Medical therapy alone can be sufficient for bilateral emphysematous pyelonephritis: report of a new case and review of previous experiences. Int Urol Nephrol. 2014;46:223-227. [PMID: 23591724 DOI: 10.1007/s11255-013-0446-7]

Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study

INTRODUCTION

Emphysematous pyelonephritis (EPN) is a deadly disease due to its associated morbidity and mortality. Attempts have been made to identify predictors of severity, mortality and need for nephrectomy in EPN with little success.

METHODS

We conducted an ambispective study of EPN patients between March 2014 and September 2019. Retrospective data were collected which included age, sex, comorbidities, symptoms, signs, laboratory investigations including imaging, need for dialysis, management and any complications. All patients were then followed prospectively for renal dynamic scan, stone surgery or nephrectomy. Univariate analysis was performed to identify factors affecting mortality and need for elective nephrectomy.

RESULTS

In total, 112 patients were included. Mean patient age was 50.01 years, 55% were female and 5% had bilateral involvement. Fever and flank pain were the most common symptoms. Diabetes was seen in 75% of cases and 30% of cases required haemodialysis at initial presentation. About 60% of patients improved with pigtail drainage. Need for nephrectomy was greater in Huang-Tseng stage 3a (14.8%). Huang-Tseng stages 3b and 4 had higher mortality rates (25%) than the other stages (2.2%). Twelve of 99 patients had non functional kidney on follow-up and underwent elective nephrectomy. Low platelet counts, high body mass index, septic shock, dialysis and higher Huang-Tseng stage were found to be predictive of mortality and renal parenchymal thickness on computed tomography scan was predictive of follow-up nephrectomy.

CONCLUSIONS

Thrombocytopaenia, high body mass index, septic shock, haemodialysis and higher Huang-Tseng stage are predictors of mortality and renal parenchymal thickness <5mm is a predictor of poor salvage of affected kidney on follow-up.

Concurrent bilateral emphysematous pyelonephritis and secondary iliopsoas abscess extending to thigh muscles with profuse rectal bleeding. A rare case scenario

INTRODUCTION

Bilateral emphysematous pyelonephritis is exceedingly rare.

CASE PRESENTATION

A 56 year old diabetic male presented with high grade fever 40^o c, chills, and bilateral loin pain since two weeks a picture of septic shock. CT showed bilateral emphysematous pyelonephritis, the left kidney was smaller in size, the right renal unit showed marked hydronephrosis, right iliopsoas abscess extending to the thigh. The patient was managed by bilateral nephrostomy tubes and two retroperitoneal drains. Initially, the patient recovered, but the general condition deteriorated and profuse rectal bleeding occurred. Colonoscopy showed bleeding colonic mucosa.

CONCLUSION

Bilateral emphysematous pyelonephritis is devastating disease that should be managed promptly to avoid septic shock.

Point-of-care ultrasound for the early diagnosis of emphysematous pyelonephritis: A case report and literature review

BACKGROUND

Emphysematous pyelonephritis (EPN) is a rare but fatal necrotic infection of the kidney, which usually leads to septic shock. Therefore, early diagnosis and optimized therapy are of paramount importance. In the past two decades, point-of-care ultrasound (POCUS) has been widely used in clinical practice, especially in emergency and critical care settings, and helps to rapidly identify the source of infection in sepsis. We report a rare case in which a “falls” sign on POCUS played a pivotal role in the early diagnosis of EPN.

CASE SUMMARY

A 57-year-old man presented with fever and lumbago for 3 d prior to admission. He went to the emergency room, and the initial POCUS detected gas bubbles in the hepatorenal space showing a hyperechoic focus with dirty shadowing and comet-tail artifacts. This imaging feature was like a mini waterfall. His blood and urine culture demonstrated Escherichia coli bacteremia, and EPN associated with septic shock was diagnosed. The patient did not respond to broad-spectrum antibiotic treatment and a perirenal abscess developed. He subsequently underwent computed tomography-guided percutaneous catheter drainage, and fully recovered. We also review the literature on the sonographic features of POCUS in EPN.

CONCLUSION

This case indicates that a “falls” sign on POCUS facilitates the rapid diagnosis of severe EPN at the bedside.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

PURPOSE

In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification.

METHODS

A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS^®.

RESULTS

Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality.

CONCLUSION

Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.

Risk of SOFA Deterioration in Conservative Treatment for Emphysematous Pyelonephritis: Pitfalls of Current Trends in Therapeutics from Multicenter Clinical Experience

INTRODUCTION

We investigated relationships between therapeutic outcomes of patients with emphysematous pyelonephritis (EPN) and changes in the Sequential Organ Failure Assessment (SOFA) score.

MATERIALS AND METHODS

We retrospectively evaluated EPN patients treated in our hospitals using the SOFA score incorporated in the Sepsis-3 updated in 2016.

