Emphysematous Pyelonephritis Patients Research Articles

Evaluation of therapeutic outcomes in emphysematous pyelonephritis: a single-center experience at Siriraj Hospital

Objective: Emphysematous pyelonephritis (EPN) is an acute, severe, necrotizing parenchymal and perirenal infection associated with high morbidity and mortality. The radiographic classifications, which determine the treatment strategies, however, remain controversial. Our study aimed to evaluate and compare the clinical parameters related to nephrectomy and the treatment outcomes in current practices. Materials and Methods: We retrospectively reviewed the data from 21 EPN patients who had been diagnosed using computed tomography (CT) scans, who were admitted to Siriraj Hospital from January 2009 to December 2019. The clinical manifestations, imaging results, laboratory findings, treatment methods, and overall outcomes of each patient were reviewed and analyzed. Huang–Tseng’s and Wan’s classifications were used to classify the images obtained from the CT scans. Results: Among the 21 patients with EPN, all had at least one comorbidity associated with a compromised immune response. Common manifestations included fever (74%) and initial laboratory findings showed hyperglycemia (66%), acute kidney injury (72%), and metabolic acidosis (76%). Inotropes were used in 13 patients for hemodynamic support. Eleven patients were treated with a non-nephrectomy approach, while 10 patients underwent nephrectomy. No statistical difference in treatment outcomes was observed between groups in both classification systems. Overall survival was 100% with a minimum one-year follow-up. Conclusion: Our study demonstrated that the current treatment approach has resulted in a zero mortality rate of EPN most probably due to advancements in antibiotics, surgical techniques, and postoperative intensive care over the years. However, refining treatment strategies, considering radiographic criteria, clinical parameters, and initial treatment response, is essential in future studies to further decrease disease morbidity.

Comparison of prognosis of five scoring systems in emphysematous pyelonephritis patients requiring intensive care

IntroductionOur study aimed to evaluate the performance of Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Systemic Inflammatory Response Syndrome (SIRS), and Global Research in the Emphysematous Pyelonephritis group (GREMP) in predicting the need of admission in intensive care units (ICU) for emphysematous pyelonephritis (EPN) patient.Patients and methodsIn this retrospective study, we reviewed 70 patients admitted to our department from January 2008 to October 2022. Data on clinical presentation and EPN management were noted. The five scoring systems were calculated by one investigator. Univariate and multivariate analyses were used to assess predictive factors of severe sepsis and mortality. Statistical analysis was made using SPSS version 22.ResultsMean age was 61.83 years with 65.7% diabetes. As per Huang and Tseng classification, 41 patients had class I EPN, 7 had class II EPN, 8 had class IIIa, 6 class IIIB EPN, and 8 had class IV EPN. Seventeen patients (24.28%) were admitted to ICU with an 18.57 mortality rate. Univariate analysis showed that ICU admission was significantly associated with higher respiration rate and heart rate, lower systolic blood pressure, confusion, CRP, lactate and creatinine serum (p = 0.0001, p = 0.0001, p = 0.001, p = 0.007, p = 0.004, p = 0.001, p = 0.001, respectively). All five scores and Huang and Tseng classification were significantly predictive of admission to ICU. All five scores showed good results under the area curves to predict ICU entry with 0.915, 0.895, 0.968, 0.887, and 0.846 for qSOFA, MEWS score, NEWS score, SIRS, and GREMP score, respectively.ConclusionNEWS score seemed to be the best performing physiologic score among the five scoring systems studied and may help with biological and radiological findings to quickly identify EPN patients that need intensive care unit.

