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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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Eswarappa M, Suryadevara S, John MM, Kumar M, Reddy SB, Suhail M. Emphysematous Pyelonephritis Case Series From South India. Kidney Int Rep 2017; 3:950-955. [PMID: 29988992 PMCID: PMC6035119 DOI: 10.1016/j.ekir.2017.12.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/27/2017] [Accepted: 12/04/2017] [Indexed: 12/31/2022] Open
Abstract
Introduction Emphysematous pyelonephritis (EPN) is a rare, life-threatening necrotizing infection of the kidney. The mortality rate for EPN is as high as 25%. We conducted a retrospective study at MS Ramaiah Hospital between January 2011 and May 2016 to observe the clinical, biochemical, and microbiological patterns of EPN at our institute. Methods The clinical and laboratory data, imaging findings, and microbiological patterns of 51 patients chosen for the study were recorded. The data were analyzed to identify the prognostic variables that could predict the morbidity and mortality of patients with EPN, and the focus of this study was to determine risk factors for and outcomes of patients who presented with EPN and who required hemodialysis. Primary endpoints were successful treatment and all-cause mortality. Secondary endpoints included need for hemodialysis and the need for a specific treatment. Results There was an equal incidence among both sexes (median age: 59 years). Common symptoms were abdominal pain (94.11%), fever (83.2%), dysuria (74.5%), vomiting (72.54%), frequency of micturition (68.62%), oliguria, generalized weakness (66.67%), and breathlessness (66.67%); 98.03% (n = 50) of the patients had diabetes. The most common organism cultured was Escherichia coli (37.2%). Nineteen patients (37.2%) required dialysis; their mean age was 60.25 ± 11.74 years. Male sex, diabetes mellitus, shock, high serum creatinine at presentation, and uremic symptoms showed no statistically significant association. Indefinite hemodialysis was required by 12.5% of patients. The antibiotic-treated group had a 100% success rate, whereas the Double J (DJ) stenting group (Double J stent, Biorad, India) had 96.42% success rate. Conclusion Early diagnosis and broad spectrum antibiotics, together with an appropriately timed intervention, resulted in decreased mortality. Pain in the abdomen and renal angle tenderness were the most common clinical finding. E coli was the most found organism, and early use of broad spectrum antibiotics decreased mortality.
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Affiliation(s)
- Mahesh Eswarappa
- Nephrology, Ramaiah Medical College & Hospitals, Bangalore, India
| | | | | | - Mahesh Kumar
- Nephrology, Ramaiah Medical College & Hospitals, Bangalore, India
| | | | - Mohammed Suhail
- Nephrology, Ramaiah Medical College & Hospitals, Bangalore, India
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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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Suzuki R, Abe T, Uchida H, Niikura K. Successful management of bilateral emphysematous pyelonephritis with abscess formation in a chronic hemodialysis patient: a case report. CEN Case Rep 2015; 4:90-94. [PMID: 28509282 DOI: 10.1007/s13730-014-0146-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/16/2014] [Indexed: 10/24/2022] Open
Abstract
Bilateral emphysematous pyelonephritis (EPN) has seldom been reported in patients on maintenance hemodialysis (HD). Percutaneous catheter drainage (PCD) or nephrectomy is often required in the treatment of bilateral EPN because of its poor response to antimicrobial agents and high mortality rate. We report a patient with bilateral EPN on maintenance HD. An octogenarian man with diabetes mellitus who had previously undergone regular HD for 22 months was admitted to our hospital because of severe inflammation resulting from bilateral EPN. His lesions of EPN had resulted in abscess formation in both kidneys and right and left side retroperitoneal space. As patient refused interventional therapy including nephrectomy or PCD, he was treated conservatively. After treatment with several antimicrobial agents for 50 days, he completely recovered from bilateral EPN. To our knowledge, this is the first case report of successful conservative management (antimicrobial therapy alone) of bilateral EPN that developed in a chronic diabetic HD patient.
