Could platelet to leucocytic count ratio (PLR) predict sepsis and clinical outcomes in patients with emphysematous pyelonephritis?

Modified National Early Warning Score 2, a reliable early warning system for predicting treatment outcomes in patients with emphysematous pyelonephritis

BACKGROUND

Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing renal parenchyma infection characterized by gas formation due to severe bacterial infection, predominantly affecting diabetic and immunocompromised patients. It carries high morbidity and mortality, requiring early diagnosis and timely intervention. Various prognostic scoring systems help in triaging critically ill patients. The National Early Warning Score 2 (NEWS 2) scoring system is a widely used physiological assessment tool that evaluates clinical deterioration based on vital parameters, but its standard form lacks specificity for risk stratification in EPN, necessitating modifications to improve treatment decision-making and prognostic accuracy in this critical condition.

AIM

To highlight the need to modify the NEWS 2 score to enable more intense monitoring and better treatment outcomes.

METHODS

This prospective study was done on all EPN patients admitted to our hospital over the past 12 years. A weighted average risk-stratification index was calculated for each of the three groups, mortality risk was calculated for each of the NEWS 2 scores, and the need for intervention for each of the three groups was calculated. The NEWS 2 score was subsequently modified with 0-6, 7-14 and 15-20 scores included in groups 1, 2 and 3, respectively.

RESULTS

A total of 171 patients with EPN were included in the study, with a predominant association with diabetes (90.6%) and a female-to-male ratio of 1.5:1. The combined prognostic scoring of the three groups was 10.7, 13.0, and 21.9, respectively (P < 0.01). All patients managed conservatively belonged to group 1 (P < 0.01). Eight patients underwent early nephrectomy, with six from group 3 (P < 0.01). Overall mortality was 8 (4.7%), with seven from group 3 (87.5%). The cutoff NEWS 2 score for mortality was identified to be 15, with a sensitivity of 87.5%, specificity of 96.9%, and an overall accuracy rate of 96.5%. The area under the curve to predict mortality based on the NEWS 2 score was 0.98, with a confidence interval of (0.97, 1.0) and P < 0.001.

CONCLUSION

Modified NEWS 2 (mNEWS 2) score dramatically aids in the appropriate assessment of treatment-related outcomes. MNEWS 2 scores should become the practice standard to reduce the morbidity and mortality associated with this dreaded illness.

The early diagnostic value of neutrophil to lymphocyte ratio and platelet to lymphocyte ratio in neonatal late-onset sepsis

Purpose

The purpose of this study is to investigate the early diagnostic value of the neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and C-reactive protein (CRP) in neonatal late-onset sepsis (LOS), as well as to evaluate the combined diagnostic utility of these markers for the early detection of neonatal LOS.

Methods

The late-onset sepsis of newborns admitted to the neonatal intensive care unit of our hospital were retrospectively collected. 142 children with Late-Onset Sepsis (LOS) were selected as the LOS group, 50 neonates with systemic infection were selected as the systemic infection group, 50 neonates who underwent physical examination were selected as the non-systemic infection group. The differences of NLR, PLR, platelet-to-neutrophil ratio (PNR), and C-reactive protein (CRP), Procalcitonin among the three groups were compared.

Results

The levels of NLR and PLR in LOS group were significantly higher than those in systemic infection group and non-systemic infection group. The Receiver Operating Characteristic (ROC) curve result revealed that the area under ROC (AUC, Area Under Curve) of NLR for the diagnosis of LOS was 0.903. When the optimal cut-off value was 1.30, the sensitivity and specificity were 89.4% and 81.0%. The AUC of PLR for the diagnosis of LOS was 0.833. When the optimal truncation value was 57.86, the sensitivity and specificity were 92.3% and 68.0%. The AUC of CRP for the diagnosis of LOS was 0.876, and the sensitivity and specificity were 76.8% and 87.0% when the optimal cut-off value was 10.21 mg/dl. When NLR, PLR, and CRP were combined to diagnosis LOS, The AUC was 0.942, the sensitivity and specificity were 90.8% and 86.0%.

