MO219EMPHYSEMATOUS PYELONEPHRITIS IN BANGLADESH

Abstract

Abstract Background and Aims Emphysematous pyelonephritis (EPN) is an uncommon, acute and severe form of necrotizing infection of the renal parenchyma, collecting system and/or perinephric tissues and is characterized by accumulation of gas within these structures. Patients may present with fever, loin pain, vomiting and shock. Risk factors for EPN include diabetes mellitus (DM), renal stone, obstructive uropathy and immunosuppression. In this report, we describe the clinical, laboratory and imaging characteristics of patients with EPN in Bangladesh. Method This systematic review included all previously published English literature containing information regarding EPN in/or from Bangladesh. Literature search was conducted via “PubMed” using the key words “Bangladesh” and “emphysematous pyelonephritis”. We also searched through Bangladesh Journals Online (BanglaJOL) for articles published in local journals. The search engine “Google” was also used to identify articles. All literature searches were conducted up to 10th January 2021. Unpublished but well-documented EPN cases (28 cases) were added. Cases mentioned elsewhere with inadequate information and possible repetition were excluded. Results Seventeen papers were identified from published literature including 10 case reports, two original research articles, one image and four conference abstracts and one research paper was identified from other source. From them, two case reports were excluded because EPN occurred in non-Bangladeshi nationals; one image and four conference abstracts were also excluded because of inadequate information for cases. Finally, a total of 10 papers (total 92 cases) were eligible for analysis, to which 28 unpublished but well documented cases were added. Among the total 120 cases, females were 92 (76.7%). Age of the patients ranged between 20 and 77 years. DM was the commonest risk factor (118, 98.3%); 16 (13.3%) patients had chronic kidney disease and nine (7.5%) had renal stones. Patients presented with fever (112, 93.3%), loin pain/renal angle tenderness (96, 80%), dysuria (76, 63.3%), altered sensorium (21, 17.5%), anorexia (93, 77.5%), vomiting (101, 84.2%), dehydration (77, 64.2%) and shock (18, 15%). Patients had neutrophil leukocytosis (total white cell counts 11,700–54,200/cmm of blood) and 22 (18.3%) patients had thrombocytopaenia. All patients had high erythrocyte sedimentation rate (36–117 mm/1st h) and C-reactive protein (24–199 mg/L). Overall glycaemic status was poor [random blood glucose during admission was 6.8–35.5 mmol/L and glycated haemoglobin (HbA1c) was 6.2–16.1%]. Fifty six (46.7%) patients were complicated by acute kidney injury (AKI) and 32 (26.7%) patients had hyponatraemia. Diagnosis of EPN was confirmed by computed tomography scan. One patient had EPN in ectopic right kidney, two patients had EPN along with emphysematous cystitis and two patients were complicated with psoas abscess. According to Huang and Tseng classification, five (4.2%) patients had class 4 EPN, 35 (29.2%) patients had class 3, 66 (55%) patients had class 2 and 14 (11.7%) patients had class 1 EPN. Escherichia coli was the most common (67, 55.8%) organism identified on urine culture and 17 (14.2%) patients were complicated by bacteraemia. All patients were treated with resuscitative measures, intravenous antibiotics and other supportive measures. Forty one (34.2%) patients required surgery/interventions [nephrectomy in 19 (15.8%), percutaneous drainage in two (1.7%), open drainage in 20 (16.7%)]. Duration of hospital stay was 6–37 days. Nine (7.5%) patients died in hospital. Conclusion EPN occurred predominantly among female diabetic patients. Clinical presentation included fever, loin pain, dysuria, vomiting, altered sensorium and shock. Class 2 EPN was common. Almost half of all EPN cases developed AKI. One-third EPN cases required surgical interventions including nephrectomy. In-hospital mortality was 7.5%.