Severe emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and antibiotics

Case report: Emphysematous pyelonephritis associated with kidney allograft abscess formation

Emphysematous pyelonephritis (EPN) is a severe, acute necrotizing infection that is defined by the presence of gas in the kidney parenchyma. Multiple case reports have described the radiological findings and clinical course of EPN. Herein, we report on EPN including the histopathological findings in a kidney transplant recipient. Our patient presented with EPN complicated by multiorgan failure and was successfully managed with transplant nephrectomy.

[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.

Deriving a management algorithm for emphysematous pyelonephritis: Can we rely on minimally invasive strategies or should we be opting for earlier nephrectomy?

PURPOSE

To analyse the incidence and management of emphysematous pyelonephritis (EPN) in North West London and examine factors that influence immediate and 6-month outcomes with the aim of guiding future management.

METHODS

This work analyses EPN cases from the London North West Healthcare NHS Trust from October 2006 to July 2015 (population ≈ 850,000). Diagnosis and stage were confirmed by computed tomography (CT). Demographic, clinical, biochemical and microbiological characteristics were assessed. Treatment modalities were medical management, minimally invasive management (MIM) and surgical. Immediate and 6-month outcomes were analysed.

RESULTS

Thirteen cases were identified (f = 8, m = 5) from 5525 CT scans. EPN occurred in patients with diabetes mellitus (n = 11, 84.6%), hypertension (n = 10, 76.9%) or urinary tract calculi (n = 7, 53.85%). Unilateral EPN occurred predominantly (n = 11, 84.6%); 46.1% (n = 6) were class 1 or 2 and 53.8% (n = 7) class 3 or 4. Escherichia coli was most commonly cultured (n = 5, 38.46%). All patients received antibiotics, and ten cases required MIM. Two patients had a delayed nephrectomy, both survived. Mortality was 15.4% (n = 2, grade 1 and 3a), both died acutely post-MIM, neither underwent emergency nephrectomy. At 6 months, eight patients had ongoing renal impairment. No specific poor prognostic factors were identifiable.

CONCLUSIONS

Patients with low-grade EPN may also have a high mortality rate. In the two cases who died, earlier consideration for nephrectomy may have been prudent. It may be beneficial to have a low threshold for prompt emergency nephrectomy in severe cases and where MIM treatment has failed. We suggest a management algorithm to guide clinicians and minimise mortality.

Clinical profile and outcome of conservatively managed emphysematous pyelonephritis

Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection characterized by production of intraparenchymal gas. EPN predominantly affects female diabetics and immunocompromised patients. In a three-year period 2008-2011, a total of 8 patients were admitted to our hospital. All of them were diabetics, and both males and females were equally affected. These patients showed vague symptoms at admission and frequently presented with fever, loin pain, dysuria, and pyuria necessitating urgent medical attention. EPN required radiological diagnosis. CT scan revealed bilateral EPN with urinary obstruction and hydronephrosis in 50% of patients. Escherichia coli was found to be the causative organism in all the patients. Treatment comprised of resuscitation, normalization of serum electrolytes and blood sugars, administration of parenteral antibiotics, and relieving ureteric obstruction if present. All the patients improved with conservative management without any mortality.

Current management of emphysematous pyelonephritis

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.

Retrospective analysis of clinical profile prognostic factors and outcomes of 19 patients of emphysematous pyelonephritis

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.