Conclusions

The levels of NLR and PLR in the LOS were higher, which have certain value in the early diagnosis of LOS, and combined with CRP can improve the diagnostic efficiency.

Report on the diagnosis and treatment of 3 cases of emphysematous pyelonephritis with two different outcomes

Background

Emphysematous pyelonephritis (EPN) is a rare acute severe necrotising infection of the kidneys in clinical practice. It is characterized by the presence of gas in the renal parenchyma, collecting system, or perirenal tissue. The prognosis is poor, with a high nephrectomy rate and a mortality rate of up to 20-40%.

Methods

Retrospective analysis of 3 cases of emphysematous pyelonephritis with two different outcomes.

Results

Three patients who we described were all female with diabetes mellitus, and their blood sugar was poorly controlled. One patient with the advanced age and poor general health died due to the patient's family choosing to terminate therapy. Two patients underwent surgical procedures achieved an excellent clinical recovery. Both of them underwent percutaneous nephrostomy and perinephric abscess puncture drainage before nephrectomy. Escherichia coli were the microorganisms implicated.

Conclusion

EPN is a rare and severe urinary system infection. Computed tomography (CT) and microbiological culture confirmed the diagnosis. Control of diabetes, sensitive antibiotic therapy, fluid resuscitation and prompt surgical intervention are crucial.

Sepsis death risk factor score based on systemic inflammatory response syndrome, quick sequential organ failure assessment, and comorbidities

OBJECTIVE

In this study, we aimed to evaluate the death risk factors of patients included in the sepsis protocol bundle, using clinical data from qSOFA, SIRS, and comorbidities, as well as development of a mortality risk score.

DESIGN

This retrospective cohort study was conducted between 2016 and 2021.

SETTING

Two university hospitals in Brazil.

PARTICIPANTS

Patients with sepsis.

INTERVENTIONS

Several clinical and laboratory data were collected focused on SIRS, qSOFA, and comorbidities.

MAIN VARIABLE OF INTEREST

In-hospital mortality was the primary outcome variable. A mortality risk score was developed after logistic regression analysis.

RESULTS

A total of 1,808 patients were included with a death rate of 36%. Ten variables remained independent factors related to death in multivariate analysis: temperature ≥38 °C (odds ratio [OR] = 0.65), previous sepsis (OR = 1.42), qSOFA ≥ 2 (OR = 1.43), leukocytes >12,000 or <4,000 cells/mm3 (OR = 1.61), encephalic vascular accident (OR = 1.88), age >60 years (OR = 1.93), cancer (OR = 2.2), length of hospital stay before sepsis >7 days (OR = 2.22,), dialysis (OR = 2.51), and cirrhosis (OR = 3.97). Considering the equation of the binary regression logistic analysis, the score presented an area under curve of 0.668, is not a potential model for death prediction.

CONCLUSIONS

Several risk factors are independently associated with mortality, allowing the development of a prediction score based on qSOFA, SIRS, and comorbidities data, however, the performance of this score is low.

Risk factors for sepsis and mortality in patients with emphysematous pyelonephritis : a series of 68 cases (case series)

Background

Emphysematous pyelonephritis (EPN) is a rare and severe necrotizing infection of the kidney with a high rate of complications and mortality. Our aim was to investigate risk factors of urosepsis and mortality in case of EPN.

Materials and methods

Between January 2010 and December 2022 the charts of patients diagnosed with EPN were retrospectively reviewed. Patients medical records were collected and data including demographics, BMI, EPN type, the organism causing the infection and biochemical variables were registered. The authors performed an univariate and multivariate logistic regression analysis for sepsis, septic shock, and mortality. Statistical significance was defined as a P-value of <0.05.

