[Emphysematous pyelonephritis: report of 3 cases]

Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes?

Objective:

The objective of the study is to analyze the risk factors determining the outcomes of patients with emphysematous pyelonephritis (EPN) by the adoption of a standardized management algorithm as well as to develop a prognostic scoring model to risk stratify these patients.

Materials and Methods:

The hospital records of 72 consecutive patients with EPN from February 2012 to January 2018 were retrospectively reviewed. Demographic, clinicoradiographic, and laboratory characteristics were recorded. Patients were managed with a standard management protocol and based on outcomes divided into three groups. Group I survived with conservative management, Group II survived after emergency nephrectomy, and Group III expired. The risk factors for nephrectomy and mortality were analyzed.

Results:

The mean age was 53 years. Male to female ratio was 4:5. There were 61 (84.7%), 4 (5.6%), and 7 (10%) patients in Groups I, II, and III, respectively. Diabetes mellitus was the most common comorbidity detected in 62 (86%) of patients. Type II EPN was the most common radiological presentation observed in 32 (44%) patients. Overall survival rate was 90%, and kidney salvage rate was 80%. Escherichia coli was the most common organism isolated. Thirty-two (45%) patients exhibited resistance to third-generation cephalosporin antibiotics. Thrombocytopenia, low body mass index (BMI), presence of >2 comorbidities, high total leukocyte count (TLC), and hypoalbuminemia were significantly associated with mortality. On adoption of the prognostic scoring system, mortality rates according to the risk subgroups were as follows: favorable - 0%, intermediate - 19%, and poor - 100%.

Conclusion:

Conservative management adopting appropriate algorithm reduces mortality and avoids unnecessary emergency nephrectomies. Thrombocytopenia, low BMI, presence of >2 comorbidities, high TLC, and hypoalbuminemia were significantly associated with mortality.

Pneumomediastinum as first manifestation of emphysematous pyelonephritis in a patient who is non-diabetic

Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney, characterised by production of gas within the renal parenchyma, collecting system or perirenal tissue. It has a high mortality rate (70% to 90%), and the majority of patients have diabetes mellitus. The left kidney is most common involved and Escherichia coli is the most common pathogen. EPN complicated with pneumomediastinum (PM) has been reported in only four cases previously. Here, a case of PM as first manifestation of EPN in a non-diabetic 81-year-old man is reported. He had experienced back pain and abdominal fullness for 1 week. A plain radiograph, CT aortography and MRI confirmed the diagnosis of EPN complicated with PM. The patient died on the 22nd day of treatment with antibiotics of cefmetazole, gentamycin and metronidazole.

[Emphysematous pyelonephritis of single kidney: review of literature about one case]

INTRODUCTION

Emphysematous pyelonephritis is a rare and severe form of acute pyelonephritis. It is defined as the presence of gas-producing bacteria in the kidney and in peri-nepheretic areas. We report a case of emphysematous pyelonephritis on a single kidney associated with urolithiasis.

OBSERVATION

A 44-year-old woman, with a history of diabetes and chronic renal failure, presented with left renal colic, anuria, fever and worsening of general state. The diagnosis of emphysematous pyelonephritis was confirmed by CT scan. The treatment was based on antibiotheray, adapted to the renal function, insulinotherapy and urine drainage by a double J stent. The evolution was favourable.

DISCUSSION

Emphysematous pyelonephritis is an uncommon infection, generally affecting female diabetic patients. CT scan is mandatory to confirm diagnosis.

CONCLUSION

Even if it is rare, emphysematous pyelonephritis is associated with a high mortality in the absence of a rapid and effective treatment.

Risk factors for mortality in patients with emphysematous pyelonephritis: a meta-analysis

PURPOSE

Emphysematous pyelonephritis, an infection most commonly seen in cases of diabetes mellitus, is associated with considerable case fatality. We identified the factors associated with mortality in patients with emphysematous pyelonephritis and estimated the magnitude of the associations.

MATERIALS AND METHODS

PubMed was searched to identify studies reporting on risk factors of mortality in patients with emphysematous pyelonephritis. A meta-analysis of the eligible studies was performed.

RESULTS

Seven study cohorts, representing 175 patients with emphysematous pyelonephritis, were included in the meta-analysis. The overall mortality rate was 25%, ranging from 11% to 42%. Conservative treatment alone (OR 2.85, 95% CI 1.19-6.81), bilateral emphysematous pyelonephritis (OR 5.36, 95% CI 1.41-20.33), type I emphysematous pyelonephritis (OR 2.53, 95% CI 1.13-5.65) and thrombocytopenia (OR 22.68, 95% CI 4.4-116.32) were associated with increased mortality. Systolic blood pressure less than 90 mm Hg, serum creatinine greater than 2.5 mg/dl and disturbance of consciousness were also found to be associated with increased mortality. However, this finding was based on limited data. On the other hand, there was no association between mortality and diabetes mellitus (OR 0.32, 95% CI 0.05-1.99) in patients with emphysematous pyelonephritis.

CONCLUSIONS

The accumulated and analyzed evidence suggests that conservative treatment, type I emphysematous pyelonephritis, bilateral emphysematous pyelonephritis and thrombocytopenia seem to be significant risk factors for mortality in patients with emphysematous pyelonephritis. These data may be taken into consideration when treating patients with this devastating infection.

La pyélonéphrite emphysémateuse

The emphysematous pyelonephritis is a rare and severe renal infection characterized by the presence of gas in renal parenchyma and its perirenal spaces. We report two cases of emphysematous pyelonephritis in two diabetic women (53 and 50 years old respectively). In the first case, the treatment was based on nephrectomy because of the presence of a septic shock and three risk factors, which are acute renal failure, hematuria and thrombopenia. In the second case, the treatment was only medical. The evolution was favorable in the two cases. We insist in this article that this diagnosis should be considered in every female diabetic patient having severe acute pyelonephritis resistant to a well-conducted medical treatment.