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Nishikawara M, Harada M, Yamazaki D, Kakegawa T, Hashimoto K, Kamijo Y. A case of emphysematous pyelonephritis in an older man with poorly controlled type 2 diabetes mellitus. CEN Case Rep 2024; 13:161-167. [PMID: 37737333 PMCID: PMC11144164 DOI: 10.1007/s13730-023-00821-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
Emphysematous pyelonephritis (EPN) is a necrotizing bacterial infection characterized by gas retention and a poor prognosis. We present the case of a 75-year-old man who was diagnosed early with EPN and received multidisciplinary treatment. He had poorly controlled type 2 diabetes mellitus (DM) and chronic kidney disease (CKD), and was treated with oral hypoglycemic drugs, including a sodium-glucose co-transporter-2 inhibitor. He experienced the onset of back pain in the midsection of his back, tenderness in the costovertebral angle, and a high fever (> 39 °C), accompanied by tachycardia, hypotension, and tachypnea. The patient was diagnosed with pyelonephritis and septic shock. Immediate measures encompassing empirical antibiotic therapy, administration of noradrenaline, blood glucose regulation, and urethral catheterization were implemented. However, due to the persistent fever (> 38 °C) and lack of improvement in his condition, abdominal computed tomography (CT) was repeated on the fourth day. This revealed the presence of gas around the right kidney parenchyma, leading to a diagnosis of EPN that had evolved from acute pyelonephritis. Subsequently, percutaneous drainage of the right kidney parenchyma was performed. Subsequently, multidisciplinary treatment was continued, and his condition gradually improved. Clinicians should evaluate abdominal CT when acute pyelonephritis does not improve within a few days of antibiotic therapy. Disease progression from acute pyelonephritis to EPN should be considered in patients with DM and CKD.
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Affiliation(s)
- Mayuka Nishikawara
- Division of Nephrology, Nagano Municipal Hospital, 1333-1, Tomitake, Nagano, 381-8551, Japan
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 390-8621, Japan
| | - Makoto Harada
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 390-8621, Japan
| | - Daiki Yamazaki
- Division of Nephrology, Nagano Municipal Hospital, 1333-1, Tomitake, Nagano, 381-8551, Japan
| | - Tetsuji Kakegawa
- Division of Nephrology, Nagano Municipal Hospital, 1333-1, Tomitake, Nagano, 381-8551, Japan
| | - Koji Hashimoto
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 390-8621, Japan
| | - Yuji Kamijo
- Department of Nephrology, Shinshu University School of Medicine, 3-1-1, Asahi, Matsumoto, 390-8621, Japan.
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Balagobi B, Gobishangar S, Heerthikan K, Priyatharsan K, Nalayini J, Jenil A. Case report on bilateral emphysematous pyelonephritis in a non-diabetic male: A complex treatment journey. Int J Surg Case Rep 2024; 114:109122. [PMID: 38100932 PMCID: PMC10762345 DOI: 10.1016/j.ijscr.2023.109122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/18/2023] [Accepted: 12/01/2023] [Indexed: 12/17/2023] Open
Abstract
INTRODUCTION Emphysematous pyelonephritis is a severe kidney infection characterized by gas formation, predominantly affecting diabetic women. Symptoms include fever, pain, and nausea, requiring urgent and accurate management due to its potentially fatal nature. CASE PRESENTATION This article reports a successful management of a case of bilateral emphysematous pyelonephritis complicated with perinephric, retroperitoneal collection and urosepsis. DISCUSSION Emphysematous pyelonephritis (EPN) is a severe kidney infection characterized by acute necrotizing infection in the renal tissue and nearby structures. While EPN typically affects individuals with risk factors such as diabetes, obstructive uropathy, and hypertension, this case is unique because the patient lacks these common risk factors but hails from a region where EPN is more prevalent. The management of EPN has evolved over the years, with recent advances in imaging, antibiotics, and drainage techniques leading to a shift from invasive surgical procedures to more conservative approaches, resulting in improved outcomes and reduced mortality rates. CONCLUSION Emphysematous pyelonephritis demands urgent intervention to prevent high mortality rates. Swift, tailored treatment, including antibiotics and possible surgical interventions, is crucial, involving a multidisciplinary approach for improved patient outcomes.
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Affiliation(s)
- B Balagobi
- Department of Surgery, Faculty of Medicine, University of Jaffna, Sri Lanka.
| | - S Gobishangar
- Department of Surgery, Faculty of Medicine, University of Jaffna, Sri Lanka
| | - K Heerthikan
- Department of Surgery, Faculty of Medicine, University of Jaffna, Sri Lanka
| | - K Priyatharsan
- Department of Surgery, Faculty of Medicine, University of Jaffna, Sri Lanka
| | | | - A Jenil
- Department of Radiology, Teaching Hospital Jaffna, Sri Lanka
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Aggarwal D, Mandal S, Parmar K, Manoharan V, Singh S, Yadav AK, Kumar S, Sharma AP, Singh SK. Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study. Ann R Coll Surg Engl 2023; 105:323-330. [PMID: 35617107 PMCID: PMC10066649 DOI: 10.1308/rcsann.2022.0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- D Aggarwal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S Mandal
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Parmar
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - V Manoharan
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S Singh
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - AK Yadav
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S Kumar
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - AP Sharma
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - SK Singh
- Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Chen CC, Hsieh MS, Hu SY, Huang SC, Tsai CA, Tsai YC. Performance of Scoring Systems in Predicting Clinical Outcomes of Patients with Emphysematous Pyelonephritis: A 14-Year Hospital-Based Study. J Clin Med 2022; 11:jcm11247299. [PMID: 36555916 PMCID: PMC9788337 DOI: 10.3390/jcm11247299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/13/2022] Open
Abstract
Background: Emphysematous pyelonephritis (EPN) is a rare but severe necrotizing infection causing there to be gas in the pelvicalyceal system, renal parenchyma, and perirenal or pararenal space. Physicians should attend to EPN because of its life-threatening septic complications. The overall mortality rate has been reported to be as high as 20−40%. In addition, most patients had diabetes mellitus (DM) and obstructive uropathy. The most common isolated microorganism is Escherichia coli. This study aims to analyze the risk factors and performance of scoring systems in predicting the clinical outcomes of patients with EPN. Materials and Methods: We collected the data of patients with EPN in this single hospital-based retrospective study from the electronic medical records of Taichung Veterans General Hospital between January 2007 and December 2020. Radiological investigations of abdominal computed tomography (CT) confirmed the diagnosis of EPN. In addition, we analyzed demographics, clinical characteristics, and laboratory data. Finally, we used various scoring systems to predict clinical outcomes. Results: A total of fifty patients with EPN, whose diagnoses were confirmed through CT, were enrolled in the study. There were 18 males (36%) and 32 females (64%), with a mean age of 64.3 ± 11.3 years. The in-hospital mortality rate was 16%. A DM of 34 (68%) patients was the most common comorbidity. Fever was the most common symptom, found in 25 (50%) patients. The Mortality in Emergency Department Sepsis (MEDS) score was 4.64 ± 3.67 for survivors and 14.25 ± 5.34 for non-survivors (p < 0.001). The National Early Warning Score (NEWS) was 3.64 ± 2.33 for survivors and 7.13 ± 4.85 for non-survivors (p = 0.046). The Rapid Emergency Medicine Score (REMS) was 5.81 ± 1.97 for survivors and 9.13 ± 3.87 for non-survivors (p = 0.024). Regarding performance of mortality risk prediction, the AUC of ROC was 0.932 for MEDS, 0.747 for REMS, and 0.72 for NEWS. Conclusions: MEDS, REMS, and NEWS could be prognostic tools for the prediction of the clinical outcomes of patients with EPN. MEDS showed the best sound performance. In those with higher scores in MEDS (≥12), REMS (≥10), and NEWS (≥8), we recommended aggressive management and appropriate antimicrobial therapy as soon as possible to reduce mortality. Further large-scale studies are required to gain a deep understanding of this disease and to ensure patient safety.
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Affiliation(s)
- Chun-Cheng Chen
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan 330, Taiwan
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Sung-Yuan Hu
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung 402, Taiwan
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Correspondence: (S.-Y.H.); (S.-C.H.); Tel.: +886-4-23592525 (ext. 3670) (S.-Y.H.); +886-4-247395955 (ext. 34121) (S.-C.H.); Fax: +886-4-23594065 (S.-Y.H.); +886-4-24714800 (S.-C.H.)
| | - Shih-Che Huang
- School of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
- Department of Emergency Medicine, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Lung Cancer Diagnosis and Treatment Research Center, Chung Shan Medical University Hospital, Taichung 40201, Taiwan
- Correspondence: (S.-Y.H.); (S.-C.H.); Tel.: +886-4-23592525 (ext. 3670) (S.-Y.H.); +886-4-247395955 (ext. 34121) (S.-C.H.); Fax: +886-4-23594065 (S.-Y.H.); +886-4-24714800 (S.-C.H.)
| | - Che-An Tsai
- Division of Infectious Disease, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
| | - Yi-Chun Tsai
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan
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Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis. World J Surg 2022; 46:2377-2388. [PMID: 35802159 DOI: 10.1007/s00268-022-06647-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 10/17/2022]
Abstract
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.