Emphysematous pyelonephritis: An assessment of prognostic factors and the role of early pigtail drainage

Abstract Introduction: The management of emphysematous pyelonephritis (EPN), a necrotizing renal infection, has shifted from more invasive to less invasive approach in due course of time with decrease or reduction in mortality rate. Aim: To analyze the clinical spectrum, prognostic factors, different management strategies, and the outcome of the patients of EPN with the role of early pigtail drainage. Materials and Methods: The study was carried out at a tertiary care hospital from January 2016 to December 2021 and included patients who were diagnosed with EPN. The data on the demographic profile, clinical features, biochemical parameters, imaging studies, management, and outcome of patients of EPN were recorded. Results: A total of 51 patients of EPN were studied and were divided into two groups, responders (40 patients) and nonresponders (11 patients), based on their clinical progression and outcome. Among responders and nonresponders, a significant difference was seen in terms of age, presentation of altered consciousness and shock, average hemoglobin, average serum creatinine, and presence of thrombocytopenia. Out of total 51 patients, 13 (25.49%) showed a response with antibiotics only, DJ stenting was done in five (9.8%) patients, and pigtail catheterization in 33(64.7%) patients. There was a significant difference seen in the response with early pigtail drainage. Nephrectomy was needed in eight (15.68%) patients, and the mortality rate was 9.8%, with the death of five patients. Conclusion: Advanced age, lower hemoglobin levels, thrombocytopenia, raised serum creatinine levels, altered mental status, and presence of shock can be used as a score for poor prognosis. With the use of broad-spectrum antibiotics and early pigtail drainage, a large number of patients with EPN can be managed effectively. Nephrectomy should be reserved for patients who fail to respond to conservative management or those with advanced disease with the presence of multiple risk factors.

Diagnostic performance of pre-management computed tomography findings as a predictor of conservative treatment success in patients with emphysematous pyelonephritis

BackgroundEmphysematous pyelonephritis (EPN) is one of the most serious urologic emergency which should be diagnosed and treated adequately to prevent impending septic shock and death. Computed tomography (CT) is the gold standard radiologic modality for diagnosis, grading and predicting the outcome. We aimed in this study to define the initial CT radiological findings correlated with EPN conservative management success.ResultsThis study involved 54 patients (42 women and 12 males) with a mean age of 48 ± 10 years. EPN grades I, II, III, and IV were noticed in 12, 17, 20, and 5 patients, respectively. Ten patients (18.5%) received successful conservative management. On the other hand, renal drainage was needed in 42 patients (77.8%). Delayed nephrectomy was required in two cases (3.7%). In univariate and multivariate analyses, the absence of hydronephrosis and decreased air locules volume were predictors of conservative treatment success (P = 0.003 and 0.01, respectively).ConclusionsConservative therapy should be selected in certain patients of emphysematous pyelonephritis. Decreased air locules volume and the absence of hydronephrosis in pre-admission computed tomography were predictors for conservative therapy success.

Feasibility and safety of laparoscopic nephrectomy in emphysematous pyelonephritic kidneys

Background: Emphysematous pyelonephritis (EPN) is a serious suppurative infection of renal and extrarenal tissues. Most of them end up in nephrectomy, either in an emergency setting or delayed, which is increasingly favored. Laparoscopic nephrectomy is difficult in the post-EPN state due to dense adhesion around the kidney. Aims and Objectives: In this study, we want to check the feasibility of laparoscopic nephrectomy in EPN kidneys. To the best of our knowledge, our series is the single largest series as of today with 10 cases of laparoscopic nephrectomies in EPN kidneys. Materials and Methods: All patients of EPN who underwent laparoscopic nephrectomy at Institute of Kidney Diseases and Research Centre, Ahmedabad, between December 2017 and October 2019 were taken as study subjects and retrospectively reviewed. Patients in whom conservative management was successful were excluded from the study. All patients were diverted initially, either ultrasound/computed tomography-guided percutaneous nephrostomy (PCN) insertion or double J stenting, with or without PCN along with antibiotics and supportive therapy. Delayed transperitoneal laparoscopic nephrectomies were performed for poorly functioning EPN kidneys in follow-up renal scans. Results: A total of 10 patients underwent nephrectomy in this period. The male-to-female ratio was 3:7. As per Huang and Tseng’s EPN classification, one patient had Class 2, four patients had Class 3a, and five patients had Class 3b EPN disease. Mean operative time was 192 min and mean blood loss was 206 ml. Two cases had intraoperative complications managed laparoscopically. No conversion to open nephrectomy or mortality was seen. The drain was placed for a mean period of 3.1 days. The mean hospital stay was 4.8 days. Conclusion: Laparoscopy is safe and feasible for nephrectomy in EPN kidneys. Experience with laparoscopy and operating on pyelonephritis cases is important to reduce complications and extend the advantages of laparoscopy in these groups of patients. An increase in class does not increase the degree of difficulty during laparoscopy.

