Urolithiasis Is a Risk Factor for Uroseptic Shock and Acute Kidney Injury in Patients With Urinary Tract Infection

Development and validation of a predictive model for acute kidney injury in patients with ureterolithiasis

OBJECTIVES

This study aims to identify risk factors for acute kidney injury (AKI) in patients with ureterolithiasis and to develop a predictive model for early AKI detection in this population.

METHODS

A retrospective analysis was conducted on data from 1,016 patients with ureterolithiasis who presented to our outpatient emergency department between January 2021 and December 2022. Using multifactorial logistic regression, we identified independent risk factors for AKI and constructed a nomogram to predict AKI risk. The predictive model's efficacy was assessed through the area under the ROC curve, calibration curves, Hosmer-Lemeshow (HL) test, and decision curve analysis (DCA).

RESULTS

AKI was diagnosed in 18.7% of the patients. Independent risk factors identified included age, fever, diabetes, hyperuricemia, bilateral calculi, functional solitary kidney, self-medication, and prehospital delay. The nomogram demonstrated excellent discriminatory capabilities, with AUCs of 0.818 (95% CI, 0.775-0.861) for the modeling set and 0.782 (95% CI, 0.708-0.856) for the validation set. Both calibration curve and HL test results confirmed strong concordance between the model's predictions and actual observations. DCA highlighted the model's significant clinical utility.

CONCLUSIONS

The predictive model developed in this study provides clinicians with a valuable tool for early identification and management of patients at high risk for AKI, thereby potentially enhancing patient outcomes.

Usefulness of serum amyloid A for the diagnosis of pyelonephritis in cats: A prospective evaluation

BACKGROUND

The diagnosis of pyelonephritis in cats is challenging and development of a noninvasive and accurate biomarker is needed.

HYPOTHESES

Serum amyloid A (SAA) is increased in cats with pyelonephritis, but not in cats with other urinary tract diseases.

ANIMALS

A cohort of 125 cats (149 observations).

METHODS

This was a prospective study. Group 1 included cats with a diagnosis of pyelonephritis either confirmed by bacterial culture of pelvic urine (Group 1a) or presumed (1b). Group 2 included cats for which pyelonephritis was ruled out (with certainty: Group 2a or judged unlikely: Group 2b). SAA concentration was compared between groups, and accuracy of SAA for the diagnosis of pyelonephritis was calculated using a Receiver Operating Characteristic (ROC) curve analysis.

RESULTS

Median SAA concentration was significantly higher in Group 1a (86.8 mg/L [73.3; 161.5]; n = 8) than in Group 2a (4 mg/L [1.8; 5.6], n = 19; P < .001) and in Group 2b (5.4 mg/L [3.1; 9.7], n = 113; P < .001). It was also significantly higher in Group 1b (98.8 mg/L [83.1; 147.3]; n = 9) than in Group 2b (P < .001) and Group 2a (P < .001). Optimal diagnostic cut-off for SAA concentration was 51.3 mg/L. yielding a sensitivity of 88% (95% confidence interval: [64%; 99%]) and a specificity of 94% (95% confidence interval: [88%; 97%]).

CONCLUSIONS AND CLINICAL IMPORTANCE

Measurement of SAA could be used to rule out pyelonephritis in the case of low suspicion of the disease. Increased SAA concentration is suggestive of pyelonephritis despite a lack of specificity.

The rationale for bladder washouts in children with neurogenic bladder

Children with a neurogenic bladder are at risk of developing recurrent urinary tract infections and long-term kidney failure. Due to an altered lower urinary tract, children may be overtreated for simple bacteriuria or undertreated for a potentially severe urinary tract infection. This group of patients represent high users of healthcare, and are at risk of colonization and development of antibiotic resistance. Bladder washouts with non-antibiotic electrochemically activated solutions are a potential new prophylactic option for patients with bladder dysfunction when clean intermittent catheterization has resulted in chronic bacteriuria.

Prevalence of urolithiasis in China: a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled prevalence, as well as the spatial and temporal distribution, of urolithiasis among subjects in China.

MATERIALS AND METHODS

We conducted a comprehensive search of both Chinese and English databases to retrieve literature pertaining to the prevalence of urolithiasis in the indigenous Chinese population. A random-effects meta-analysis model was employed to calculate the pooled prevalence of urolithiasis. Subgroup analyses were conducted based on factors such as time, region, gender, and sample size. Prevalence and spatial distribution maps were created based on provinces and latitude/longitude coordinates.