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Fernandez Felix DA, Madrigal Loria G, Sharma S, Ali M, Arias Morales CE. Emphysematous Pyelonephritis Complicated With Hyperglycemic Hyperosmolar State and Sepsis: A Case Report and Literature Review. Cureus 2022; 14:e25498. [PMID: 35663692 PMCID: PMC9156399 DOI: 10.7759/cureus.25498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2022] [Indexed: 12/01/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is an acute life-threatening necrotizing infection of the renal parenchyma and perirenal tissues. There are multiple treatment strategies for EPN depending on the initial classification; over the last three decades, the treatment approach has favored kidney sparing strategies and the use of nephrectomy only as salvage therapy. We report a case involving a patient with unilateral emphysematous pyelonephritis complicated with hyperglycemic hyperosmolar state (HHS), sepsis, and multiple risk factors associated with poor prognosis who was successfully treated with conservative management sparing nephrectomy. This case report aims to create awareness among clinicians that even in the presence of multiple risk factors for poor prognosis, conservative management should be considered before nephrectomy.
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Desai R, Batura D. A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis. Int Urol Nephrol 2022; 54:717-736. [PMID: 35103928 DOI: 10.1007/s11255-022-03131-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/25/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We conducted a meta-analysis to assess the impact of risk factors and treatment choices on outcomes in EPN. METHODS We conducted a database search of all studies in English, reporting more than 12 patients of EPN from 1980 to 2020. We compiled the demographics, clinical presentations, risk factors, critical diagnostic results, treatment modalities and outcomes, including mortality. RESULTS We identified 37 observational studies, 32 retrospective and 5 prospective. The studies reported on 1146 patients, of which 790(68.9%) were female, and 946 (82.5%) were diabetic. In addition, 184 (16.1%) patients had stones, and 235 (20.5%) had obstructive uropathy. Fever and flank pain were the most frequent symptoms. The most common clinical features were pyuria, fever, flank tenderness, and tachycardia. E. coli, Klebsiella pneumoniae and Proteus were the most frequent organisms isolated. X-ray KUB and ultrasound were used as initial diagnostic modalities, but CT scan was the usual diagnostic and confirmatory investigation. Confusion, shock, thrombocytopenia, sepsis, emergency nephrectomy and hyponatremia were significantly associated with mortality. In particular, confusion and hyponatremia were associated with a sevenfold increase in mortality risk. There was no evidence that diabetes, stones, obstructive uropathy, AKI or proteinuria was associated with higher mortality. Nevertheless, 143 of the total 1146 patients died (12.5%). While 26% of the patients who had upfront emergency nephrectomy died, only 9.7% and 10% of patients with medical management and medical management plus minimally invasive treatments died. However, patients that failed medical and minimally invasive treatments and needed salvage emergency nephrectomy had a mortality of upwards of 27%. CONCLUSION The risk factors for mortality in emphysematous pyelonephritis are shock, thrombocytopenia, confusion, hyponatremia and emergency nephrectomy. Conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis as they carry lesser mortality risks. The presence of risk factors may help predict the subset of patients who need aggressive treatment and minimally invasive treatment modalities or early nephrectomy.
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Affiliation(s)
- Rajeev Desai
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK
| | - Deepak Batura
- Department of Urology, London North West University Healthcare NHS Trust, Watford Road, Harrow, London, HA1 3UJ, UK.
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Mallikarjun N, Kone K, R. K. Keerthi Rams MD. Mortality in emphysematous pyelonephritis: Can we reduce it further by using a protocol-based treatment? The results of a prospective study. Urol Ann 2022; 14:73-80. [PMID: 35197707 PMCID: PMC8815352 DOI: 10.4103/ua.ua_164_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/28/2021] [Indexed: 11/04/2022] Open
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Hsu CK, Wu SY, Yang SD, Chang SJ. Emphysematous pyelonephritis: classification, management, and prognosis. Tzu Chi Med J 2022; 34:297-302. [PMID: 35912050 PMCID: PMC9333110 DOI: 10.4103/tcmj.tcmj_257_21] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 09/28/2021] [Accepted: 11/02/2021] [Indexed: 11/04/2022] Open
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Elbaset MA, Osman Y, Ghobrial FK, Ashour R, Badawy M, El Refaie E, Zahran MH. Is JJ Ureteral Stenting Inferior to Percutaneous Nephrostomy as a Drainage Method in Emphysematous Pyelonephritis? Urol Int 2021; 106:1252-1259. [PMID: 34847563 DOI: 10.1159/000519897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 09/19/2021] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Mohamed A Elbaset
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Yasser Osman
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Fady K Ghobrial
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Rawdy Ashour
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mohamed Badawy
- Radiology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Eman El Refaie
- ICU and Nephrology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Mohamad H Zahran
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Moudi E, Darzi M, Ramzani S, Akbarzadeh Pasha A. Xanthogranulomatous pyelonephritis combined with emphysematous pyelonephritis: A rare case report. CASPIAN JOURNAL OF INTERNAL MEDICINE 2021; 12:S505-S508. [PMID: 34760116 PMCID: PMC8559650 DOI: 10.22088/cjim.12.0.505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/28/2022]
Abstract
Background: Xanthogranulomatous pyelonephritis (XGP) is a rare and intense type of chronic kidney infection characterized by subversion of the renal tissue and its replacement by lipid- laden macrophages. XGP combined with emphysematous pyelonephritis(EPN) is rare and up until now only 7 cases with these presentations have been reported; so abundant clinical skills and appropriate radiographic imaging is required to reach the correct diagnosis. In this report, we present a case with two uncommon variants of pyelonephritis. Case Presentation: A 55-year-old female presented with a history of type 2 diabetes mellitus, and a stroke leading to a left-sided hemiplegia state for 7 years, coronary artery bypass grafting(CABG), hypertension(HTN) , seizure, progressive fatigue, loss of appetite , fecal and urinary incontinence and right costovertebral angle tenderness. According to clinical signs, symptoms and documentation of gas within the renal parenchyma on computed tomography (CT) of abdomen, of EPN diagnosis was suggested; however histopathologic evaluation showed acute emphysematous pyelonephritis on chronic xanthogranulomatous pyelonephritis. Conclusion: EPN can emerge in a patient suffering from XPG which would add to the severity of the situation. In the case presented, concurrent underlying diseases such as diabetes mellitus, stroke, CABG, HTN along with severe fatigue and loss of appetite existed. Surgical treatment produces dramatic results.
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Affiliation(s)
- Emadoddin Moudi
- Department of Urology, Babol University of Medical Sciences, Babol, Iran.,Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
| | - Mohammadmehdi Darzi
- Cancer Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran.,Clinical Research Development Center, Shahid Beheshti Hospital, Babol University of Medical Sciences, Babol, I.R.Iran
| | - Sepehr Ramzani
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran.,Faculty of Medicine, Babol University of Medical Science, Babol, Iran
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Tam CA, Linder KA, Napolitano LM, Shields J, Ghani KR. 'Case of the Month' from University of Michigan, Ann Arbor, MI, USA: emphysematous pyelonephritis following ureteroscopy in a solitary kidney. BJU Int 2021; 127:300-303. [PMID: 33630420 DOI: 10.1111/bju.15331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Kathleen A Linder
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - James Shields
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Khurshid R Ghani
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
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Krishnamoorthy S, Zumla A, Sekar H, Muneer A, Thiruvengadam G, Kumaresan N. Prognostic scoring system and risk stratification in patients with emphysematous pyelonephritis: an 11-year prospective study at a tertiary referral centre. BJU Int 2020; 127:418-427. [PMID: 32871043 DOI: 10.1111/bju.15225] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To define pre-morbid, clinical, laboratory, and imaging features and identify prognostic factors associated with morbidity and mortality in patients with emphysematous pyelonephritis (EPN) and develop a prognostic scoring system for improving management outcomes. PATIENTS AND METHODS From January 2009 to December 2019, we performed a prospective study of all patients with a suspected diagnosis of EPN referred to a specialist tertiary centre in South India. All patients who underwent non-contrast computed tomography of the abdomen and those diagnosed with EPN were included in this study. Demographic parameters, imaging, haematological and microbiology results were recorded. Patients were divided into three groups: Group 1, patients who survived without any intervention; Group 2, those who survived with surgical intervention; and Group 3, those who died with or without intervention. A prognostic scoring system was developed from 18 different parameters and risk stratification was developed. The scores were correlated with overall prognosis. RESULTS Data from 131 patients with EPN enrolled in the study were analysed: Group 1 (n = 22), Group 2 (n = 102) and Group 3 (n = 7). By using univariate analysis, 10 factors were identified to be significantly associated with prognosis. Diabetes mellitus was the most common comorbidity. Shock at initial admission indicated a poor prognosis and warranted immediate attention (P < 0.001). CONCLUSIONS A multi-disciplinary approach, a high index of clinical suspicion, an early diagnosis and administration of culture-specific antibiotics with identification of prognostic indicators and risk stratification, allows prompt and appropriate medical and surgical treatments that could improve EPN management outcomes.
