Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy

A case of emphysematous pyelonephritis in an older man with poorly controlled type 2 diabetes mellitus

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative study of the bacterial distribution and antimicrobial susceptibility of uropathogens in older and younger patients with urinary stones

Background

This study compared the bacterial spectrum and antibiotic susceptibility of uropathogens in older and younger patients with urinary stones to provide appropriate antibiotic management.

Methods

We retrospectively reviewed urinary tract infection patients with urolithiasis, presented to Xiangya Hospital from March 2014 to April 2021. Patients were divided into older and younger groups according to 60 years of age. The bacterial spectrum and drug sensitivity of uropathogens were compared.

Results

A total of 542 strains of uropathogens (177 in older and 365 in younger groups) were isolated from 507 patients. E. coli (41.8% vs 43.6%) remains the most common pathogen, followed by E. faecalis (6.2% vs 9.6%) in older and younger groups, respectively. Particularly, K. pneumoniae was significantly more frequent in older (9.6%) than in younger group (4.7%, P < .05). E. faecium was substantially more prevalent in older group (6.2%) than in younger group (2.7%, P < .05). The proportion of males increased in older patients (47.3%) than in younger patients (34.9%, P = 0.007). In both groups, major Gram-negative bacteria (E. coli and K. pneumoniae) revealed a high sensitivity over 70% to piperacillin/tazobactam, imipenem and amikacin, whereas the resistance level was high to penicillin, tetracycline and vancomycin. Major Gram-positive (E. faecalis and E. faecium) isolates demonstrated high sensitivity of over 50% to gentamicin and vancomycin in both groups. Furthermore, uropathogens isolated from younger urolithiasis patients were more susceptible to antimicrobials than those isolated from older patients.

Conclusions

The male increased in the older urolithiasis patients with UTI and uropathogens microbial spectrum in older urolithiasis patients are different from younger. High susceptibility and age should be utilized in empirical antibiotic selection to avoid increased multidrug-resistant bacteria.

A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis

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.

Case report: Bilateral emphysematous pyelonephritis with pneumatosis intestinalis

Emphysematous pyelonephritis is a severe and rare gas producing infection in the renal parenchyma or collecting system. Diabetes mellitus is an established risk factor. Treatment options include antibiotics, minimally invasive management such as percutaneous drainage, or nephrectomy. This case report describes a 40-year-old female with newly diagnosed diabetes and cirrhosis who presented with left sided emphysematous pyelonephritis. After initial management with intravenous antibiotics and drainage of the collecting system, this patient's clinical condition worsened, and subsequent repeat imaging revealed bilateral emphysematous pyelonephritis as well as pneumatosis intestinalis.