Results

Our study included 68 patients (63% females, mean age 58.6 years old). Forty-eight patients (70.6%) had diabetes. Half of the patients (50%) presented with sepsis and 11 patients (16.2%) developed a septic shock. The following factors were associated with sepsis by univariate analysis: diabetes (P=0.01), higher blood sugar on admission (P=0.01), higher leukocytic count (P<0.001), higher lymphocytic count (P<0.001), and lower platelet to leukocytes ratio (P<0.001). Multivariate regression analysis revealed that the main risk factors of urosepsis were the leukocytic (OR: 85.7; 95% CI: 9.177-800.486; P<0.001) and lymphocytic count (OR: 6.65; 95% CI: 1.228-36.050; P=0.028). Neither of the variables was significantly associated with a higher risk of mortality.

Conclusion

Leukocytic and lymphocytic count on admission are independent simple predictors for sepsis in patients with EPN.

Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis

BACKGROUND

Emphysematous pyelonephritis (EP) is a severe necrotizing infection of the renal parenchyma which is associated with significant case mortality. We sought to identify the incidence and predictive risk factors associated with EP mortality.

METHODS

Two electronic databases, PubMed and Web of Science, were searched from their inception until June 06, 2021 for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines.

RESULTS

Of the 1080 retrieved abstracts, 79 underwent full-text review and 45 studies were included in the final analysis, comprising a total cohort of 1303 patients and 177 mortalities. The pooled prevalence of mortality among the patients with EP disease was 13%. Our analysis found a significantly decreasing trend in mortality rates, an increasing trend in minimally invasive intervention and decreasing trends in emergency nephrectomy in the EP studies from 1985 to 2020. Significant risk factors that were associated with a negative impact on survival of EP patients included sepsis (OR = 15.99), shock (OR = 15.57), disturbance of consciousness (OR = 12.11), thrombocytopenia (OR 7.85), acute renal failure (OR = 5.41), Wan classification I (OR = 4.57), emergency nephrectomy (OR = 3.73), Huang-Tseng classification III-IV (OR = 2.4) and medical management alone (OR = 2.04). Female sex (OR = 0.52) and minimally invasive intervention (OR = 0.47) (percutaneous nephrostomy or ureteral stent placement) were associated with decreased mortality rates.

CONCLUSIONS

Our study results demonstrated several significant risk factors that could help guide treatment to reduce the mortality risk of EP patients. Clinically, early treatment with a combination of minimally invasive intervention and appropriate medical management may be protective for reducing mortality risk in EP patients.

Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis?

INTRODUCTION

The aim of the study was to examine the efficacy of JJ stenting in comparison with percutaneous nephrostomy (PCN) as a drainage method in patients with emphysematous pyelonephritis (EPN).

METHODS

We retrospectively identified patients with EPN between January 2000 and January 2021. Platelet-to-leukocytic ratio (PLR) at the time of hospital admission and discharge, time taken to clear air locules and to normalize leukocytic count, and air locule volume in mm3 were identified. Renal drainage by either PCN or JJ stent was required if symptoms persist for ≥3 days or in obstructed renal units. Failure of drainage method was defined as conversion to another method of drainage, need for intensive care unit admission, salvage nephrectomy, and mortality.

RESULTS

Twenty-nine patients were managed by JJ stent. Treatment success was identified in 20 patients and 19 patients who were managed by PCN and JJ stent, respectively. Higher air locule volume ≥16.7 mm3 and lower PLR ≤18.4 increased the risk of drainage failure (p = 0.009 and 0.001, respectively).

CONCLUSION

Ureteral JJ stenting is an effective method for EPN drainage with a comparable overall success to the PCN use. Higher air locule volume and lower PLR increased the risk of drainage failure.

Study of C-reactive protein, procalcitonin, and immunocyte ratios in 194 patients with sepsis

BACKGROUND

Evidence suggests that C-reactive protein (CRP), procalcitonin (PCT), and immune cells can predict sepsis severity in adult patients. However, the specific values of these indicators are not consistent in predicting prognosis.