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Affiliation(s)
- Ryuji Suzuki
- Department of Internal Medicine, Hitotsubashi Hospital, 1-2-25 Gakuen Nishimachi, Kodaira-shi, Tokyo, 187-0045, Japan.
| | - Takehiko Abe
- Department of Radiology, Japan Anti-Tuberculosis Association, Fukujuji Hospital, 3-1-24 Matsuyama, Kiyoshe-shi, Tokyo, 204-8522, Japan
| | - Hiroji Uchida
- Department of Urology, Hitotsubashi Hospital, 1-2-25 Gakuen Nishimachi, Kodaira-shi, Tokyo, 187-0045, Japan
| | - Kazuhiko Niikura
- Department of Internal Medicine, Hitotsubashi Hospital, 1-2-25 Gakuen Nishimachi, Kodaira-shi, Tokyo, 187-0045, Japan
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Misgar RA, Wani AI, Bashir MI, Pala NA, Mubarik I, Lateef M, Laway BA. Successful medical management of severe bilateral emphysematous pyelonephritis: case studies. Clin Diabetes 2015; 33:76-9. [PMID: 25897188 PMCID: PMC4398010 DOI: 10.2337/diaclin.33.2.76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Raiz A Misgar
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Arshad I Wani
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mir I Bashir
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Nazir Ahmad Pala
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Idrees Mubarik
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Muzamil Lateef
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Bashir A Laway
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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Vlachopanos G, Kassimatis T, Zerva A, Kokkona A, Stavroulaki E, Zacharogiannis C, Agrafiotis A. Successful medical treatment of emphysematous pyelonephritis in chronic hemodialysis. Hemodial Int 2015; 19:E54-8. [PMID: 25643771 DOI: 10.1111/hdi.12274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Emphysematous pyelonephritis (EPN) is a life-threatening renal infection caused by gas-producing bacteria and fungi. It usually occurs in patients with diabetes and patients with urinary tract obstruction. A combination of systemic antibiotics, percutaneous catheter drainage, or open nephrectomy is typically required to achieve cure. Because of grim prognosis, resorting to interventional methods is frequently inevitable. We report the case of a 77-year-old woman with diabetes and end-stage renal disease on chronic hemodialysis that presented with fever and left flank pain. A bubbly gas pattern inside the left kidney was demonstrated on abdominal computed tomography scan and blood cultures grew Escherichia coli. She was successfully treated solely with systemic antibiotics. This highlights the fact that prompt recognition of imaging findings associated with benign prognosis is essential for a favorable outcome. It allows for an effective management avoiding high-risk interventions, especially in frail patients with multiple comorbidities. Finally, we review all published cases of EPN in chronic dialysis patients.
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Affiliation(s)
| | | | - Adamantia Zerva
- Department of Nephrology, "Asklepieion" General Hospital, Athens, Greece
| | - Anastasia Kokkona
- Department of Nephrology, "Asklepieion" General Hospital, Athens, Greece
| | - Eirini Stavroulaki
- Department of Nephrology, "Asklepieion" General Hospital, Athens, Greece
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Herbland A, Leloup M, Levrat Q, Guillaume F, Verrier V, Bouillard P, Landois T, Ouaki CF, Lesieur O. Fulminant course of unilateral emphysematous pyelonephritis revealing a renal actinomycosis caused by Actinomyces meyeri, an unknown cause of septic shock. J Intensive Care 2014; 2:42. [PMID: 25878793 PMCID: PMC4397714 DOI: 10.1186/2052-0492-2-42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 06/12/2014] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Alexandre Herbland
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Maxime Leloup
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Quentin Levrat
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Frédéric Guillaume
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Virginie Verrier
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Philippe Bouillard
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
| | - Thierry Landois
- Service de Radiologie, Hôpital Saint-Louis, 17019 La Rochelle, France
| | | | - Olivier Lesieur
- Service de Réanimation Polyvalente, Hôpital Saint-Louis, 17019 La Rochelle, France
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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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Medical therapy alone can be sufficient for bilateral emphysematous pyelonephritis: report of a new case and review of previous experiences. Int Urol Nephrol 2013; 46:223-7. [PMID: 23591724 DOI: 10.1007/s11255-013-0446-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 04/08/2013] [Indexed: 12/11/2022]
Abstract
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.