RESULTS

A total of 46 studies conducted in 22 provinces across China were included in this meta-analysis and the pooled prevalence of urolithiasis, kidney stones, ureteric calculi, urethral and bladder stones were 8.1% (95% confidence interval [CI] 5.6-11.1%), 7.8% (95% CI 5.8-10.0%), 3.2% (95% CI 0.6-5.7%), 0.5% (95% CI 0.1-0.9%). Most of the urolithiasis prevalence screening in China was concentrated between 100° E and 120° E, with higher rates observed in low latitude areas. Subgroup analysis of kidney stones revealed that Guangdong (12.7%) and Guangxi (10.3%) had the highest prevalence, with the eastern developed area exhibiting higher rates compared to the west. The prevalence in males was higher than in females (odds ratio 1.67, 95% CI 1.46-1.92), although the gender gap has significantly reduced since 2006. Moreover, a greater sample size is associated with a decreased prevalence of urolithiasis.

CONCLUSIONS

The prevalence of urolithiasis is increasing in China, and there are noteworthy regional or provincial disparities in occurrence. It is worth noting that the current number of screening studies in some areas is insufficient. Additional investigations with appropriate sample sizes should be supplemented in time.

High risk and low prevalence diseases: Infected urolithiasis

INTRODUCTION

Infected urolithiasis is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of infected urolithiasis, including presentation, diagnosis, and management in the emergency department based on current evidence.

DISCUSSION

Although urolithiasis is common and the vast majority can be treated conservatively, the presence of a concomitant urinary tract infection significantly increases the risk of morbidity, to include sepsis and mortality. Identification of infected urolithiasis can be challenging as patients may have symptoms similar to uncomplicated urolithiasis and/or pyelonephritis. However, clinicians should consider infected urolithiasis in toxic-appearing patients with fever, chills, dysuria, and costovertebral angle tenderness, especially in those with a history of recurrent urinary tract infections. Positive urine leukocyte esterase, nitrites, and pyuria in conjunction with an elevated white blood cell count may be helpful to identify infected urolithiasis. Patients should be resuscitated with fluids and broad-spectrum antibiotics. Additionally, computed tomography and early urology consultation are recommended to facilitate definitive care.

CONCLUSIONS

An understanding of infected urolithiasis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.

Analysis, treatment modality and demographic characteristics of urolithiasis patients visiting Korle-Bu Teaching Hospital in Ghana

Background

Globally urolithiasis is on the rise and gradually becoming a public health concern due to the associated complications. This study reviewed the demographic characteristics, the chemical composition of stones, treatment modality and duration of hospitalisation of urolithiasis patients at Korle-Bu Teaching Hospital, Accra, Ghana.

Materials and Methods

This was a retrospective study conducted between March 2019 and April 2022. Data from consecutive patients treated for urolithiasis were used for this study. Data on demographic characteristics, stones chemical composition, urine factors, urolithiasis treatment modality and duration of hospital stay after therapy were collated and analysed using descriptive and inferential approaches.

Results

The age of the patients ranged from 2 to 75 years with a mean of 45 (±13.4). The predominant age group for stone formation was 30-39 years - 52(26.3%). Urolithiasis was common among patients in the formal employment sector: 81(40.9%). All stones had two or more chemical compositions, with the combination of calcium oxalate monohydrate, calcium oxalate dihydrate and uric acid being the predominant stone type: 88(57.5%). Ureteroscopy with semi-rigid and Percutaneous nephrolithotomy were the predominant treatment modalities: 105(53.0%) and 74(37.4%), respectively. Escherichia coli was responsible for most urinary tract infections in urolithiasis patients 8(4.0%) and the least duration of hospital stay after the procedure was associated with the use of semi-rigid ureteroscope as the treatment modality with a median duration of 2 days (1-2 days) with P < 0.0001.

Conclusions

Urolithiasis was predominant among professionals in the formal sector. All stones were mixed with Calcium oxalate monohydrate, calcium oxalate dihydrate, and uric acid combination being the majority. Ureteroscopy with semi-rigid and percutaneous nephrolithotomy were the common treatment modality.