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Affiliation(s)
- Sriram Krishnamoorthy
- Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London (UCL), London,, UK.,UK National Institute for Health Research (NIHR) Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Hariharasudhan Sekar
- Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
| | - Asif Muneer
- Division of Surgery and Interventional Science UCL, Department of Urology and NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK
| | - Gayathri Thiruvengadam
- Department of Bio-Statistics, Faculty of Allied Health Science, Sri Ramachandra Institute of Higher Education & Research, Chennai, India
| | - Natarajan Kumaresan
- Department of Urology and Renal Transplantation, Sri Ramachandra Institute of Higher Education and Research, Chennai, India
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14
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Adapala RR, Shetty R, Venugopal P, Prabhu GGL, Yalla D, Unnikrishnan B. Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy. Urol Ann 2020; 12:156-162. [PMID: 32565654 PMCID: PMC7292438 DOI: 10.4103/ua.ua_67_19] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 11/25/2019] [Indexed: 12/18/2022] Open
Abstract
Introduction Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN. Materials and Methods We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality. Results The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%. Conclusion Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.
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Affiliation(s)
| | - Ranjit Shetty
- Department of Urology, Kasturba Medical College Hospitals, MAHE, Manipal, Karnataka, India
| | - P Venugopal
- Department of Urology, Kasturba Medical College Hospitals, MAHE, Manipal, Karnataka, India
| | - G G L Prabhu
- Department of Urology, Kasturba Medical College Hospitals, MAHE, Manipal, Karnataka, India
| | - Durgarao Yalla
- Department of Biochemistry, Kasturba Medical College, Mangalore, MAHE, Manipal, Karnataka, India
| | - B Unnikrishnan
- Department of Community Medicine, Kasturba Medical College, Mangalore, MAHE, Manipal, Karnataka, India
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15
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Yap XH, Ng CJ, Hsu KH, Chien CY, Goh ZNL, Li CH, Weng YM, Hsieh MS, Chen HY, Chen-Yeen Seak J, Seak CK, Seak CJ. Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems. Sci Rep 2019; 9:16618. [PMID: 31719593 PMCID: PMC6851397 DOI: 10.1038/s41598-019-52989-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 10/27/2019] [Indexed: 12/22/2022] Open
Abstract
This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients' need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals' emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ2 tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.
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Affiliation(s)
- Xiao-Han Yap
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chip-Jin Ng
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Kuang-Hung Hsu
- Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Laboratory for Epidemiology, Department of Health Care Management, and Healthy Aging Research Center, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Yu Chien
- Department of Emergency Medicine, Ton-Yen General Hospital, Zhubei City, Hsinchu County, Taiwan
| | | | - Chih-Huang Li
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yi-Ming Weng
- Department of Emergency Medicine, Prehospital Care Division, Taoyuan General Hospital, Ministry of Health and Welfare, Taoyuan, Taiwan
| | - Ming-Shun Hsieh
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Hsien-Yi Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | - Chen-Ken Seak
- Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Chen-June Seak
- College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Department of Emergency Medicine, Lin-Kou Medical Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Institute of Occupational Medicine and Industrial Hygiene, College of Public Health, National Taiwan University, Taipei, Taiwan.
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16
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Hirshberg B, Rheinboldt M. MDCT Imaging of Acute Bladder Pathology. Curr Probl Diagn Radiol 2019; 49:422-430. [PMID: 31142434 DOI: 10.1067/j.cpradiol.2019.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 04/01/2019] [Accepted: 05/07/2019] [Indexed: 11/22/2022]
Abstract
In this review, we will discuss and illustrate the pathophysiology, presentation, and multidetector computed tomography findings associated with emergent bladder conditions, limiting our discussion to traumatic, infectious, and obstructive etiologies. After reviewing computed tomography cystographic technique, the commonly utilized classification systems for bladder trauma will be presented with illustrative examples of associated typical and more infrequent secondary injuries and complications. Next, the pathogenesis and imaging appearance of both mechanical and neurogenic acute urinary retention will be addressed, including less common though potentially pathognomonic obstructive etiologies including urethral calculi and ectopic ureteroceles. Finally, we will review and illustrate the imaging features of both inflammatory and infectious cystitis, including hemorrhagic and emphysematous variants, as well as the potentially encountered secondary complications.
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Affiliation(s)
- Benjamin Hirshberg
- Department of Diagnostic Radiology, Emergency Radiology Division, Henry Ford Hospital, Detroit, MI
| | - Matthew Rheinboldt
- Department of Diagnostic Radiology, Emergency Radiology Division, Henry Ford Hospital, Detroit, MI.
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17
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Jain A, Manikandan R, Dorairajan LN, Sreenivasan SK, Bokka S. Emphysematous pyelonephritis: Does a standard management algorithm and a prognostic scoring model optimize patient outcomes? Urol Ann 2019; 11:414-420. [PMID: 31649464 PMCID: PMC6798304 DOI: 10.4103/ua.ua_17_19] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Amit Jain
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Ramanitharan Manikandan
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | | | | | - Sriharsha Bokka
- Department of Urology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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18
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[A CASE OF EMPHYSEMATOUS PYELONEPHRITIS WHO PRESENTED THE PRESERVATION OF THE IPSILATERAL KIDNEY FOLLOWING OPEN DRAINAGE]. Nihon Hinyokika Gakkai Zasshi 2019; 110:134-137. [PMID: 32307382 DOI: 10.5980/jpnjurol.110.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
We report a case of a 53-year-old woman with emphysematous pyelonephritis who presented the preservation of the ipsilateral kidney following open drainage. She was transferred to our hospital with chief complaints of right back pain and high fever. On diagnosis, diabetes mellitus and a stone in the right ureter were confirmed, and she was followed up at a local clinic. Computed tomography revealed the presence of gas in the right renal pelvis, and the stone led to right hydronephrosis. Additionally, her hemoglobin A1c level was 11.3%. Hence, we diagnosed the patient with emphysematous pyelonephritis. Although right percutaneous nephrostomy was performed immediately after her admission, the gas in the right renal pelvis extended to the renal parenchyma one day later. Therefore, we performed open drainage of the right kidney to control severe inflammation. The gas disappeared after the procedure, and her systemic status gradually improved. We hypothesize that emphysematous pyelonephritis is treated with open drainage instead of nephrectomy while preserving the ipsilateral kidney.
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Lasri A, Saouli A, Yddoussalah O, Karmouni T, Elkhader K, Koutani A, Andaloussi AIA. [Favorable evolution after medical treatment in three cases of emphysematous pyelonephritis: about 3 cases]. Pan Afr Med J 2018; 30:233. [PMID: 30574251 PMCID: PMC6295303 DOI: 10.11604/pamj.2018.30.223.12086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 06/21/2017] [Indexed: 11/25/2022] Open
Abstract
La pyélonéphrite emphysémateuse est une infection nécrotique du rein caractérisée par la présence de gaz au sein du parenchyme rénal, des cavités excrétrices ou des espaces péri rénaux. Il s'agit d'une forme grave pouvant engager le pronostic vital. La prise en charge reste controversée: entre l'attitude chirurgicale et le traitement purement médical, il existe une place pour le drainage percutané. Nous rapportons 3 cas de PNE traité par des antibiotiques seuls avec une bonne évolution, nous montrons à travers que le traitement médical pourrait suffire.