Surgical Intervention for Emphysematous Pyelonephritis – Our Experience

Introduction: Emphysematous pyelonephritis (EPN) is considered a rare renal infection. It is an acute severe necrotizing infection resulting in the production of gas in the renal parenchyma, collecting system or perinephric tissue. In this report, we describe the clinical, laboratory and imaging findings and in-hospital outcomes of EPN patients who underwent different surgical procedures. Method: This prospective observational study was carried out at BIRDEM General Hospital, Dhaka, Bangladesh between January 2018 and November 2021. Result:A total of 29 patients were recruited to the study (mean age 52.18 + 8.352 year; range 40 – 68 year) including female predominance (89.7%). Comorbidities includes diabetes (96.55%), hypertension (58.6%), acute kidney injury (58.6%), chronic kidney disease (37.9%), renal stones (20.7%), associated hydronephrosis (HDN) or hydroureteronephrosis (HDUN) (27.6%) and multiple comorbidities (93.1%). Neutrophilic leucocytosis with poor glycaemic status was common laboratory findings. CT scan used to confirm the diagnosis and classify EPN. Class 2 EPN (17%), class 3A EPN (26%), class 3B EPN (46%) and class 4 EPN (11%). Escherichia coli was the most common organism identified on urine culture (62%). Along with medical management, intervention includes DJ stenting (24.1%), incision drainage (I/D) with primary closure (65.5%), I/D with open wound (6.9%) and nephrectomy (3.4%). Mean + SD duration of drain tube was 12.36 + 4.83 days. Wound infection rate in I/D with primary closure was 15.8%. No patient died in our series. Conclusion: Multidisciplinary team approach with aggressive medical management and timely interventions are key to decrease mortality in management of EPN. The result of incision drainage with primary wound closure along with a drain tube in situ is promising. Bangladesh J. Urol. 2021; 24(2): 181-187

Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis.

Emphysematous pyelonephritis (EP) is a severe necrotizing infection of the renal parenchyma which is associated with significant case mortality. We sought to identify the incidence and predictive risk factors associated with EP mortality. Two electronic databases, PubMed and Web of Science, were searched from their inception until June 06, 2021 for relevant articles. Two independent teams reviewed abstracts and extracted data from the selected manuscripts. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. Of the 1080 retrieved abstracts, 79 underwent full-text review and 45 studies were included in the final analysis, comprising a total cohort of 1303 patients and 177 mortalities. The pooled prevalence of mortality among the patients with EP disease was 13%. Our analysis found a significantly decreasing trend in mortality rates, an increasing trend in minimally invasive intervention and decreasing trends in emergency nephrectomy in the EP studies from 1985 to 2020. Significant risk factors that were associated with a negative impact on survival of EP patients included sepsis (OR = 15.99), shock (OR = 15.57), disturbance of consciousness (OR = 12.11), thrombocytopenia (OR 7.85), acute renal failure (OR = 5.41), Wan classification I (OR = 4.57), emergency nephrectomy (OR = 3.73), Huang-Tseng classification III-IV (OR = 2.4) and medical management alone (OR = 2.04). Female sex (OR = 0.52) and minimally invasive intervention (OR = 0.47) (percutaneous nephrostomy or ureteral stent placement) were associated with decreased mortality rates. Our study results demonstrated several significant risk factors that could help guide treatment to reduce the mortality risk of EP patients. Clinically, early treatment with a combination of minimally invasive intervention and appropriate medical management may be protective for reducing mortality risk in EP patients.