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10
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Risk factors of renal failure and severe complications in patients with emphysematous pyelonephritis-a single-center 15-year experience. Am J Med Sci 2012; 343:186-91. [PMID: 21804369 DOI: 10.1097/maj.0b013e318225b891] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Emphysematous pyelonephritis (EPN) is a rare but severe infection of renal parenchyma. Risk factors of renal failure in patients survived from EPN are not clear. METHODS The authors retrospectively reviewed the patients with a diagnosis of EPN at Taipei Veterans General Hospital from January 1, 1995, to December 31, 2009. The authors analyzed the demographic, characteristics and the treatment modalities of those patients. The renal function of survivors after EPN episode had been followed for 1 year. RESULTS A total of 23 patients with a mean age of 62.8 ± 17.1 years were enrolled. Mean hospital duration was 31.8 ± 21.6 days. Fifteen (65.2%) patients had a history of diabetes mellitus. Mean serum HbA1c level among the diabetic patients was 11.7 ± 3.3. More than half of patients had Escherichia coli in culture. Eleven (47.8%) patients received antibiotic treatment alone. Twelve (52.2%) patients received the concurrent percutaneous drainage and antibiotics. The overall mortality rate was 8.6%. Shock, long hospital duration and the extensive classes of computed tomography image were correlated with poor outcome. A higher initial serum creatinine level (2.8 ± 1.4 versus 1.6 ± 0.8, P = 0.015) and receiving invasive therapy (67.7% versus 12.5%, P = 0.017) significantly contributed to chronic kidney disease in the follow-up. Shock is also an independent predictor of the poor outcome in those patients (P = 0.026). CONCLUSIONS In the current era, antibiotics alone provide a high success rate for the treatment of EPN. Invasive therapy is a predictor of development of chronic kidney disease. Initial resuscitation and antibiotic therapy are still the cornerstone and have the benefit of the preservation of renal function.
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Kolla PK, Madhav D, Reddy S, Pentyala S, Kumar P, Pathapati RM. Clinical profile and outcome of conservatively managed emphysematous pyelonephritis. ISRN UROLOGY 2012; 2012:931982. [PMID: 22567427 PMCID: PMC3329657 DOI: 10.5402/2012/931982] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 01/11/2012] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Praveen Kumar Kolla
- Department of Nephrology, Narayana Medical College Hospital, Chinthareddypalem, Andhra Pradesh, Nellore 524002, India
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Laway BA, Bhat MA, Bashir MI, Ganie MA, Mir SA, Daga RA. Conservative management of emphysematous pyelonephritis. Indian J Endocrinol Metab 2012; 16:303-305. [PMID: 22470875 PMCID: PMC3313756 DOI: 10.4103/2230-8210.93776] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Emphysematous pyelonephritis, though uncommon, is a severe necrotizing kidney infection common in patients with diabetes. Surgical treatment has been advocated as the treatment of choice in most of the patients. We present the clinical course of an elderly lady who presented with emphysematous pyelonephritis and was successfully managed with medical treatment despite the presence of adverse prognostic factors like acute renal failure and thrombocytopenia.
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Affiliation(s)
- Bashir Ahmad Laway
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Manzoor Ahmad Bhat
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mir Iftikhar Bashir
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Mohd Ashraf Ganie
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Shahnaz Ahmad Mir
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Riyaz Ahmad Daga
- Department of Endocrinology, Sher-I-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
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Wong EKS, Hartley R, Main J. Successful management of bilateral emphysematous pyelonephritis in end-stage polycystic kidneys: bilateral native nephrectomies and preservation of functioning renal transplant. NDT Plus 2011; 4:452-3. [PMID: 25984225 PMCID: PMC4421677 DOI: 10.1093/ndtplus/sfr102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Edwin K S Wong
- Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne
| | - Richard Hartley
- James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough
| | - John Main
- James Cook University Hospital, South Tees NHS Foundation Trust, Middlesbrough
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Abstract
OBJECTIVE Emphysematous pyelonephritis (EPN) with calculus is well recognized but with very few reports on its treatment. Our aim is to elucidate our experience in its successful management. MATERIALS AND METHODS Over four years, we diagnosed seven cases (eight renal units) of EPN, out of which two patients (three renal units) had EPN with urinary calculi. After the initial conservative management of EPN, the stones were tackled appropriately. RESULTS EPN was initially managed effectively with antibiotics and supportive care. Once the patient was stable, the stones were cleared in a step-wise fashion. The associated postoperative complications were also tackled efficiently with preservation of renal function. CONCLUSION In EPN with stones, nephrectomy is not the sole option available and they can be effectively managed with open / endoscopic measures.
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Affiliation(s)
- Tanmaya Goel
- Department of Urology, Kasturba Medical College, Manipal, India
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Abstract
The author reports the case of a well and fit patient who presented herself to the emergency department and was found to have bilateral emphysematous pyelonephritis. She was admitted to the intensive care where she was initially treated conservatively with antibiotics, percutaneous drainage and continuous renal replacement therapy, but her condition deteriorated. She underwent a left total nephrectomy and a partial right nephrectomy that resulted in remarkable improvement. The patient started passing urine spontaneously, so no haemofiltration was required. She was discharged home and her case was followed-up by an urologist and nephrologist. This case lays emphasis on thoroughly investigating and managing a patient with bilateral emphysematous pyelonephritis and, in relation to its management, on the dilemma of whether the treatment of choice should be conservative or surgical.