Role of Ureteroscopy (URS) and Stone Treatment in Patients with Recurrent UTIs: Outcomes over a 10-Year Period

Background. The study aimed to assess whether the eradication of kidney stones might result in a substantial reduction in the onset of recurrent UTIs. Methods. We selected all the patients who underwent ureteroscopy (URS) for stone disease between 2012 and 2021, with either a history of recurrent UTIs (rUTIs), urosepsis or pre-operative positive urine culture (UC). Data included patient demographics, microbiological data, stone parameters, stone-free and infection-free rates (SFR and IFR, respectively) at follow-up, defined as fragments <2 mm at imaging and the absence of symptoms and urine-culture-proven UTI. Results. Overall, 178 patients were selected. The median age was 62 years. The median cumulative stone size was 10 mm (7-17.25), and the commonest locations were the lower pole (18.9%) and proximal ureter (14.9%). The overall stone-free rate at follow-up was 89.3%. The IFR at 3 months was 88.3%. As follow-up duration increased, the IFR reduced to 85.4%, 74.2%, 68% and 65% at 6, 12, 18 and 24 months, respectively. Patients who had infection recurrence were more likely to present stone persistence or recurrence compared to those who were infection-free at follow-up (20% vs. 4.4%, p = 0.005). Conclusions. SFR after URS is a significant predicting variable for the likelihood of infection-free status at follow-up in patients with an rUTI or positive UC at the time of URS.

Diabetes mellitus is associated with increased risk of positive qSOFA score but not with increased ICU admission in patients undergoing ureteral stent placement for ureteral stone and suspected infection

INTRODUCTION

Patients presenting with an obstructing ureteral stone and urinary tract infection (UTI) are at risk for severe infectious complications. Historically, diabetes mellitus (DM) was considered a risk factor for the development of septic shock in these patients. This study aimed to evaluate DM's impact on risk of septic shock in ureteral stent placement for ureteral stone and presumed UTI.

METHODS

An institutional review board-approved, retrospective review was performed at two institutions. All patients who met the following criteria from July 2016 to April 2020 were included in the study: emergency department visit with obstructing ureteral stone, concern for UTI, and ureteral stent placement. The primary outcome of interest was the development of postoperative septic shock defined by sepsis with hypotension requiring vasopressor support for at least one hour.

RESULTS

The study cohort was made up of 187 patients. Median age was 61 (range 16-91). Males represented 40.1% (n=75) of the population, while DM was present in 26.2% (n=49). Thirty-five of 143 patients (18.7%) met the criteria for postoperative septic shock. Quick Sequential Organ Failure Assessment (qSOFA) criteria were met by 11 (22.4%) patients with DM compared to 13 (9.5%) of patients without DM (p=0.026). This difference did not translate into significant differences in use of vasopressors, with DM cohorts requiring pressors in 11 (22.4%), and 241 (17.5%) in non-DM (p=0.523). Purulent urine was more frequently described in patients with DM (22 [44.9%] vs. 342 [4.8%], p=0.011). Intensive care unit (ICU) admissions were similar between DM and non-DM at 13(27.1%) vs. 29 (21.2%), respectively (p=0.543). ICU stay and length of stay were similar between cohorts.

CONCLUSIONS

In this multicenter study of patients who underwent ureteral stenting for ureteral stone and presumed UTI, DM was not associated with an increased risk of development of septic shock but was associated with an increased risk of positive qSOFA score.

Acute kidney injury secondary to urinary tract infection in kidney transplant recipients

Acute kidney injury (AKI) in kidney transplant recipients (KTRs) is a common, yet poorly investigated, complication of urinary tract infections (UTI) and urosepsis. A retrospective comparative analysis was performed, recruiting 101 KTRs with urosepsis, 100 KTRs with UTI, and 100 KTRs without history of UTI or sepsis. The incidences of AKI in the urosepsis and UTI groups were 75.2% and 41%, respectively. The urosepsis group has also presented with a significantly higher prevalence of AKI stage 2 and 3 than the UTI group. The rates of recovery from AKI stages 1, 2 and 3, were 75,6%, 55% and 26.1%, respectively. Factors independently associated with renal recovery from AKI were: AKI severity grade (AKI stage 2 with OR = 0.25 and AKI stage 3 with OR = 0.1), transfusion of red blood cells (RBC) (OR = 0.22), and the use of steroid bolus in the acute phase of treatment (OR = 4). The septic status (urosepsis vs UTI) did not influence the rates of renal recovery from AKI after adjustment for the remaining variables. The dominant cause of RBC transfusions in the whole population was upper GI-bleeding. In multivariable analyses, the occurrence of AKI was also independently associated with a greater decline of eGFR at 1-year post-discharge and with a greater risk of graft loss. In KTRs with both urosepsis and UTI, the occurrence of AKI portends poor transplantation outcomes. The local transfusion policy, modulation of immunosuppression and stress ulcer prophylaxis (which is not routinely administered in KTRs) in the acute setting may be modifiable factors that significantly impact long-term transplantation outcomes.

