend upon the bacteria detected on the urine tests.

If the infecting pathogen remains unidentified, your doctor will recommend a broad-spectrum antibiotic that will treat the most commonly seen bacteria in this condition. The severity of your symptoms helps decide the choice of antibiotic and duration of the treatment.

Although your condition will show signs of improvement within a few days of taking the antibiotic, it is imperative that you complete the full course of antibiotics prescribed by your doctor to ensure that the infection is completely eradicated.

On occasion, the doctor may change your medication after 2 days, particularly in the event that:

  • Your symptoms are not getting better.
  • The urine test results indicate the need for a different antibiotic.

Oral drugs sometimes prove ineffective and insufficient for treating severe kidney infections. People who exhibit particularly severe symptoms, such as considerable nausea and vomiting, persistently high fever, signs of dehydration, and debilitating pain, may need to be hospitalized for a few days.

Treatment in the hospital may include intravenous administration of antibiotics and fluids as well as regular sampling of your blood and urine to track the improvement of the infection. Your stay at the hospital usually depends upon how well you respond to the treatment, and once you are released, the doctor will give you 10 to 14 days’ worth of oral antibiotics to take home.

How Can You Backent a Kidney Infection?

A kidney infection generally results due to the advancement of preexisting bacteria from the lower urinary tract up to the kidneys. Thus, the ideal way to stave off the threat of kidney infections is by not having bacteria in the urethra or bladder. The following preventive steps can help in this regard:

  • Keep your body sufficiently hydrated by drinking plenty of water. The higher is your water intake, the higher are your chances of flushing out bacteria from the urethra while passing urine.
  • Holding off on the need to urinate is a complete no-no. Find a toilet to answer the call of nature as soon as you feel the urge. Develop a habit of going to the bathroom every 4–6 hours to urinate.
  • Emptying your bladder after having sexual intercourse can help eliminate any bacteria festering in the urethra. It is also recommended to wash the genitals before and after sex.
  • It is recommended to wipe the genitals from front to back after passing stools or urine, to reduce the risk of spreading bacteria to the urethra.
  • Eat plenty of fiber so that stools come out easily and do not irritate or cause skin lesions. Constipation increases the risk of developing a kidney infection.
  • Refrain from using feminine products that can irritate the urethra, such as deodorant sprays and douches.

When to See a Doctor

Kidney infections can take a turn for the worst if left untreated and lead to complications that can jeopardize your health to the extent of being fatal. Thus, it is paramount that you consult with your healthcare provider the minute you notice possible signs of pyelonephritis. The onset of certain symptoms particularly warrants the need for prompt medical assistance, which include:

  • If you run a high temperature
  • If you experience persistent pain in the abdomen, middle and lower back, or genitals
  • If you notice blood in your urine
  • If you are grappling with constant nausea and frequent vomiting
  • If you are already undergoing treatment for a UTI but the symptoms haven’t improved after a few days

Professional medical help is especially indispensable in the case of children who may have a kidney infection.

What Should You Expect from the Doctor?

The usual line of questioning that a doctor follows to evaluate your condition touches upon the following:

  • When did you first notice your symptoms?
  • Are your symptoms consistent or sporadic?
  • How would you rate your symptoms in terms of severity?
  • Are there are any mitigating factors that seem to make your symptoms better or less intense?
  • Are there any aggravating factors that tend to worsen your symptoms?

Complications

Negligent or delayed treatment of acute pyelonephritis can give rise to potentially serious complications:

  • There can be irreversible damage to the kidney tissue leading to chronic kidney disease or, rarely, kidney failure.
  • Pregnant women with infected kidneys have a higher likelihood of delivering low-birthweight babies.
  • Your kidneys are responsible for filtering waste from your blood and then returning the purified blood to the rest of your body. However, if bacteria start to breed within the kidneys, there is a chance that the infection could spill over into the bloodstream and spread to other parts of your body. This life-threatening condition is referred to as sepsis.
  • Severe kidney infection can lead to acute kidney failure.
  • Very rarely, there may be a buildup of pus within the infected kidney, resulting in the development of a kidney abscess. This may require a surgical procedure to drain the pus from the kidneys.
  • Your kidneys may be vulnerable to renal scarring, which is often accompanied by chronic kidney disease.

What Does Chronic Pyelonephritis Entail?

As far as chronic pyelonephritis is concerned, the outlook of this condition tends to vary from patient to patient. For the majority of patients, the condition is characterized by occasional bouts of kidney infection without any major discomfort or pain. Others require regular monitoring by a kidney specialist.