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Affiliation(s)
- John Surur
- Department of Acute Medicine/Anaesthetics, Kings College Hospital, Westminster, London, UK.
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16
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Lin YH, Shih SC, Wu CL, Chen YC, Chen YW, Lee SY. Experience of Using Activated Protein C in a Patient With Emphysematous Pyelonephritis Receiving Percutaneous Nephrostomy Drainage. INT J GERONTOL 2010. [DOI: 10.1016/s1873-9598(10)70042-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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17
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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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Debnath J, Baliga KV, George RA, Satija L, Khanduja R, Vaidya A, Sandhu AS, Hanagandi PB, Sawant MB. Temporal evolution of emphysematous pyelonephritis in a renal allograft: imaging findings. Emerg Radiol 2008; 16:231-3. [DOI: 10.1007/s10140-008-0728-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2008] [Accepted: 03/28/2008] [Indexed: 10/22/2022]
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19
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Salmonella Emphysematous Pyelonephritis in a Nondiabetic and Non-Obstructive End-Stage Renal Disease Patient. Tzu Chi Med J 2007. [DOI: 10.1016/s1016-3190(10)60024-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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20
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Dutta P, Bhansali A, Singh SK, Gupta KL, Bhat MH, Masoodi SR, Kumar Y. Presentation and outcome of emphysematous renal tract disease in patients with diabetes mellitus. Urol Int 2007; 78:13-22. [PMID: 17192727 DOI: 10.1159/000096929] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Emphysematous renal tract disease (ERTD) is a rare necrotizing infection of the renal parenchyma and urinary tract caused by gas-producing organisms. ERTD deserves special attention because of its life-threatening potential. OBJECTIVES To study the clinical features, radiological classification and prognostic factors of ERTD; and to compare the modalities of management and the outcome among the various radiological classes of ERTD. PATIENTS AND METHODS Twenty consecutive patients with diabetes and ERTD, seen over last 3 years in a tertiary care institute of north India, were included in the study. All patients were subjected to computerized tomography (CT) after initial diagnosis by ultrasonography. They were classified into 5 classes as previously described. All patients included in the study were conservatively managed with appropriate antibiotics and/or percutaneous drainage or surgery if required. RESULT Mean age (+/- SD) of these subjects was 54.4 +/- 20.6 years; duration of diabetes mellitus 8.6 +/- 5.8 years, and duration of symptoms related with ERTD ranged from 3 days to 3 months. Two patients had isolated emphysematous cystitis, 13 patients had emphysematous pyelonephritis (EPN), 3 had both EPN and cystitis, and 1 patient had EPN with cholecystitis, and 1 patient had EPN with pyomyositis. Only 7 (35%) patients had a history of pneumaturia. Escherichia coli was the commonest microorganism. The radiological distribution in 18 (2 had isolated cystitis) patients with EPN was: 2 patients had class 1; 1 had class 2; 2 had class 3A; 11 had class 3B, and 2 had class 4. Of 20 patients 11 (55%) survived. However, those patients who died had severe EPN based on radiological class (6 had class 3B and 1 had class 4). There was no significant difference between the survivor and non-survivor groups with respect to age, gender, duration of diabetes mellitus, duration of symptoms, serum creatinine level, total leukocyte count, hemoglobin, platelet count and culture positivity. CONCLUSION Computerized tomographic class 3B or 4 is the most reliable predictor of outcome in patients with ERTD.
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Affiliation(s)
- Pinaki Dutta
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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21
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Arun N, Hussain A, Kapoor MM, Abul F. Bilateral emphysematous pyelonephritis and emphysematous cystitis with autosomal-dominant polycystic kidney disease: is conservative management justified? Med Princ Pract 2007; 16:155-7. [PMID: 17303954 DOI: 10.1159/000098371] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2005] [Accepted: 05/25/2006] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To report a case of bilateral emphysematous pyelonephritis (EPN) and emphysematous cystitis in a 64-year-old diabetic male with autosomal-dominant polycystic kidney disease (ADPKD). CASE PRESENTATION AND INTERVENTION A 64-year-old diabetic male presented with worsening of renal function and fluid overload. Diagnosis was confirmed by computerized tomography (CT scan) and conservative management with broad-spectrum antibiotics was instituted. There was good clinical response and repeated CT scan showed complete resolution. CONCLUSION This case shows that conservative management is an acceptable alternative to surgery in EPN occurring with ADPKD. However, it is recommended that patients should be closely monitored, both clinically and radiologically, and percutaneous catheter drainage or surgical intervention carried out whenever deemed necessary.