Adverse Clinical Outcomes among Inflammatory Bowel Disease Patients Treated for Urinary Tract Infection

Background: Urinary tract infection (UTI) is the most common urologic complication among patients with inflammatory bowel disease (IBD). However, data regarding UTI outcomes in this population are scarce. We aimed to evaluate adverse outcomes of UTI among patients with IBD. Methods: This was a retrospective cohort study of consecutive adult patients who visited the emergency room (ER) at Sheba Medical Center due to a UTI between 2012 and 2018. Data included demographic and clinical variables. UTI cases were extracted using ICD-10 coding. Results: Of 21,808 (ER) visits with a UTI, 122 were IBD patients (Crohn’s disease—52, ulcerative colitis—70). Contrary to non-IBD subjects, patients with IBD had higher rates of hospitalization, acute kidney injury (AKI) and 30 day-recurrent hospitalization (59.3% vs. 68.9%, p = 0.032; 4.6% vs. 13.9%, p < 0.001; 7.3% vs. 15.6%, p = 0.001, respectively). Among patients with IBD, advanced age (p = 0.005) and recent hospitalization (p = 0.037) were associated with increased risk for hospitalization, while hydronephrosis (p = 0.005), recent hospitalization (p = 0.011) and AKI (p = 0.017) were associated with increased 30-day recurrent hospitalization. Neither immunosuppressants nor biologics were associated with UTI outcomes among patients with IBD. Conclusions: Patients with IBD treated for a UTI had higher rates of hospitalization, AKI and 30-day recurrent hospitalization than non-IBD patients. No association was observed between immunosuppressants or biologics and UTI outcomes.

Ureteral stone with hydronephrosis and urolithiasis alone are risk factors for acute kidney injury in patients with urinary tract infection

To identify whether urolithiasis with or without hydronephrosis has an impact on acute kidney injury (AKI) in patients with urinary tract infection (UTI). This study aimed to identify whether urolithiasis with or without hydronephrosis has an impact on AKI in patients with UTI. This retrospective study enrolled hospitalized UTI patients who underwent imaging in an acute care setting from January 2006 to April 2019. Of the 1113 participants enrolled, 191 (17.2%) had urolithiasis and 76 (6.8%) had ureteral stone complicated with hydronephrosis. Multivariate logistic regression analysis showed that in UTI patients with urolithiasis, the presence of ureteral stone with concomitant hydronephrosis was an independent risk factor for AKI (odds ratio [OR] 2.299, 95% confidence interval [CI] 1.112–4.755, P = 0.025). In addition, urolithiasis was associated with an increased risk for AKI (OR 2.451, 95% CI 1.369–4.389, P = 0.003) in UTI patients without hydronephrosis. The presence of ureteral stone with hydronephrosis increases the risk for AKI of UTI patients with urolithiasis, and urolithiasis remains a risk factor of AKI in UTI patients without hydronephrosis.

Risk of Urolithiasis in Patients With Inflammatory Bowel Disease: A Nationwide Danish Cohort Study 1977-2018

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) are suggested to be at increased risk of urolithiasis, but the magnitude of risk and the impact of medical and surgical treatment on this risk remain unknown. We therefore aimed to determine overall and treatment-related risk of urolithiasis in patients with IBD in a nationwide population-based cohort study.

METHODS

Using national registers, we identified all patients with IBD and all cases of urolithiasis in Denmark during 1977-2018. We obtained information on all IBD medications and surgical procedures during 1995-2018. IBD cases were matched 1:10 on age and sex to non-IBD individuals.

RESULTS

In total, 2,549 (3%) of 75,236 IBD patients and 11,258 (2%) of 767,403 non-IBD individuals developed urolithiasis, resulting in a 2-fold increased risk of urolithiasis (HR, 2.27; 95% CI, 2.17-2.38) in patients with IBD. The patients were also at increased risk of repetitive urolithiasis events (RR, 1.09; 95% CI: 1.04-1.15) and had increased risk of urolithiasis prior to IBD diagnosis (OR, 1.42; 95% CI: 1.34-1.50). After IBD diagnosis, risk of urolithiasis was associated with anti-TNF therapy and surgery.

CONCLUSION

Patients with IBD had a 2-fold increased risk of urolithiasis after IBD diagnosis and a 42% increased risk prior to IBD diagnosis. Risk was increased in anti-TNF exposed patients, and after surgery, suggesting that IBD severity per se and surgery, with altered intestinal absorption, increase risk of urolithiasis. Since stone formation is associated with adverse outcomes including sepsis, subpopulations of IBD patients, especially those undergoing strong immunosuppression might benefit from additional urolithiasis screening.