In some patients, the infection causes significant damage to the kidneys, resulting in a significant impairment of kidney function leading to kidney failure. In such extreme cases, the patient may require long-term dialysis or a kidney transplant.

Medic to Treat a Kidney Infection

If not treated in time, a kidney infection can lead to serious complications and can permanently damage your kidneys. Often, antibiotics are recommended to treat the infection. You can also use some home remedies to reduce the symptoms and promote healing.

Here are the some home remedies for a kidney infection.

1. Increase Fluid Intake

Increasing your fluid intake when suffering from a kidney infection can help reduce the symptoms and promote quick recovery. It will help flush out bacteria, waste, and toxic products from your kidneys, keeping them clean and healthy.

A study published in the American Journal of Nephrology suggested a potentially protective effect of higher total water intake, particularly plain water, on the kidney. However, evidence from a large, well-designed randomized controlled trial is needed to conclusively establish this claim.

  • Drink at least 8 to 10 glasses of water daily.
  • You can also drink 1 to 2 glasses of tender coconut water or lemon water daily.
  • Also, drink fruit and vegetable juices so that your body gets all the necessary vitamins and minerals it requires to fight off the infection.
Note: Avoid coffee and alcoholic and fizzy beverages until your infection has cleared. Check with your doctor about fruit juices if you have diabetes.

2. Manage Symptomatic Pain with a Hot Compress

Pain in the lower abdomen, back, and hips is very common when suffering from a kidney infection. You can apply hot compresses to reduce the pain, relax the muscles of your abdomen, and relieve the pressure from your bladder.

  1. Prepare a hot water bottle or warm a heating pad on low setting.
  2. Place it on the lower abdominal area, back, and hips for a few minutes.
  3. Repeat as needed.
Note: You can also use cold compress instead of warm compress.

3. Consider Drinking Cranberry Juice

Cranberry juice is reported to reduce urinary tract infections. However, there is no strong data to support its use for urinary tract infections.

Cranberry juice contains certain chemicals that may deter the bacteria from sticking to the urinary tract. This may prevent bacteria from thriving on the wall of the bladder and thus lessens your risk of infection.

In one study, researchers found that cranberry juice reduced E. coli colonization of the bladder in an experimental mouse model of urinary tract infection and that the organic acids are active agents. The active treatments reduced bacterial counts in the bladder but did not cure the infection, indicating that cranberry juice is not a definitive treatment but it may promote clearance of the infection, for instance, in combination with antibiotics.

Consider drinking a glass of unsweetened cranberry juice. Do not drink this juice in large amounts or for extended time periods as it can cause side effects. Drinking more than 1 liter of this juice daily for a long time may increase the chances of developing kidney stones because it contains oxalates.

Many cranberry juice products contain significant amounts of sugar, so it is important to check if you have diabetes.

4. Yogurt Releases an Army of Good Bacteria

Yogurt that contains antioxidants and probiotics can help treat a kidney infection and even prevent it from recurring. The live bacteria in yogurt inhibit adherence of bacteria to the epithelial cells of the urinary tract. Moreover, yogurt helps boost the immune system.

  • Eat plain yogurt with active live cultures daily.
  • You can also add fruits high in fiber such as apples.

5. Increase Vitamin C Intake

Vitamin C helps your immune system to fight off infection. It acidifies the urine, thus making it difficult for the infection-causing bacteria to grow.

A study published in Advances in Urology showed that administration of antioxidants, namely, vitamins A and E, can prevent the scarring of kidneys due to pyelonephritis, with or without antibiotic administration.

Another study showed that the combined intake of vitamin E and vitamin C exerts a protective role against hydroxyl-L-proline (HLP)-induced oxalate nephropathy.

  • Eat oranges, grapefruits, or any other citrus fruit.
  • Also, eat vitamin C-rich foods such as broccoli, kiwi, peppers, potatoes, strawberries, sprouts, and tomatoes.
  • You can also take vitamin C supplements once a day, preferably with breakfast. Consult a doctor before taking any tablet.
Note: Do not take high-dose vitamin C supplements as they are linked to kidney stones.

6. Drink Parsley Juice to Detox Your Kidneys

Parsley juice works as a cleanser for the kidneys by promoting increased urine flow. This means it can help flush out harmful toxins and microorganisms present in the kidneys.