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Affiliation(s)
- Narayanaswamy Arun
- Departments of Surgery (Urology Unit) and Nephrology, Al-Amiri Hospital, Kuwait.
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22
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Affiliation(s)
- J Yao
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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23
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Nayeemuddin M, Wiseman OJ, Turner AG. Emphysematous pyelonephritis. ACTA ACUST UNITED AC 2006; 2:108-12. [PMID: 16474656 DOI: 10.1038/ncpuro0095] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2004] [Accepted: 01/11/2005] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 54-year-old nondiabetic male presented with high fever, vague lower abdominal pain and leakage of urine around his long-standing suprapubic catheter. Examination revealed pyrexia and tenderness in the right renal angle. White cell count was 22.8 x 10(9)/l. Plain abdominal X-ray showed calculi in the right kidney, ureter and bladder. Intravenous pyelogram showed gas confined to the right upper renal pelvis and perinephric space. INVESTIGATIONS Urine and blood cultures, plain abdominal X-ray, intravenous pyelogram, abdominal ultrasound, MAG3 renogram and histopathology. DIAGNOSIS Emphysematous pyelonephritis: class 2 or type 1. Escherichia coli was isolated from urine obtained by endoscopic drainage. MANAGEMENT Endoscopic drainage of pus and simple nephrectomy.
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Ramanathan V, Nguyen PT, Van Nguyen P, Khan A, Musher D. Successful medical management of recurrent emphysematous pyelonephritis. Urology 2006; 67:623.e11-3. [PMID: 16504262 DOI: 10.1016/j.urology.2005.09.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2005] [Revised: 09/09/2005] [Accepted: 09/29/2005] [Indexed: 01/25/2023]
Abstract
Emphysematous pyelonephritis is characterized by infection and gas formation in the renal parenchyma. This rare disorder tends to occur more frequently in patients with diabetes mellitus and urinary tract obstruction. In this case report, we describe a nondiabetic patient with Hinman syndrome who developed recurrent emphysematous pyelonephritis that was successfully treated with antibiotics on both occasions.
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Affiliation(s)
- Venkataraman Ramanathan
- Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Baylor College of Medicine, Houston, Texas 77030, USA.
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Lemaitre L, Puech P, Delomez J, Leroy C, Fantoni JC, Biserte J. [Imaging in the management of urinary tract infections]. ANNALES D'UROLOGIE 2005; 39:170-96. [PMID: 16370169 DOI: 10.1016/j.anuro.2005.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
This review analyzes the role of imaging in the diagnosis, follow-up and management of urinary tract infections. Uncomplicated infection of the urinary tract is frequent and usually resolves rapidly with treatment; in such cases imaging is unnecessary except to exclude dilatation or the existence of an obstacle. Progression towards complex infection often occurs in patients with predisposing factors. Imaging helps in evaluating the extent of the disease; it has a role in the selection of therapy and interventional procedures.
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Affiliation(s)
- L Lemaitre
- Service de radiologie, hôpital Claude Huriez, CHRU-Lille, 59037 Lille, France.
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27
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Abstract
Emphysematous pyelonephritis is a necrotizing kidney infection characterized by the presence of gas in renal parenchyma, collecting system or perinephric tissue. This rare affection occurs almost exclusively in patients with diabetes mellitus and is due to non-anaerobic gas-producing bacteria. This life-threatening condition leads to septic shock and multiple organ failure. Diagnosis is suspected when a pyelonephritis does not respond to correct treatment, especially with altered vital signs or a diabetic patient. Computed tomography scan permits visualization of the gas and a radiologic classification with a prognostic value. Current treatment modalities are based upon repeated clinical and scanographic evaluations. In addition to systematic antibiotic therapy, percutaneous drainage is probably the first therapeutic stage in the majority of cases, but should not delay emergent rescue nephrectomy if necessary.
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Affiliation(s)
- E Kaiser
- Anesthésiste-réanimateur des Hôpitau des Armées, département d'anesthésie-réanimation, France.