Distribution and drug resistance of pathogens causing urinary tract infection in patients with urinary calculi

OBJECTIVE

This study set out to clarify the distribution and drug resistance of pathogens causing urinary tract infection (UTI) in patients with urinary calculi.

METHODS

Pathogens were isolated from urine samples of patients with urinary calculi also complicated with UTIs, during the period from 2015 to 2019, and the samples were cultured for drug sensitivity testing to study the drug resistance of pathogens. The results were analyzed by SPSS 22.0 software.

RESULTS

Gram-negative bacteria were the main pathogens found in patients with urinary calculi complicated with UTI (84.52%). Escherichia coli, Enterococcus faecalis and Monilia albicans were the most common Gram-negative bacteria (48.84%), Gram-positive bacteria (34.78%) and fungus (29.41%), respectively. The UTI rates were higher in female patients than in male patients, and were higher in patients ≥ 60 years old compared with those < 60 years old. Escherichia coli and Klebsiella pneumoniae had the highest resistance to ampicillin and the lowest resistance to imipenem. Enterococcus faecalis Enterococcus Faecium had the highest resistance to penicillin and ampicillin, but the lowest resistance to vancomycin and linezolid.

CONCLUSION

The present study found that the pathogenic bacteria found in patients with urinary calculi complicated with UTI are mainly Gram-negative bacteria; and Escherichia coli is the main pathogenic bacteria causing the infection. Gender and age may be risk factors for urinary calculi complicated with UTI. Antibiotics should be selected reasonably according to the drug resistance pattern of pathogenic bacteria in clinical anti-infection management.

Temporal Trend of Urolithiasis Incidence in China: An Age-Period-Cohort Analysis

Purpose

Urolithiasis is one of the commonest disease of the urinary system. This study aimed to assess the long-term urolithiasis incidence trends in China between 1990 and 2019.

Patients and Methods

The incidence data of urolithiasis were extracted from Global Burden of Disease Study 2019, and an age–period–cohort framework was used to estimate the age, period, and cohort effects.

Results

We found that the net drift was −2.72% (95% CI: −2.84% to −2.60%) per year for men and −2.14% (95% CI: −2.24% to −2.05%) per year for women, and except men in age group 0–4, the local drift values were below 0 in all age groups (P<0.05 for all) in both sexes during the period of 1990 to 2019. In the same birth cohort, the risk of incidence from urolithiasis rose first and then decreased with age for both sexes after controlling for period deviations, and in addition, after 20 years old, the risk of incidence of urolithiasis in men was higher than that in women (significantly with P<0.05). In general, the estimated period and cohort relative risks were found in similar downward patterns for both sexes.

Conclusion

In the past 30 years, the age-standard incidence of urolithiasis in both sex of Chinese people has decreased, but the crude incidence of urolithiasis in Chinese women has increased. Considering the aging of population structure in China, the overall number of female urolithiasis patients may increase, contributes to higher crude incidence rate. The problem of urolithiasis in Chinese women needs to be paid more attention.

Construction and Evaluation of a Sepsis Risk Prediction Model for Urinary Tract Infection

Background: Urinary tract infection (UTI) is one of the common causes of sepsis. However, nomograms predicting the sepsis risk in UTI patients have not been comprehensively researched. The goal of this study was to establish and validate a nomogram to predict the probability of sepsis in UTI patients.

Methods: Patients diagnosed with UTI were extracted from the Medical Information Mart for Intensive Care III database. These patients were randomly divided into training and validation cohorts. Independent prognostic factors for UTI patients were determined using forward stepwise logistic regression. A nomogram containing these factors was established to predict the sepsis incidence in UTI patients. The validity of our nomogram model was determined using multiple indicators, including the area under the receiver operating characteristic curve (AUC), correction curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision-curve analysis (DCA).

Results: This study included 6,551 UTI patients. Stepwise regression analysis revealed that the independent risk factors for sepsis in UTI patients were congestive heart failure, diabetes, liver disease, fluid electrolyte disorders, APSIII, neutrophils, lymphocytes, red blood cell distribution width, urinary protein, urinary blood, and microorganisms. The nomogram was then constructed and validated. The AUC, NRI, IDI and DCA of the nomogram all showed better performance than traditional APSIII score. The calibration curve and Hosmer-Lemeshow test results indicate that the nomogram was well-calibrated. Improved NRI and IDI values indicate that our nomogram scoring system is superior to other commonly used ICU scoring systems. The DCA curve indicates that the DCA map of the nomogram has good clinical application ability.

Conclusion: This study identified the independent risk factors of sepsis in UTI patients and used them to construct a prediction model. The present findings may provide clinical reference information for preventing sepsis in UTI patients.