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Affiliation(s)
- Abdelouahed Lasri
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Amine Saouli
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Othmane Yddoussalah
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Tarik Karmouni
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Khalid Elkhader
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Abdellatif Koutani
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
| | - Ahmed Ibn Attya Andaloussi
- Service d'Urologie B, CHU Ibn Sina, Faculté de Médecine et de Pharmacie, Université Mohamed V Souissi, Rabat, Maroc
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20
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Uscanga-Yépez J, González-Oyervides R, Barrera-Juárez E. Severe bilateral emphysematous pyelonephritis. JOURNAL OF CLINICAL UROLOGY 2018. [DOI: 10.1177/2051415817720354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Jaime Uscanga-Yépez
- Instituto Tecnológico de Estudios Superiores de Monterrey, Zambrano Hellion Medical Center, N.L. México
| | | | - Eduardo Barrera-Juárez
- Instituto Tecnológico de Estudios Superiores de Monterrey, Zambrano Hellion Medical Center, N.L. México
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21
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McCafferty G, Shorette A, Singh S, Budhram G. Emphysematous Pyelonephritis: Bedside Ultrasound Diagnosis in the Emergency Department. Clin Pract Cases Emerg Med 2017; 1:92-94. [PMID: 29849419 PMCID: PMC5965426 DOI: 10.5811/cpcem.2016.12.32714] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 11/30/2016] [Accepted: 12/12/2016] [Indexed: 12/23/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a rare, life-threatening infection, and misdiagnosis as uncomplicated pyelonephritis is potentially fatal. Point-of-care ultrasound (POCUS) is a valuable tool for evaluation of the kidneys in patients with septic shock and pyelonephritis. While used primarily to assess for the complication of obstruction and hydronephrosis, POCUS may also detect signs of EPN and prompt surgical consultation for nephrectomy. We present a case in which the emergency physician diagnosed EPN by POCUS in a patient with septic shock and pyelonephritis.
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Affiliation(s)
- Gillian McCafferty
- Lahey Hospital and Medical Center, Department of Emergency Medicine, Burlington, Massachusetts
| | - Amanda Shorette
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
| | - Sukhdeep Singh
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
| | - Gavin Budhram
- University of Massachusetts Medical School-Baystate Health Springfield Campus, Baystate Medical Center, Department of Emergency Medicine, Springfield, Massachusetts
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22
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Abstract
Six patients (all women, mean age 59.8 years) with emphysematous pyelonephritis, a rare, severe inflammation causing renal parenchymal destruction and affecting diabetics more commonly than non-diabetics, are described. Four of the patients were diabetics. All underwent ultrasound examination (US), and five computed tomography (CT) of the kidneys. CT was the most reliable diagnostic method. Differentiation between gas and calcification was difficult at US in three patients. Conventional tomography was performed in two patients and showed intra-renal gas. All six patients recovered; three patients had nephrectomy, one as an emergency procedure and two as an elective procedure after two weeks of antibiotic treatment. Infection was eradicated in the other three patients by percutaneous drainage, electrolyte correction and antibiotics. It was concluded that while conventional abdominal radiography may permit the diagnosis of emphysematous pyelonephritis by demonstrating intra-renal gas, CT is the most reliable diagnostic examination. Emergency nephrectomy may not be necessary in all cases.
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Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA. Emphysematous pyelonephritis: A 10-year experience with 26 cases. Indian J Endocrinol Metab 2016; 20:475-480. [PMID: 27366713 PMCID: PMC4911836 DOI: 10.4103/2230-8210.183475] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Raiz Ahmad Misgar
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Idrees Mubarik
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Arshad Iqbal Wani
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Mahroosa Ramzan
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - Bashir Ahmad Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
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Kangjam SM, Irom KS, Khumallambam IS, Sinam RS. Role of Conservative Management in Emphysematous Pyelonephritis - A Retrospective Study. J Clin Diagn Res 2015; 9:PC09-11. [PMID: 26675196 DOI: 10.7860/jcdr/2015/16763.6795] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Accepted: 09/17/2015] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Emphysematous pyelophritis (EPN) is a serious condition with significant mortality. The prognosis of patients with EPN has changed over the years. Mortality has declined with prompt and aggressive medical management and minimally invasive strategies. AIM To identify the prognostic factors and assess the outcome of conservative management of emphysematous pyelonephritis. SETTINGS AND DESIGN This was a retrospective study of 8 consecutive patients who were diagnosed with EPN in two medical institutes between July 2010 and June 2015. MATERIALS AND METHODS Eight consecutive patients diagnosed with emphysematous pyelonephritis between July 2010 and June 2015 was studied retrospectively. On the basis of Computerised tomographic scan findings they were grouped into four classes (1 to 4) according the modified classification recommended by Huang and Tseng. The management was conservative (combination of percutaneous drainage and antibiotics), immediate nephrectomy or delayed nephrectomy (when conservative management failed). Demographic, clinical, biochemical and radiological characteristics were assessed and compared between survivors and nonsurvivors. RESULTS Seven (87.5%) of a total of 8 patients had diabetes mellitus. Escherichia coli (71.4 %) was the most common offending pathogen identified in pus culture. With conservative management in 7 patients (combination of percutaneous drainage and antibiotics), treatment was successful in 57.14 % and with immediate nephrectomy (one patient), the success rate was 100%. The risk factors for mortality were thrombocytopenia, shock and altered sensorium at presentation. The mortality rate in class 1, 2 and 3 was 0%, 33.3% and 66.7%. None of the patient had class 4 EPN. CONCLUSION A combination of percutaneous drainage with antibiotics offers an effective therapy for emphysematous pyelonephritis.
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Park SH, Kim KH. Treatment of a case of emphysematous pyelonephritis that presented with acute abdomen and pneumoperitoneum: a case report. BMC Nephrol 2015; 16:124. [PMID: 26231049 PMCID: PMC4522122 DOI: 10.1186/s12882-015-0125-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 07/28/2015] [Indexed: 11/10/2022] Open
Abstract
Background Emphysematous pyelonephritis is a severe, life-threatening infection of the renal parenchyma and perinephric tissues. This condition is primarily encountered in patients with diabetes mellitus or ureteral obstruction, and is characterized by the production of intrarenal and perinephric gas. Emphysematous pyelonephritis is associated with a high degree of morbidity and a high mortality rate. Case presentation A 72-year-old woman with a history of diabetes mellitus, hypertension, and renal calculi was referred to our emergency department following 6 days of abdominal pain. She suddenly developed pain in the entire abdomen, and was transferred. Physical examination was a distended abdomen with hypoactive bowel sounds. The tenderness was diffuse, but was most prominent in the right upper abdominal quadrant; moreover, rebound tenderness was noted. Laboratory tests revealed a white blood cell count of 4,480/mm3, platelet count of 17,000/mm3, creatinine level of 1.64 mg/dl, and serum glucose level of 603 mg/dl. Abdominal computed tomography indicated the presence of free air in the intraperitoneal cavity and right perirenal space, hydronephrosis of the right kidney, and stones in the right distal ureter. After 1 hour, the vital signs changed and she appeared to become drowsy. Therefore, the patient was transferred to the operation room for laparotomy. On exploration of the abdomen, 1.5 L of pus-colored fluid was removed. Although the abdominal viscera and pelvic organs were examined, hollow viscus perforation site could not be observed. Moreover, tissue necrosis and a perforation site were identified at the superior border of the right kidney. Thus, emphysematous pyelonephritis was diagnosed and she underwent right radical nephrectomy. After the surgery, the patient was admitted to the intensive care unit for postoperative management. Follow-up CT performed after 10 days showed fluid collection and hematoma at the nephrectomy site. Hence, percutaneous drainage was performed. Another follow-up computed tomography after 3 weeks indicated that the fluid collection at the nephrectomy site had nearly disappeared. Conclusions We believe that cases with free intraperitoneal air should promptly undergo laparotomy to identify the cause of the pneumoperitoneum. Moreover, an immediate nephrectomy may be effective for the treatment of emphysematous pyelonephritis in cases with poor prognostic factors.
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Affiliation(s)
- Sang Hyun Park
- Department of Urology, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 612-896, Republic of Korea.
| | - Ki Hoon Kim
- Department of Surgery, Inje University College of Medicine, Haeundae Paik Hospital, Busan, 612-896, Republic of Korea.
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Tilden W, Valliani S, Chana HS. Severe emphysematous pyelonephritis: conservative management plus image-guided percutaneous drainage prior to successful elective nephrectomy. A case report and review of the literature. BJR Case Rep 2015; 1:20140004. [PMID: 30363171 PMCID: PMC6159160 DOI: 10.1259/bjrcr.20140004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 04/02/2015] [Indexed: 11/23/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the kidney, characterized by gas within the renal parenchyma. It is strongly associated with diabetes mellitus and ureteric obstruction. We describe the case of a young female with severe EPN and gas extending diffusely throughout the abdomen. We demonstrate the progression of her infection on CT images from initial admission to percutaneous drainage (PCD) of a large air-fluid collection and then to a period of non-resolution that required elective nephrectomy. Although emergency nephrectomy was historically indicated in EPN, image-guided PCD is emerging as an effective nephron-sparing intervention when combined with supportive care and antibiotic therapy. This can be followed by elective nephrectomy if indicated.
