Emphysematous pyelonephritis in a kidney allograft

[Emphysematous pyelonephritis and cystitis: An exceptional complication in a kidney transplant recipient]

Emphysematous pyelonephritis is a rare and severe infectious complication characterized by the presence of gas in the renal parenchyma, excretory cavities and surrounded tissues. It is due to the development of non-anaerobic gasifier bacteria. We report a new rare case of emphysematous pyelonephritis in a kidney transplant recipient, particular by its occurrence in a non-functional graft and its exceptional association with emphysematous cystitis.

Emphysematous pyelonephritis in renal allograft related to antibody-mediated rejection: A case report and literature review

Emphysematous pyelonephritis (EPN) is a rare condition which can rapidly progress to sepsis and multiple organ failure with high mortality. We experienced a rare case of EPN in a renal allograft related to antibody-mediated rejection (AMR). The patient received a deceased donor kidney transplant due to end-stage renal disease secondary to diabetes mellitus. Cross-match test was negative but she had remote history of anti-HLA-A2 antibody corresponding with the donor HLA. Surgery concluded without any major events. Anti-thymoglobulin was given perioperatively for induction. She was compliant with her immunosuppressive medications making urine of 2 L/d with serum creatinine of 1.9 mg/dL at discharge on post-operative day (POD) 6. She did well until POD 14 when she presented to the clinic with features of sepsis, pain over the transplanted kidney area and decline in urine volume with elevated serum creatinine. CT revealed extensive gas throughout the transplanted kidney. Renal scan revealed non-functional transplant kidney with no arterial flow. Based on these findings, a decision to perform transplant nephrectomy was made. At laparotomy, the kidney was completely necrotic. Pathology showed non-viable kidney parenchyma with the tubules lacking neutrophilic casts suggestive of ischemic necrosis. Donor-specific antibody (DSA) returned positive with high intensity anti-HLA-A2 antibody. This is the first case of early EPN in allograft considered to have occurred as a result of thrombotic ischemia secondary to AMR. This case suggests consideration of perioperative anti-B-cell and/or anti-plasma cell therapies for historical DSA and strict post-operative follow-up in immunologically high-risk recipients to detect early signs of rejection and avoid deleterious outcomes.

Emphysematous pyelonephritis in a transplanted kidney

Emphysematous pyelonephritis is a rare infection characterized by necrosis and gas accumulation in the renal parenchyma, adjacent tissues, and/or urinary collecting system. This entity is rarely reported in transplanted kidneys. Computed tomography imaging is necessary for diagnosis and risk classification. The authors described the case of a 58-year-old man who underwent a kidney transplant and presented sepsis from a urinary tract infection. An abdominal tomography showed some characteristics of emphysematous pyelonephritis associated with an abscess. A graft biopsy, performed 45 days after the transplant, failed to show signs of infection, and tubule-interstitial and vascular rejection were ruled out. The patient had a poor outcome, and a nephrectomy was needed, the pathological analysis of which yielded the diagnosis of chronic pyelonephritis with necrotizing papillitis. The patient became hemodynamically unstable and died. The authors highlight the current tomographic criteria for the diagnosis and treatment of emphysematous pyelonephritis and question the validity of accepting the same standards used to guide the treatment of patients without transplants, and call attention to the importance of the clinical status for the indication of nephrectomy in cases of emphysematous pyelonephritis.

Fulminant course of unilateral emphysematous pyelonephritis revealing a renal actinomycosis caused by Actinomyces meyeri, an unknown cause of septic shock

The objective of this case report is to describe the first case of renal actinomycosis caused by Actinomyces meyeri presenting as severe emphysematous pyelonephritis and complicated by septic shock and multi-organ failure. Emphysematous pyelonephritis is a potentially life-threatening infection mostly described in diabetic patients and predominantly caused by uropathogenic bacteria. Actinomycosis is an uncommon chronic infection due to anaerobic gram-positive bacteria that unusually involves the urinary tract. We report the first case of emphysematous pyelonephritis caused by A. meyeri in a 75-year-old non-diabetic woman. The patient presented with an altered status, fever, nausea, and vomiting lasting for 2 days. A computed tomography scan revealed unilateral emphysematous pyelonephritis. She was rapidly admitted to intensive care unit for a septic shock with multiple organ dysfunctions. A conservative management consisting in renal percutaneous drainage, supportive measures, and prolonged adapted antibiotic therapy resulted in complete recovery. This case report illustrates that renal actinomycosis should be considered in case of emphysematous pyelonephritis given the good prognosis of this infection with conservative medical treatment.

Case of emphysematous pyelonephritis in kidney allograft: Conservative treatment

Emphysematous pyelonephritis is an acute necrotizing infection with gas in the kidney and perinephric space that carries a bad prognosis. Apart from its predisposing clinical entities, diabetes mellitus and immune-incompetence are quite common in patients with this infection. We report a case of a 53-year-old kidney transplant recipient diabetic male, suffering from recurrent fever, abdominal pain and nausea episodes. Immediate broad-spectrum antibiotics were administered and percutaneous drainage was performed after the diagnosis. The bacteria involved were Stahpylococcus epidermidis and Escherichia coli. After 4 weeks of antibiotic treatment and abscesses drainage, the case was resolved. Consecutives urine cultures and ultrasonographies confirm the complete resolution of the disease. We discuss the predisposing factors, clinical presentation and management.

Renal allograft failure due to emphysematous pyelonephritis: successful non-operative management and proposed new classification scheme based on literature review

Emphysematous pyelonephritis (EPN) is a rare necrotizing infection of the kidney caused by gas-forming organisms, usually occurs in diabetic patients, and often requires nephrectomy for effective therapy. EPN is rarely reported in renal allografts, with only 20 cases found in the English literature. We report herein a case of EPN in a transplanted kidney resulting in acute renal failure and sepsis. The patient was managed non-operatively with subsequent recovery of renal allograft function. Based on this experience and a review of the literature, we suggest an amended classification system for EPN in kidney transplantation to plan and guide treatment options accordingly. However, the scarcity of this disease process, coupled with the lack of prospective validation of the new classification scheme, prevents drawing definitive conclusions regarding optimal management strategies including the role and timing of allograft nephrectomy.