RESULTS

Seventeen typical EPN patients were included in this study, and were treated with medical management with no drainage (n = 3), retrograde stenting (n = 10), or percutaneous drainage (n = 3). One patient without drainage died of sepsis, yielding an overall mortality rate of 5.9%. Twelve patients recovered without increase in the SOFA score during hospitalization. However, the SOFA score deteriorated in the other patients from admission, with the initial scores not significantly different from those of the 12 cases. The changes in the SOFA score were significantly affected by the selected approaches of drainage (100% patients for no drainage, 22% for stenting, and 0% for percutaneous drainage, p = 0.029), but not by other clinical data.

CONCLUSION

Most EPN patients can currently be conservatively managed successfully. However, it should be noted that less-invasive management could cause deterioration in SOFA after admission, yielding a risk of septic mortality.

Bilateral emphysematous pyelonephritis cured by antibiotics alone in a black African woman

A 78-year-old black woman with a 10-year history of diabetes mellitus was admitted to the intensive care unit. Upon admission, she presented with chills, nausea, and left flank pain. The presence of hyperglycemia (fasting blood glucose, 19.7 mmol/L) and an altered consciousness required immediate treatment with insulin analog. Laboratory investigations and enhanced computed tomography scan led to the diagnosis of bilateral emphysematous pyelonephritis (EPN). The patient responded well to conservative treatment with antibiotics, and was finally discharged after 22 days when the computed tomography scan showed resolution of all the pockets of air. This case and associated literature review of 25 previously reported cases of bilateral EPN show the changing trend of EPN management from emergency nephrectomy toward conservative treatment with potent antibiotics and/or percutaneous drainage, and has been associated with higher survival rates compared to emergency nephrectomy.

Emphysematous pyelonephritis: A 10-year experience with 26 cases

BACKGROUND

Emphysematous pyelonephritis (EPN) is a necrotizing infection which results in gas within the renal parenchyma, collecting system, or perinephric tissue. A majority of cases occur in patients with diabetes mellitus (DM). In EPN, early aggressive medical treatment may avoid nephrectomy.

AIMS

The aim of this study was to analyze the characteristics of patients with EPN with respect to patient demographics, clinical presentation, diagnostic investigations, microbiological findings, treatment modality and outcome, and the influence of prognostic factors on the outcome.

MATERIALS AND METHODS

We reviewed the hospital records of 26 patients with EPN for clinical, laboratory, radiological, and microbiological findings, treatments given, and outcome. The severity of EPN was graded as per the Huang classification. We applied the reported prognostic factors to our patients to find out whether these factors correlated with failure of conservative treatment.

RESULTS

All the study subjects had DM and all but two of them were females. The majority of our patients (61.5%) had extensive EPN (class 3 or 4) and majority (76.9%) had two or more bad prognostic factors. Escherichia coli was the most common causative organism involved in 50% of our cases. Twenty-three (88.5%) of our patients responded to conservative treatment, two required nephrectomy, and one expired on conservative treatment.

CONCLUSIONS

In this series of patients with EPN, all had DM, nearly all were women, and E. coli was the most frequently isolated pathogen. Nearly a third of our patients had bilateral disease. Despite the presence of two or more bad prognostic factors and extensive EPN (class 3 or 4) in a majority of our patients, conservative treatment afforded a striking success rate of 88.5%. We recommend early aggressive medical treatment and suggest that nephrectomy should be considered only if patients deteriorate or do not improve on conservative treatment.

Successful management of bilateral emphysematous pyelonephritis with abscess formation in a chronic hemodialysis patient: a case report

Bilateral emphysematous pyelonephritis (EPN) has seldom been reported in patients on maintenance hemodialysis (HD). Percutaneous catheter drainage (PCD) or nephrectomy is often required in the treatment of bilateral EPN because of its poor response to antimicrobial agents and high mortality rate. We report a patient with bilateral EPN on maintenance HD. An octogenarian man with diabetes mellitus who had previously undergone regular HD for 22 months was admitted to our hospital because of severe inflammation resulting from bilateral EPN. His lesions of EPN had resulted in abscess formation in both kidneys and right and left side retroperitoneal space. As patient refused interventional therapy including nephrectomy or PCD, he was treated conservatively. After treatment with several antimicrobial agents for 50 days, he completely recovered from bilateral EPN. To our knowledge, this is the first case report of successful conservative management (antimicrobial therapy alone) of bilateral EPN that developed in a chronic diabetic HD patient.

Severe emphysematous pyelonephritis mimicking intestinal obstruction

Emphysematous pyelonephritis is a severe necrotizing infection characterized by the presence of gas and/or fluid in the renal parenchyma, collecting system, or perirenal tissues. Emphysematous pyelonephritis with approximately 15 cm air-fluid level, diffused ureteral involvement, and the accumulation of gas in liver and peritoneal cavity is very rare. Here, we reported a severe emphysematous pyelonephritis with multiple huge air-fluid level mimicking intestinal obstruction and with the accumulation of gas in liver and ureter in computed tomography imaging. The patient was successfully managed by percutaneous nephrostomy combined with medical treatment.