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Affiliation(s)
- W Tilden
- Northwick Park Hospital, London, UK.,0000-0002-7166-9639
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27
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Min JW, Lee SK, Ko YM, Kwon KW, Lim JU, Lee YB, Lee HW, Won YD, Kim YO. Emphysematous pyelonephritis initially presenting as a spontaneous subcapsular hematoma in a diabetic patient. Kidney Res Clin Pract 2014; 33:150-3. [PMID: 26877965 PMCID: PMC4714164 DOI: 10.1016/j.krcp.2014.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 04/29/2014] [Accepted: 05/09/2014] [Indexed: 11/25/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a life-threatening infection characterized by the formation of gas. Complications of EPN include septic shock, acute renal failure, and disseminated intravascular coagulation. Spontaneous subcapsular hematoma (SCH) has also been reported as a rare complication of EPN, although there have been no reports to date of this occurring prior to the presentation of EPN. We report a case of EPN that initially presented as spontaneous SCH. The patient was admitted for left flank pain, and initial computed tomography revealed SCH without any air shadows. Laboratory findings and clinical symptoms suggested the presence of urinary tract infection and the patient was started on antibiotics. Fever developed 24 hours after admission. On follow-up computed tomography 7 days later, EPN was newly observed, and a percutaneous drain was inserted. Blood, urine, and drainage fluid cultures all revealed growth of extended-spectrum β-lactamase-negative Escherichia coli.
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Affiliation(s)
- Ji Won Min
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soon Kyu Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yu Mi Ko
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki Wook Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Uk Lim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yeong Bok Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hye Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Dong Won
- Department of Radiology, The Catholic University of Korea, Seoul, Korea
| | - Young Ok Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Lu YC, Chiang BJ, Pong YH, Huang KH, Hsueh PR, Huang CY, Pu YS. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis 2014; 14:418. [PMID: 25074590 PMCID: PMC4124134 DOI: 10.1186/1471-2334-14-418] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 07/23/2014] [Indexed: 12/11/2022] Open
Abstract
Background Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma and perirenal tissues that is caused by gas-producing bacterial pathogens. Percutaneous drainage is now the gold standard of definitive management. The aim of this study is to analyze the predictors associated with failure of conservative treatment among patients with EPN and offer the recommendation of appropriate empirical antibiotic regimen. Methods From January 2001 to December 2013, 44 consecutive patients were diagnosed with EPN. The demographic characteristics, clinical presentations, management strategies, and final outcomes were analyzed retrospectively. Results The overall survival rate was 88.6% (39/44). Need for emergency hemodialysis, shock on initial presentation, altered mental status, severe hypoalbuminemia, inappropriate empirical antibiotic treatment and polymicrobial infections were significantly more common in the patients who died compared with the survivors. The overall failure rate of conservative treatment was 32.6% (14/43). Severe hypoalbuminemia (p = 0.003), need for emergency hemodialysis (p = 0.03), and polymicrobial infections (p = 0.04) were significantly associated with failure of conservative treatment. Severe hypoalbuminemia was independently associated with conservative management failure (p = 0.02). Even in the patients treated with percutaneous drainage plus effective antibiotics, failure was still associated with severe hypoalbuminemia (p = 0.01). According to the in vitro susceptibility data, third-generation cephalosporins is recommended as the empirical antibiotic regimen. Conclusions Both appropriate empirical antibiotic and percutaneous drainage were essential for patients with EPN. Patients with severe hypoalbuminemia had a higher risk of conservative treatment failure, and additional management may be required. Electronic supplementary material The online version of this article (doi:10.1186/1471-2334-14-418) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | | | | | | | | | - Chao-Yuan Huang
- Department of Urology, National Taiwan University Hospital, National Taiwan University, College of Medicine, 10002 No, 7 Chung-Shan South Road, Taipei, Taiwan.
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Arsene C, Saste A, Arul S, Mestrovich J, Kammo R, Elbashir M, Berger G. A case series of emphysematous pyelonephritis. Case Rep Med 2014; 2014:587926. [PMID: 24812561 PMCID: PMC4000642 DOI: 10.1155/2014/587926] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Revised: 03/15/2014] [Accepted: 03/15/2014] [Indexed: 12/18/2022] Open
Abstract
Introduction. Emphysematous pyelonephritis (EPN) is an uncommon infection characterized by gas in the renal parenchyma and surrounding tissues. It is rapidly progressive, requiring appropriate therapy to salvage the infected kidney. Case Description. The case series presents 5 patients with a clinical and radiologic diagnosis of EPN. Each patient had a unique predisposing factor for developing EPN. Early goal directed therapy with intravenous fluids and antibiotics was given. This was followed by less invasive urologic interventions in an attempt to avoid nephrectomy and thereby salvage the infected kidney. All five patients were discharged in clinically stable conditions. Discussion and Conclusion. This case series provides added practice based support to available literature for managing EPN. Early goal directed medical therapy for sepsis coupled with interventional urologic procedures is a valuable alternative to circumvent an upfront emergent nephrectomy, except in cases where a fulminant infection may be present at the time of admission or develop later on in the course of the patients illness despite conservative line of therapy. It also highlights the importance of considering a diagnosis of EPN in patients with urinary infections, who have certain common predisposing factors listed in our case series.
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Affiliation(s)
- Camelia Arsene
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
| | - Abhijit Saste
- Department of Emergency Medicine, Detroit Receiving Hospital/Detroit Medical Center, 4201 Street Antoine, Suite 3R, Detroit, MI 48201, USA
| | - Shankar Arul
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
| | - Janee Mestrovich
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
| | - Revark Kammo
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
| | - Mohammed Elbashir
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
| | - Gregory Berger
- Department of Medicine, Sinai-Grace Hospital, Detroit Medical Center/Wayne State School of Medicine, 4th Floor, 6071 West Outer Drive, Detroit, MI 48235, USA
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Aboumarzouk OM, Hughes O, Narahari K, Coulthard R, Kynaston H, Chlosta P, Somani B. Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach. Arab J Urol 2013; 12:106-15. [PMID: 26019934 PMCID: PMC4434438 DOI: 10.1016/j.aju.2013.09.005] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/21/2013] [Accepted: 09/22/2013] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Emphysematous pyelonephritis (EPN) is a life-threatening necrotising kidney infection, but there is no consensus on the best management. METHODS We systematically reviewed previous articles published from 1980 to 2013 that included studies reporting on EPN, and applying the Cochrane guidelines, we conducted a meta-analysis of the results. RESULTS In all, 32 studies were included, with results for 628 patients (mean age 56.6 years, range 33.8-79.9). There were 462 women, outnumbering men by 3:1. Diabetes was present in 85% of the cases. Fevers and rigor (74.7%), pyuria (78.2%) and pain (70.4%) were the most common symptoms. Shock was associated with 54.4% of deaths while obstructive uropathy was associated with 15.1% of deaths. Computed tomography was diagnostic in all the cases. Percutaneous drainage (PCD) and medical management (MM) alone were associated with a significantly lower mortality rate than was emergency nephrectomy (EN), with an odds ratio (95% confidence interval) for PCD vs. EN of 3.13 (1.89-5.16; P < 0.001), for EN vs. MM of 2.84 (1.62-4.99; P = 0.001), and of 0.91 (0.53-1.56; P = 0.73, i.e., no difference) for PCD vs. MM. Open drainage also had a significantly lower mortality rate than EN, with a ratio of 0.12 (0.02-0.91; P < 0.04). CONCLUSION The overall mortality rate was ≈18%; shock was associated with a high mortality rate and therefore should be managed aggressively. PCD and MM were associated with significantly higher survival rates than EN, and therefore EN should only be considered if the patient does not improve despite other treatments.