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28
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Puech P, Lagard D, Leroy C, Dracon M, Biserte J, Lemaître L. [Imaging in urinary tract infections in adults]. ACTA ACUST UNITED AC 2004; 85:220-40. [PMID: 15094614 DOI: 10.1016/s0221-0363(04)97572-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Uncomplicated infection of the urinary tract is frequent and usually resolves rapidly with treatment and imaging is unnecessary. Progression to complex infection often occurs in patients with predisposing factors. Imaging assists in evaluating the extent of disease, plays a role in directing therapy and guides interventional procedures if necessary. This pictorial essay reviews the role of imaging and intervention in infections of the urinary tract.
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Affiliation(s)
- P Puech
- Service de radiologie, Hôpital Claude Huriez, CHRU-Lille, 59037 Lille Cedex
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29
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Abstract
Urinary tract infections (UTIs) are a common infectious disease in primary care practice. This article reviews topics highlighting recent research, including UTIs in pregnancy and pediatric UTIs. The authors also discuss catheter-associated UTIs, given the large number of hospitalized patients undergoing catheterization and residents of long-term care facilities, in whom catheters are used frequently, and complicated UTIs.
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Affiliation(s)
- Pat F Bass
- Division of General Internal Medicine, University of Louisville, School of Medicine, 500 South Preston Street, Instructional Building, Louisville, KY 40292, USA.
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30
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Anwar N, Chawla LS, Lew SQ. Emphysematous pyelitis presenting as an acute abdomen in an end-stage renal disease patient treated with peritoneal dialysis. Am J Kidney Dis 2002; 40:E13. [PMID: 12324934 DOI: 10.1053/ajkd.2002.35703] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Emphysematous pyelitis is air in the renal collecting system in patients with urinary tract infections. This entity is uncommon and seen primarily in patients with diabetes mellitus. We report a case of a patient with end-stage renal disease treated with peritoneal dialysis who developed emphysematous pyelitis who presented with signs and symptoms that were more consistent with appendicitis. The spectrum of infections causing air in the urinary tract and the method by which end-stage renal disease patients are treated are discussed. Patients receiving dextrose peritoneal dialysis are at risk for emphysematous pyelonephritis, pyelitis, and cystitis.
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Affiliation(s)
- Nelofar Anwar
- Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC, USA
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31
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Mallet M, Knockaert DC, Oyen RH, Van Poppel HP. Emphysematous pyelonephritis: no longer a surgical disease? Eur J Emerg Med 2002; 9:266-9. [PMID: 12394626 DOI: 10.1097/00063110-200209000-00012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Emphysematous pyelonephritis is a rare, life-threatening infection of the kidney characterized by the presence of gas within the renal parenchyma, the renal collecting system and the perinephric tissue. It usually develops in diabetic patients and often presents abruptly with bacteraemia, septic shock and acute renal failure. Diagnosis can be delayed because the symptoms mimic a classical upper urinary tract infection. Aggressive management, including parenteral antibiotic therapy, treatment of septic shock and control of the glycaemia, is mandatory. Immediate nephrectomy has been considered to be essential to increase the chance of survival. Recently, percutaneous drainage has been reported as a kidney-saving and life-saving alternative to surgery. We present a case of severe emphysematous pyelonephritis in which there was full recovery after antibiotic treatment combined with temporary percutaneous drainage. The therapeutic options in this rare, life-threatening condition are discussed.
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Affiliation(s)
- M Mallet
- Division of General Internal Medicine, University Hospital Gasthuisberg, Leuven., Belgium
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32
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Flores G, Nellen H, Magaña F, Calleja J. Acute bilateral emphysematous pyelonephritis successfully managed by medical therapy alone: a case report and review of the literature. BMC Nephrol 2002; 3:4. [PMID: 12057010 PMCID: PMC116587 DOI: 10.1186/1471-2369-3-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2002] [Accepted: 06/03/2002] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Bilateral emphysematous pyelonephritis is a life threatening condition usually occurring in diabetics. Management of this condition has traditionally been aggressive and surgery is considered mandatory. However, this is itself a hazardous intervention in a septic, unstable patient with circulatory or liver failure. When bilateral disease is present, the need for long-term dialysis is obviously unavoidable. CASE PRESENTATION We herein report one of the few cases of bilateral emphysematous pyelonephritis successfully managed by non-surgical treatment.
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Affiliation(s)
- Guillermo Flores
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Haiko Nellen
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Francisco Magaña
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Juan Calleja
- Department of Internal Medicine, Division of Medicine, Hospital de Especialidades Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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