  • Add 1 tablespoon of crushed fresh parsley or dried parsley to a cup of boiling water. Steep for 5 minutes, let the water cool, and then strain it. Drink this tea twice daily for a couple of weeks to combat a kidney infection.
  • Another option is to mix ¼ cup of parsley juice, ½ cup of water, and a little honey and lemon juice. Drink the mixture two times daily for 1 to 2 weeks.
Note: Parsley may help in minimizing the symptoms and promoting recovery from a kidney infection, but it is advisable to consult your doctor before using this herb as it may interfere with certain medications.

7. Garlic Helps Protect Your Kidneys

The natural antibiotic properties of garlic can also help fight kidney infection. Moreover, it acts as a diuretic to help the kidneys flush out harmful toxins and microorganisms from the body.

A study published in Pathogens and Disease showed that oral treatment with garlic significantly lowered renal bacterial counts and protected mouse kidney from tissue destruction caused by P. aeruginosa. Prophylactic treatment with garlic was able to significantly lower renal bacterial counts in test group animals. Renal tissue lesions were of less severity in the garlic-treated group, suggesting attenuation of virulence of P. aeruginosa in the UTI model.

  • Add garlic to your regular cooking and try incorporating them in soups, pasta dishes, and rice dishes. However, note that eating raw garlic daily on an empty stomach can cause stomach discomfort.
  • Alternatively, you can try garlic capsules or supplements but only after consulting your doctor.

8. Use Apple Cider Vinegar for Improved Renal Function

Apple cider vinegar contains malic acid, which has antibacterial properties that can help in treating kidney infections that are particularly caused by E. coli. Plus, it can help balance the pH levels in the body and prevent the infection from spreading.

  1. Mix 1 tablespoon of organic apple cider vinegar and 2 teaspoons of honey in 1 glass of warm water.
  2. Drink this mixture two times a day for a couple of weeks.
Caution: Do not drink undiluted apple cider vinegar on empty stomach.

9. An Apple a Day Keeps Kidney Infection at Bay

Apples are high in fiber and anti-inflammatory properties and thus help treat kidney infections. Apples can prevent harmful bacteria from growing. Regular consumption of this fruit can even reduce the risk of kidney-related problems.

  • Eat an organic apple each day to keep your kidneys functioning properly.

Additional Tips

  • Take special care of your personal hygiene to prevent bacteria from entering your body.
  • After intercourse, urinate and wash your private parts properly to prevent bacteria from spreading.
  • Empty your bladder whenever you feel the urge to urinate and do not delay.
  • Quit smoking.
  • Obesity can increase your risk of developing kidney stones, so focus on losing weight.
  • Avoid bubble baths, which can make kidney infections worse.
  • Avoid wearing tight pants or synthetic undergarments to reduce the risk of a kidney infection.

Expert Answers (Q&A)

Answered by Dr. Seyedmahdi Pahlavani, M.D. (Nephrologist)

Is it possible to treat a kidney infection without treatment?

Kidney infection is a serious condition and may lead to blood-stream infection (known as sepsis), local expansion of infection (abscess formation), and kidney failure if left untreated. The appropriate antibiotic regimen should be chosen based on patient’s condition and underlying etiologic pathogen for prompt treatment of kidney infection (pyelonephritis) to avoid complications.

Is pyelonephritis a life-threatening condition?

The severity of pyelonephritis depends on many factors such as, type of pathogen, patient’s age, gender, immune status, and other co-morbidities. It may result in blood stream infection (known as sepsis), if left untreated, which has a very high mortality rate.

Treatment of pyelonephritis could be complicated in elderly individuals, pregnant patients, patients with immunosuppression, patients with a current kidney stone, and patients with recent history of hospitalization and antibiotic treatment and it could be fatal in these groups of patients.

What steps can be taken to improve the kidney functions?

Prompt treatment by seeking medical attention is the first step to protect your kidneys from potential complications from pyelonephritis. Once the diagnosis is confirmed, follow the instructions provided by your healthcare provider and ensure you have completed the antibiotic course.

Sometimes, you need to confirm the infection’s eradication by a urine test after the treatment has completed.

Can kidney infection be passed on sexually?

Sexually transmitted disease may increase the chance of urinary tract infection but it is very unusual that a kidney is infected because of sexual activity.

Can pyelonephritis lead to kidney failure?

Pyelonephritis may cause scars in kidney parenchyma and recurrent infections will increase the chance of chronic kidney disease (CKD) and eventually end-stage renal disease (ESRD) in long term. However, severe pyelonephritis may cause acute kidney failure.

On the other hand, a complicated form of pyelonephritis that is called xanthogranulomatous pyelonephritis requires nephrectomy (surgical removal of affected kidney).