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Affiliation(s)
| | - Owen Hughes
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Krishna Narahari
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Richard Coulthard
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Howard Kynaston
- Department of Urology, University Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Piotr Chlosta
- Department of Urology, Jagiellonian University, Cracow, Poland
| | - Bhaskar Somani
- Department of Urology, University Hospital of Southampton NHS Foundation Trust, Southampton, UK
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Dutta D, Shivaprasad KS, Kumar M, Biswas D, Ghosh S, Mukhopadhyay P, Mukhopadhyay S, Chowdhury S. Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature. Indian J Endocrinol Metab 2013; 17:S329-S332. [PMID: 24251204 PMCID: PMC3830350 DOI: 10.4103/2230-8210.119631] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is a life-threatening condition most commonly observed in diabetes, with nephrectomy believed to be the treatment of choice. However, nephrectomy in EPN is associated with increased risk of complications secondary to associated hemodynamic instability and may result in lifelong hemodialysis in case of bilateral EPN. We present three patients of severe bilateral EPN and one patient of unilateral EPN with diabetic ketoacidosis (DKA) successfully managed conservatively. Patient 1 (severe bilateral EPN) and patient 4 (unilateral EPN with DKA) responded to aggressive broad spectrum antibiotics, whereas patients 2 and 3 (severe bilateral EPN) responded to broad spectrum antibiotics along with percutaneous catheter drainage (PCD). PCD resulted in initial drainage of 300 and 200 ml of pus, respectively. All patients had associated uncontrolled hyperglycemia, poor glycemic control (HbA1c >8.5%), prerenal and intrinsic renal failure, leukocytosis, and dyselectrolytemia which responded to aggressive supportive management and insulin. There are several reports of successful medical management of severe bilateral EPN. Nephrectomy might no longer be the preferred treatment of severe bilateral EPN and may be reserved for patients' refractory to antibiotics and PCD. Urgent randomized controlled trials are warranted in EPN to optimize the treatment protocols.
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Affiliation(s)
- Deep Dutta
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - K. S. Shivaprasad
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Manoj Kumar
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Dibakar Biswas
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Sujoy Ghosh
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Pradip Mukhopadhyay
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Satinath Mukhopadhyay
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
| | - Subhankar Chowdhury
- Department sof Endocrinology and Metabolism, The Institute of Post-Graduate Medical Education and Research and Seth Sukhlal Karnani Memorial Hospital, Bose Road, Kolkata, West Bengal, India
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Sharma PK, Sharma R, Vijay MK, Tiwari P, Goel A, Kundu AK. Emphysematous pyelonephritis: Our experience with conservative management in 14 cases. Urol Ann 2013; 5:157-62. [PMID: 24049377 PMCID: PMC3764895 DOI: 10.4103/0974-7796.115734] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Accepted: 04/07/2012] [Indexed: 12/03/2022] Open
Abstract
Context: Emphysematous pyelonephritis (EPN) is a rare, severe, acute, necrotizing infection of the kidney. In this study, we present the clinical details, the management strategies, and the outcome of fourteen patients of EPN managed at our center. Materials and Methods: A retrospective analysis of the hospital records was done. A total of fourteen patients with EPN were admitted in our hospital from August 2007 to February 2011. All the patients were managed conservatively. Follow-up ranged from six months to one year. Results: Of the fourteen patients, four belonged to class I, five to class II, four to class IIIA and one to class IIIB. All the patients had history of fever, 43% had localized flank pain while 36% had vague abdominal discomfort. Renal angle tenderness was the most common sign, seen in 86% of the patients. E. coli was the most common bacteria, which was isolated from urine in 57% of the patients. On the risk factor stratification, three patients had simultaneous presence of 2 or more risk factors (thrombocytopenia-2 patients; renal function impairment-7 patients; shock-1 patient). All the patients were initially managed with aggressive fluid and electrolyte resuscitation, control of blood sugar levels, and broad spectrum antibiotics. Intervention, in the form of percutaneous drainage or DJ stenting, was done in six patients. One patient failed to respond to this minimally invasive modality of treatment and had to undergo an open drainage. Thus, the acute episode was managed with conservative management strategies in all the patients; however, three patients underwent nephrectomy due to poorly-functioning kidney during follow-up. Conclusions: EPN is now being more readily diagnosed, at an early stage, making conservative management of EPN a safe, effective, and feasible option.
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Affiliation(s)
- Pramod Kumar Sharma
- Department of Urology, Institute of Post Graduate Medical Education and Research, SSKM Hospital, Kolkata, India
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Pyélonéphrite emphysémateuse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2013. [DOI: 10.1007/s13341-013-0330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Lu YC, Chiang BJ, Pong YH, Chen CH, Pu YS, Hsueh PR, Huang CY. Emphysematous pyelonephritis: clinical characteristics and prognostic factors. Int J Urol 2013; 21:277-82. [PMID: 24033515 DOI: 10.1111/iju.12244] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 07/04/2013] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Emphysematous pyelonephritis is a severe necrotizing infection of the renal parenchyma and perirenal tissues that is caused by gas-producing bacterial pathogens. The aim of the present study was to determine the clinical characteristics and prognostic factors of patients with emphysematous pyelonephritis. METHODS We retrospectively analyzed the clinical and laboratory data, imaging findings, and outcomes of 32 patients with emphysematous pyelonephritis. Receiver operating characteristic curve analysis was carried out on variables that were significantly associated with patient mortality. RESULTS The overall survival rate was 87.5% (28/32). Escherichia coli (43.6%) was the most common organism cultured from urine and blood specimens. Hypoalbuminemia, shock as the presenting feature, bacteremia, need for hemodialysis and polymicrobial infection were significantly more common in cases resulting in death. The area under the receiver operating characteristic curve was 0.96. The cut-off point determined by the maximum Youden index (0.93) for three of these five factors yielded a sensitivity of 1.00 and specificity of 0.93. Shock as an initial presentation (P = 0.039) and polymicrobial infection (P = 0.010) were significantly associated with poor outcome. There were no significant differences in the clinical or laboratory features of the patients who did or did not undergo nephrectomy. CONCLUSION Hypoalbuminemia, shock as an initial presentation, bacteremia, indications for hemodialysis and polymicrobial infection represent prognostic factors for mortality in patients with emphysematous pyelonephritis. Patients presenting with more than two of these prognostic factors carry the highest risk of mortality, and they require timely diagnosis and aggressive management.
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Affiliation(s)
- Yu-Chuan Lu
- Department of Urology, National Taiwan University College of Medicine, Taipei, Taiwan
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Pojak K, Raza A, Rafique A, Sandhu G, Mehta S. Emphysematous pyelonephritis: a rare but potentially life-threatening complication of poorly controlled diabetes. ACTA ACUST UNITED AC 2013. [DOI: 10.1177/1474651413490306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 50-year-old man with poorly controlled type 1 diabetes presented with a 48-h history of diarrhoea, vomiting and poor appetite. He had recently visited India where he was treated for enteric fever. On admission he was febrile, dehydrated, hypotensive and tachycardic with diffuse abdominal tenderness. Plasma glucose was 56.1 mmol/L, venous pH 7.11, and urinalysis showed significant ketonuria, confirming diabetic ketoacidosis. He was treated with intravenous fixed dose insulin and fluids. In view of his symptoms, an erect chest and abdominal X-ray were performed to exclude small bowel obstruction and perforation respectively. The abdominal X-ray showed a gas density adopting the outline of the right kidney. Computed tomography of the abdomen showed gas within the parenchyma of the right kidney, in keeping with emphysematous pyelonephritis, and also a right sided hydronephrosis and hydroureter. Blood cultures were positive for Enterobacter aerogenes. He was reviewed by the urologists and infectious diseases team, was started on intravenous meropenem and had a percutaneous nephrostomy, drainage of gas from the emphysematous region of the right kidney and ureteric stent insertion. He responded well to treatment and was discharged on a basal bolus insulin regime, with his nephrostomy and drain being removed before discharge. He is under out-patient review by the diabetes, urology and infectious diseases teams. Emphysematous pyelonephritis is a potentially life-threatening complication of poorly controlled diabetes, characterised by bacterial production of gas within the kidney parenchyma. Early diagnosis and multidisciplinary care can lead to good outcomes, avoiding the need for emergency nephrectomy.
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Affiliation(s)
- Katie Pojak
- Department of Diabetes and Endcrinology, Ealing Hospital NHS Trust, Uxbridge Road, Southall, London, UK
| | - Asif Raza
- Department of Urology, Ealing Hospital NHS Trust, Uxbridge Road, Southall, London, UK
| | - Akkib Rafique
- Department of Radiology, Ealing Hospital NHS Trust, Uxbridge Road, Southall, London, UK
| | - Gurinder Sandhu
- Department of Infectious Diseases, Ealing Hospital NHS Trust, Uxbridge Road, Southall, London, UK
| | - Sanjeev Mehta
- Department of Diabetes and Endcrinology, Ealing Hospital NHS Trust, Uxbridge Road, Southall, London, UK
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Tsu JHL, Chan CK, Chu RWH, Law IC, Kong CK, Liu PL, Cheung FK, Yiu MK. Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals. Asian J Surg 2013; 36:121-5. [PMID: 23810162 DOI: 10.1016/j.asjsur.2013.01.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 12/07/2012] [Accepted: 01/09/2013] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE To retrospectively review our experience of managing patients with emphysematous pyelonephritis (EPN). METHODS Case notes of patients with EPN were reviewed. The patients' demographic data, clinical presentation, investigation findings, treatment, and outcome were studied. RESULTS Twelve patients were diagnosed with EPN. Majority (66.7%) of them had diabetes mellitus. All patients had been evaluated by computed tomography (CT). Using the classification proposed by Wan et al, five patients had type 1 EPN, whereas six, two, and four patients had Huang and Tseng CT class 2, 3a, and 3b EPN, respectively. Immediate nephrectomy was performed in six patients, whereas conservative treatment was adopted in the other six. In the nephrectomy group, one patient died of disseminated sepsis after a protracted course. Conservative treatment failed in three patients, who succumbed despite salvage nephrectomy in two of them. Analysis revealed that severe hyperglycemia and radiological CT class (both Wan and Huang systems) were significant predictors of mortality from EPN. CONCLUSION Severe hyperglycemia and CT class of EPN are significant risk factors for death. CT is the investigation of choice for correct diagnosis of EPN. Additional intervention should be offered to EPN patients with Wan type 1 and Huang and Tseng class 3 CT features.
