[Bilateral emphysematous pyelonephritis cured by medical therapy alone]

Predictors of mortality and nephrectomy in emphysematous pyelonephritis: a tertiary care centre study

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.

Emphysematous pyelonephritis: A 10-year experience with 26 cases

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.

Medical therapy alone can be sufficient for bilateral emphysematous pyelonephritis: report of a new case and review of previous experiences

Bilateral emphysematous pyelonephritis (EPN) is an extremely uncommon, life-threatening gas-forming infection of renal parenchyma and its surrounding areas. Surgical treatment, including percutaneous catheter drainage and nephrectomy, has been advocated as the treatment of choice in most of the patients. However, nephrectomy is itself a hazardous intervention in an unstable septic patient. Whenever bilateral disease is present, the need for long-term renal replacement therapy is unavoidable. We present the clinical course of a lady who presented with bilateral EPN and was successfully managed by medical therapy alone. We also reviewed almost all published cases of bilateral EPN that had been managed medically.

[Bilateral emphysematous pyelonephritis caused by Candida glabrata: An exceptional entity]

Acute emphysematous pyelonephritis (AEP) is a severe form of urinary tract infection. It occurs usually in diabetics. The most concerned agents are the Gram-negative bacilli. We report a first case of bilateral AEP due to Candida glabrata, occurred in a 64-year-old diabetic woman. The clinical presentation started with fever and abdominal pains, without signs of urinary tract infection. Within six hours, the patient had developed a septic shock with renal failure and ketoacidosis. The diagnosis was confirmed by CT scan and the pathogen was isolated in urine. Despite antibiotic and antifungal treatment, she died from a septic shock. Acute emphysematous pyelonephritis due to Candida species is rare. However, the addition of antifungal therapy seems justified if a severe emphysematous pyelonephritis is associated with risk factors of Candida infection.