Please provide some tips to maintain healthy kidneys for the benefit of our readers.

It is important to have regular visits to your healthcare provider to diagnose kidney dysfunction at early stages especially if you have a risk factor for kidney diseases like diabetes, hypertension, and chronic recurrent infections.

Controlling blood pressure and maintaining good diabetes control are the major conditions to decrease the rate of declining kidney function and its rate of progression.

A healthy diet and regular exercise may play an important role in maintaining a good blood pressure and glucose control and will eventually result in maintaining good kidney function.

About Dr. Seyedmahdi Pahlavani, MD: Dr. Pahlavani earned his MD degree from Zahedan University of Medical Sciences after which he did his post graduate training in internal medicine at Tehran University of Medical Sciences. He was the chief resident at Rasool Akram hospital and was selected as best resident of internal medicine in 2010.

Dr. Pahlavani joined PERFUSE study group at Beth Israel Deaconess Medical Center as postdoctoral research fellow when he had many scholarly activities. He started his fellowship training in nephrology at Saint Louis University Hospital (SLUH) in 2018 and currently is a senior fellow at SLUH.

Resources:

  1. Wu L- W, Chen W-L, Liaw F- Y. Association between fluid intake and kidney function, and survival outcomes analysis: a nationwide population-based study. BMJ Open. . Published May 12, 2016.
  2. Sontrop JM, Dixon SN, Garg AX, Buendia-Jimenez I, OrianeDohein S-HSH, Clark WF. Association between Water Intake, Chronic Kidney Disease, and Cardiovascular Disease: A Cross-Sectional Analysis of NHANES Data. American Journal of Nephrology. . Published April 17, 2013.
  3. Pham PC, Khaing K, Sievers TM. 2017 update on pain management in patients with chronic kidney disease. Clinical Kidney Journal. . Published August 18, 2017.
  4. Raz R, Chazan B, Dan M. Cranberry Juice and Urinary Tract Infection. Clinical Infectious Diseases. . Published May 15, 2004.
  5. Jensen HD, Struve C, Christensen SB. Cranberry Juice and Combinations of Its Organic Acids Are Effective against Experimental Urinary Tract Infection. Frontiers in Microbiology. . Published April 4, 2017.
  6. Waigankar SS, Patel V. Role of probiotics in urogenital healthcare. Journal of Mid-life Health. . Published 2011.
  7. Gupta V, Nag, D, Garg P. Recurrent urinary tract infections in women: How promising is the use of probiotics? Indian Journal of Medical Microbiology. . Published October 12, 2017.
  8. Mohseni M- J, Aryan, Z, Paydary K. Combination of Probiotics and Antibiotics in the Backention of Recurrent Urinary Tract Infection in Children. Iranian Journal of Pediatrics. . Published August 2013.
  9. Emamghorashi, F, Owji SM, Motamedifar M. Evaluation of Effectiveness of Vitamins C and E on Backention of Renal Scar due to Pyelonephritis in Rat. Advances in Urology. Published December 12, 2010.
  10. JATURAKAN O, DISSAYABUTRA T, CHAIYABUTR N. Combination of vitamin E and vitamin C alleviates renal function in hyperoxaluric rats via antioxidant activity. The Journal of Veterinary Medical Science. . Published April 8, 2017.
  11. Abdullah RM, Sorchee S, Anwar K. Antibacterial activity of parsley and celery aqueous extract on the isolated bacteria from children UTI in Erbil International Journal of Advanced Research. . Published January 2014.
  12. Mansour A, Shelh S, Hariri E. Efficient and Cost-Effective Alternative Treatment for Recurrent Urinary Tract Infections and Interstitial Cystitis in Women: A Two-Case Report. Case Reports in Medicines. . Published December 21, 2014.
  13. Harjai K, Kumar R, Singh S. Garlic blocks quorum sensing and attenuates the virulence of Pseudomonas aeruginosa. FEMS Immunology & Medical Microbiology. . Published March 1, 2010.
  14. Yagnik D, Serafin V, Shah AJ. Antimicrobial activity of apple cider vinegar against Escherichia coli, Staphylococcus aureus and Candida albicans; downregulating cytokine and microbial protein expression. Scientific Report. . Published January 29, 2018.
  15. Neithercott T. Kind-to-Kidneys Meal Planning. Diabetes Forecast. . Published March 2012.
  16. An apple a day keeps kidney stones away. American Society of Nephrology. . Published August 13, 2009.

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Published by
Kalyani Perumal MD (Nephrology)

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