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Affiliation(s)
- James Hok-Leung Tsu
- Division of Urology, Department of Surgery, University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region
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Lakshminarayana G, Mathew A, Rajesh R, Kurien G, Unni VN. Bilateral emphysematous pyelonephritis in autosomal dominant polycystic kidney disease. Indian J Nephrol 2012; 22:136-8. [PMID: 22787318 PMCID: PMC3391813 DOI: 10.4103/0971-4065.97138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Emphysematous pyelonephritis (EPN) is an uncommon infection of renal parenchyma with gas-forming organisms. EPN is usually seen in patients with diabetes mellitus (DM). The association of EPN with conditions other than DM is extremely rare. We report a case of autosomal dominant polycystic kidney disease with bilateral EPN who had to undergo bilateral nephrectomy.
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Affiliation(s)
- G Lakshminarayana
- Department of Nephrology, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India
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Bjurlin MA, Hurley SD, Kim DY, Cohn MR, Jordan MD, Kim R, Divakaruni N, Hollowell CMP. Clinical outcomes of nonoperative management in emphysematous urinary tract infections. Urology 2012; 79:1281-5. [PMID: 22513034 DOI: 10.1016/j.urology.2012.02.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2012] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To investigate the clinical outcomes of nonoperative management of emphysematous urinary tract infections (EUTIs). METHODS We retrospectively reviewed 28 consecutive cases of EUTI over a 5-year period, all of which were treated with urinary drainage and medical management without surgical intervention. EUTIs were classified as either emphysematous pyelonephritis (EP) or emphysematous cystitis (EC). Clinical, diagnostic, and therapeutic data were analyzed. RESULTS Of the 28 patients evaluated, 13 had EP and 15 had EC, all of which were diagnosed by computed tomography. Of EP patients, the mean age was 54 years with a median serum creatinine (sCr) of 1.8 mg/dL (estimated glomerular filtration rate [eGFR] 38 mL/min/1.73 m(2)). Obstructive uropathy was present in 69%, and 100% received antibiotics and percutaneous drainage without mortality. Median follow-up was 10 months without any subsequent nephrectomy and median sCr decreased to 1.1 mg/dL (P = .04) and eGFR increased to 63.5 mL/min/1.73 m(2) (P = .06). Of EC patients, the mean age was 60 years with a median sCr of 1.3 mg/dL (eGFR 55 mL/min/1.73 m(2)). All were managed with antibiotics and catheter drainage with a single mortality (7%). Median follow-up was 2 months and median sCr decreased to 1.2 mg/dL (P = .83) and eGFR increased to 46 mL/min/1.73 m(2) (P = .68). The most common causative pathogen was Escherichia coli for both EP (54%) and EC (53%). CONCLUSION Early detection, medical management, and urinary drainage of EUTI can result in a favorable prognosis. This strategy results in low levels of mortality without the need for surgical intervention and can preserve renal function.
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Affiliation(s)
- Marc A Bjurlin
- Division of Urology, Department of Surgery, Cook County Hospital, Cook County Health and Hospitals System, Chicago, IL 60612, USA
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Benelhoul W, Basset T, Salhi MS, Kallel H, Hommel D. [Emphysematous pyelonephritis: a rare complication of upper urinary tract infections]. ACTA ACUST UNITED AC 2012; 31:262-3. [PMID: 22305396 DOI: 10.1016/j.annfar.2011.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2011] [Accepted: 11/22/2011] [Indexed: 11/29/2022]
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Yang WS, Kim WY, Sohn CH, Seo DW, Lee JH, Kim W, Lim KS. Clinical Feature and Prognostic Factors of Emphysematous Pyelonephritis. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.2.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Won Soek Yang
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung-Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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El-Nahas AR, Shokeir AA, Eziyi AK, Barakat TS, Tijani KH, El-Diasty T, Abol-Enein H. Kidney preservation protocol for management of emphysematous pyelonephritis: Treatment modalities and follow-up. Arab J Urol 2011; 9:185-9. [PMID: 26579294 PMCID: PMC4150599 DOI: 10.1016/j.aju.2011.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2011] [Revised: 09/24/2011] [Accepted: 09/25/2011] [Indexed: 11/28/2022] Open
Abstract
Objectives To present treatments for kidney preservation in the management of emphysematous pyelonephritis (EPN), and to evaluate the functional outcome of preserved kidneys during the follow-up. Patients and methods The computerized files of patients with EPN from 2000 to 2010 were reviewed. After initial resuscitation, ultrasonography-guided percutaneous tubes were placed for drainage of infected fluid and gas. A radio-isotopic renal scan was done after stabilization of the patients’ condition. Preservation of the affected kidney was attempted when the differential function was >10%. A renal isotopic scan was taken during the follow-up to evaluate renographic changes in preserved kidneys. Results The study included 33 kidneys in 30 consecutive patients (mean age 51.7 years, SD 10.9). Kidney preservation was applicable for 23 kidneys (20 patients). Preservation methods included percutaneous nephrostomy for 12, percutaneous tube drain for two and conservative treatment for nine kidneys (six patients). Nephrectomy was performed for 10 kidneys (emergency in three and delayed in seven). The frequency of post-treatment septic shock after kidney preservation (10%) was significantly lower than after nephrectomy (20%, P = 0.005). The overall mortality rate was 7% (two patients). The follow-up was completed for 13 patients with 15 preserved kidneys for a mean duration of 21 months. During the follow-up, differential renographic clearance of the affected kidney was stable in 13 of 15 while two kidneys showed improvement. Conclusions Kidney preservation should be the primary goal in the treatment of EPN when the differential renal clearance is >10%. It was associated with fewer complications than nephrectomy and the follow-up showed a favourable functional outcome of the preserved kidneys.
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Affiliation(s)
- Ahmed R El-Nahas
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Ahmed A Shokeir
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Amogu Kalu Eziyi
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Tamer S Barakat
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Kehinde Habeeb Tijani
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Tarek El-Diasty
- Radiology Unit, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
| | - Hassan Abol-Enein
- Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
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Koh GCKW, Peacock SJ, van der Poll T, Wiersinga WJ. The impact of diabetes on the pathogenesis of sepsis. Eur J Clin Microbiol Infect Dis 2011; 31:379-88. [PMID: 21805196 PMCID: PMC3303037 DOI: 10.1007/s10096-011-1337-4] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 06/21/2011] [Indexed: 02/06/2023]
Abstract
Diabetes is associated with an increased susceptibility to infection and sepsis. Conflicting data exist on whether the mortality of patients with sepsis is influenced by the presence of diabetes, fuelling the ongoing debate on the benefit of tight glucose regulation in patients with sepsis. The main reason for which diabetes predisposes to infection appears to be abnormalities of the host response, particularly in neutrophil chemotaxis, adhesion and intracellular killing, defects that have been attributed to the effect of hyperglycaemia. There is also evidence for defects in humoral immunity, and this may play a larger role than previously recognised. We review the literature on the immune response in diabetes and its potential contribution to the pathogenesis of sepsis. In addition, the effect of diabetes treatment on the immune response is discussed, with specific reference to insulin, metformin, sulphonylureas and thiazolidinediones.
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Affiliation(s)
- G C K W Koh
- The Wellcome Trust Sanger Institute, Hinxton, Cambridge, UK.