METHODS

A retrospective study analyzed the medical records of 194 patients based on the concept of sepsis in 2016 (Sepsis 3.0) from January 2017 to December 2019. A comparative analysis of inflammatory factors associated with patients in the sepsis survival and the non-survival group was performed. The concentrations of CRP and PCT, neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and platelet-to-lymphocyte ratio (PLR) were measured. ROC curve was used to assess the diagnosis and analysis of the selected indices of sepsis. According to each index's cut-off value of the ROC curve, the patients were divided into two groups, and the prognosis was calculated.

RESULTS

Among the 194 patients, 32 died (16.49%), the median age of the patients was 79 (66.0, 83.3) years, and 118 were male (60.8%). Analysis of related inflammatory indicators showed that CRP, NLR, MLR, PLR, and CRP*PCT in the non-survival group were statistically higher than those in the survival group (all p values were < 0.05). Regression analysis showed that PCT, CRP, NLR, PLR, and CRP*PCT were all independent prognostic factors for patients. The ROC curve results showed that CRP*PCT had the best diagnostic value (AUC = 0.915). The cut-off values of PCT, CRP, NLR, PLR, MLR, and CRP*PCT were 0.25 ng/mL, 85.00 mg/L, 8.66, 275.51, 0.74%, and 5.85 (mg/L)2, respectively. Kaplan-Meier survival estimate showed that patient prognosis between the CRP, PCT, NLR, PLR, and CRP*PCT was statistically different (all values P < 0.05, respectively). However, there was no statistically significant difference in gender and MLR (all values P > 0.05, respectively), grouping based on diagnostic cut-off values.

CONCLUSIONS

In this study, inflammation-related markers PCT, CRP, NLR, MLR, PLR, and CRP*PCT can be used as independent risk factors affecting the prognosis of patients with sepsis. Furthermore, except for MRL, these indicators have cut-off values for predicting patient death.

Thrombocytopenia Preceding Urosepsis in an Otherwise Asymptomatic Patient After Bilateral Retrograde Intrarenal Surgery

Introduction and Background: Urosepsis is commonly predicted by the systematic inflammatory response syndrome (SIRS) criteria. We report a case of urosepsis preceded only by thrombocytopenia. Case Presentation : An 80-year-old Caucasian female presented with recurrent urinary tract infections, type 1 second-degree heart block (Mobitz I), and chronic deep venous thrombosis for which she was taking apixaban. Computed tomography (CT) revealed a 1.3 cm right upper pole calculus (Hounsfield units (HU) = 704) and a left 5 mm nonobstructing interpolar calculus (HU = 904). A preoperative urine culture was sterile as the patient was on antibiotics. While on antibiotic coverage, the patient underwent bilateral retrograde intrarenal surgery with bilateral stent placement: the procedure time was 188 minutes. She was continued on vancomycin and gentamicin immediately postoperatively. On postoperative day (POD) 1, she was feeling well; her vital signs were within normal limits. However, the hemoglobin and the platelet counts declined from 12.4 to 10.0 g/dL and from 215 to 58/mm³, respectively. Because of the unexplained thrombocytopenia, the patient was kept at the hospital. In the afternoon, she became hypotensive (78/37 mm Hg) and a rapid response was called. She was admitted to the surgical intensive care unit and antibiotics were broadened. On POD 2, the patient met sepsis SIRS criteria with white blood cell (WBC) of 2.9/mm³ and heart rate of 92 bpm. Stone culture was positive for methicillin-resistant Staphylococcus aureus (MRSA). On POD 3, her blood pressure had returned to 116-142/47-84. On POD 5, platelet count recovered to 94/mm³ and WBC to 3.8/mm³. She was discharged on POD 6 with a 2-week ongoing course of intravenous vancomycin. On follow-up 7 weeks postoperatively, she was asymptomatic with WBC of 6.5/mm³ and platelet count of 206/mm³. Follow-up CT demonstrated normal renal anatomy with subcentimeter calculi clustered within the left renal parenchyma and no stones on the right side. Conclusion: This case shows an uncommon non-SIRS presentation of postoperative urosepsis signaled only by thrombocytopenia.