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Abstract
Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma. The clinical course of EPN can be severe and life-threatening if not recognized and treated promptly. Most of the information has been from case reports, a few large series have also been reported. Using an evidence-based approach, this review describes the pathogenesis, classification, complications, and management of EPN. Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The cause for mortality in EPN is primarily due to septic complications. Up to 95% of the cases with EPN have underlying uncontrolled diabetes mellitus. The risk of developing EPN secondary to a urinary tract obstruction is about 25-40%. There are three classifications of EPN based on radiological findings. Acute renal failure, microscopic or macroscopic haematuria, severe proteinuria are other positive findings in EPN. Escherichia coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases. A plain radiograph shows an abnormal gas shadow in the renal bed raising the suspicion whereas an ultrasound scan or computed tomography (CT) will confirm the presence of intra-renal gas thus supporting the diagnosis of EPN. Gas may extend beyond the site of inflammation to the sub capsular, perinephric and pararenal spaces. In some cases, gas was found to be extending into the scrotal sac and spermatic cord. Subsequent case studies have shown patients being successfully treated with PCD when used in addition to medical management, with significant reduction in the morality rates. PCD should be performed on patients who have localized areas of gas and functioning renal tissue is present. The treatment strategies include MM alone, PCD plus MM, MM plus emergency nephrectomy, and PCD plus MM plus emergency nephrectomy. In small proportion of patients managed with MM and PCD, subsequent nephrectomy will be required and in these patients the reported mortality is 6.6% Nephrectomy in patients with EPN can be simple, radical or laparoscopic.
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Affiliation(s)
- Sarvpreet Singh Ubee
- Department of Urology, The Heart of England NHS Foundation Trust, Birmingham, UK.
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Wang JH. Emphysematous Pyelonephritis. UROLOGICAL SCIENCE 2010. [DOI: 10.1016/s1879-5226(10)60029-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Krishnasamy PV, Liby C. Emphysematous pyelonephritis caused by Candida tropicalis. Am J Med 2010; 123:e7-8. [PMID: 20362742 DOI: 10.1016/j.amjmed.2009.07.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Revised: 07/25/2009] [Accepted: 07/28/2009] [Indexed: 10/19/2022]
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Chow L, Sharma G. Diabetes mellitus and confusion. Am J Med 2010; 123:228-30. [PMID: 20193830 DOI: 10.1016/j.amjmed.2009.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2009] [Revised: 11/20/2009] [Accepted: 11/20/2009] [Indexed: 10/19/2022]
Affiliation(s)
- Leonard Chow
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, 77555-0561, USA
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Abstract
Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection that is characterized by the production of intraparenchymal gas. EPN predominantly affects female diabetics, and can occur in insulin-dependent and non-insulin-dependent patients in the absence of ureteric obstruction. Nondiabetic patients can also develop EPN, but often have ureteric obstruction and do not seem to develop such extensive disease. One gaseous component-carbon dioxide-is generated by bacterial fermentation of glucose (present in excess in diabetics) and acids. Patients with EPN show relatively vague symptoms initially, but frequently undergo a sudden deterioration in their condition, necessitating urgent medical attention. Treatment of patients with EPN comprises resuscitation, correction of any electrolyte and glucose problems, and administration of antibiotics targeting Gram-negative bacteria. Ureteric obstruction, if present, is relieved by a percutaneous nephrostomy or stent. Definitive management is by percutaneous drainage, except when there is extensive diffuse gas with renal destruction; in this case, a nephrectomy is advised. The requirement for a nephrectomy could potentially be avoided by early diagnosis and treatment of diabetics with urinary infection. With the advent of CT, a staging system of the gas patterns generated in the kidneys of EPN patients has evolved. Risk factors have been defined to aid management.
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Kapoor R, Muruganandham K, Gulia AK, Singla M, Agrawal S, Mandhani A, Ansari MS, Srivastava A. Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis. BJU Int 2009; 105:986-9. [PMID: 19930181 DOI: 10.1111/j.1464-410x.2009.08930.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyse the factors predicting the mortality and need for nephrectomy in patients with emphysematous pyelonephritis (EPN). PATIENTS AND METHODS Clinical features, laboratory variables, imaging studies, management strategy and the final outcomes were analysed in 39 consecutive patients with EPN. The mean (sd) age was 57 (7.2) years and the male to female ratio was 2:11. The baseline risk factors (clinical, laboratory and radiological) were compared among three groups; group 1, survived with renal salvage (26); group 2, survived after nephrectomy (eight); and group 3, died (five). RESULTS The overall survival rate was 87% (34/39) and the kidney was salvaged in 67% (26) patients at a median follow-up of 18 months. Altered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation were significantly associated with mortality rate. There was no significant difference in final outcome based on radiological classification. Extensive renal parenchymal destruction of >50% (based on computed tomography) significantly predicted the need for nephrectomy (P < 0.001) and death (P = 0.02). Early (<1 week) nephrectomy resulted in a higher mortality rate (three of seven patients) than initial conservative management. There were no deaths in selected patients who received antibiotics alone or had delayed nephrectomy (four patients each). Of 24 patients who had minimally invasive treatment alone, two (8%) died. Minimally invasive treatment resulted in high renal salvage (22/24, 92%). CONCLUSION Altered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation are associated with higher mortality rates, whereas extensive renal parenchymal destruction is associated with a need for nephrectomy. Early nephrectomy is associated with higher mortality rates than is initial conservative management.
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Affiliation(s)
- Rakesh Kapoor
- Sanjay Gandhi Post Graduate Institute, Lucknow, India.
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Park BS, Lee SJ, Kim YW, Huh JS, Kim JI, Chang SG. Outcome of nephrectomy and kidney-preserving procedures for the treatment of emphysematous pyelonephritis. ACTA ACUST UNITED AC 2009; 40:332-8. [PMID: 16916776 DOI: 10.1080/00365590600794902] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Emphysematous pyelonephritis (EPN) is an acute necrotizing infection of the kidney characterized by gas formation. In order to compare the outcome of nephrectomy and kidney-preserving procedures for the treatment of EPN we reviewed our experiences of EPN over the past 18 years. MATERIAL AND METHODS The medical records of 17 patients with EPN treated between October 1986 and September 2004 were retrospectively reviewed. Abdominal X-ray and/or CT were used as diagnostic methods. RESULTS Women outnumbered men (12 vs five), and all patients had diabetes. Obstruction of the corresponding reno-ureteral unit was found in one patient. Thirteen of the 17 patients (76%) had poorly controlled diabetes (hemoglobin A1c>7%). The diagnosis of EPN was confirmed by gas in the parenchymal or perinephric space as detected by abdominal X-ray or CT. Escherichia coli was the commonest organism present in urine cultures (52%), followed by Klebsiella pneumoniae (24%). Prompt efforts were made to control diabetes, and i.v. antibiotics were given. Nephrectomy was performed in 10 patients and nine patients survived (90% success rate). The success rate among those who received medical therapy only was 50% (2/4 patients). Percutaneous drainage was performed in three patients, two of whom survived (67% success rate). The overall mortality rate was 17.6% (3/17 patients). CONCLUSIONS Immediate nephrectomy with glycemic control measures and antibiotic administration is crucial for the successful treatment of EPN. However, in inoperable cases, percutaneous drainage can be an effective treatment option.
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Affiliation(s)
- Bum Soo Park
- Department of Urology, School of Medicine, Kyung Hee University, Seoul, South Korea
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Khaira A, Gupta A, Rana DS, Gupta A, Bhalla A, Khullar D. Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis. Int Urol Nephrol 2009; 41:959-66. [PMID: 19404766 DOI: 10.1007/s11255-009-9552-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Accepted: 02/27/2009] [Indexed: 10/20/2022]
Abstract
AIM We aimed to study the clinical profile, prognostic factors, and the 6-month outcome of patients with emphysematous pyelonephritis (EPN) METHODS: All patients admitted with a diagnosis of emphysematous pyelonephritis between January 2001 and July 2007 were included. RESULTS Overall 19 cases were diagnosed to have emphysematous pyelonephritis. There were 16 females and three males. Fourteen cases had type 2 diabetes mellitus. Fourteen cases had unilateral involvement and five had bilateral involvement. Eleven cases were classified as having class 1 or 2 disease and eight cases had class 3 and 4 disease. E. coli was the most common organism cultured (68.4%). Five cases underwent percutaneous drainage of the collecting system and three cases had nephrectomy of which 10.5% (two with advanced disease) expired. Shock at admission (p = 0.03), serum creatinine >5.0 mg/dl (p = 0.035) and DIC (p = 0.017) were independent poor prognostic factors. There was no difference in the prognosis between patients who had >or=2 or <2 poor prognostic factors (p = 0.16). However, prognosis was not related to disease class, unilateral vs. bilateral involvement, sepsis or the age of the patient. At 6 months, two patients were on maintenance hemodialysis. CONCLUSIONS In cases of EPN, shock, serum creatinine >5.0 mg/dl and DIC at admission are poor prognostic factors. Larger prospective studies are needed to confirm our findings.
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Affiliation(s)
- Ambar Khaira
- Department of Nephrology, All India Institute of Medical Sciences, Ansari Nagar, Delhi, 110029, India.
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