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

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. 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. 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. 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.

A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis.

Emphysematous pyelonephritis (EPN) is an acute, severe necrotising infection of the kidney. There has been a shift from early nephrectomy to conservative methods. We conducted a meta-analysis to assess the impact of risk factors and treatment choices on outcomes in EPN. We conducted a database search of all studies in English, reporting more than 12 patients of EPN from 1980 to 2020. We compiled the demographics, clinical presentations, risk factors, critical diagnostic results, treatment modalities and outcomes, including mortality. We identified 37 observational studies, 32 retrospective and 5 prospective. The studies reported on 1146 patients, of which 790(68.9%) were female, and 946 (82.5%) were diabetic. In addition, 184 (16.1%) patients had stones, and 235 (20.5%) had obstructive uropathy. Fever and flank pain were the most frequent symptoms. The most common clinical features were pyuria, fever, flank tenderness, and tachycardia. E. coli, Klebsiella pneumoniae and Proteus were the most frequent organisms isolated. X-ray KUB and ultrasound were used as initial diagnostic modalities, but CT scan was the usual diagnostic and confirmatory investigation. Confusion, shock, thrombocytopenia, sepsis, emergency nephrectomy and hyponatremia were significantly associated with mortality. In particular, confusion and hyponatremia were associated with a sevenfold increase in mortality risk. There was no evidence that diabetes, stones, obstructive uropathy, AKI or proteinuria was associated with higher mortality. Nevertheless, 143 of the total 1146 patients died (12.5%). While 26% of the patients who had upfront emergency nephrectomy died, only 9.7% and 10% of patients with medical management and medical management plus minimally invasive treatments died. However, patients that failed medical and minimally invasive treatments and needed salvage emergency nephrectomy had a mortality of upwards of 27%. The risk factors for mortality in emphysematous pyelonephritis are shock, thrombocytopenia, confusion, hyponatremia and emergency nephrectomy. Conservative and minimally invasive treatment should be the initial management strategy for emphysematous pyelonephritis as they carry lesser mortality risks. The presence of risk factors may help predict the subset of patients who need aggressive treatment and minimally invasive treatment modalities or early nephrectomy.

Diagnosis and treatment for emphysematous pyelonephritis: analysis of 14 cases from a single centre

Objective: To examine the modalities of treatment and clinical outcomes of emphysematous pyelonephritis (EPN), in order to improve the survival rate of EPN patients. Methods: Totally 14 patients diagnosed as EPN between October 2011 and November 2020 at Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were included in this article. Data collection including patient demographics, clinical manifestations, management and clinical outcomes were conducted by retrospective charts review, after receiving the institutional review board's approval. There were 11 females and 3 males with a median age of 59 years (range: 52 to 73 years). The lesions were located on the left side in 10 patients and right side in 4 patients. All the 14 patients suffered from fever, and present with severe sepsis or septic shock. The median time from symptom onset to admission to hospital was 3 days(range: 2 to 5 days). All cases had diabetes mellitus. Escherichia coli was the most common organism been cultured (11 cases), while Klebsiella pneumonia was the second (3 cases). CT scan showed bubbly or located gas in the renal parenchyma in 5 cases and presence of steaky or mottled gas in the renal parenchyma in 9 cases. All patients had been admitted to ICU for anti-septic shock therapy. Three patients had undergone percutaneous catheter drainage along with broad-spectrum antibiotics therapy while 3 patients had immediate nephrectomy, the other 8 cases had a combination of an initial percutaneous catheter drainage and second stage nephrectomy. Results: In this case series, 3 patients were died from EPN while the other 11 were survived. The median ICU stay time was 6 days (range: 3 to 11 days). Of the 3 patients died from EPN, 2 had undergone percutaneous catheter drainage along and 1 had received immediate nephrectomy. Among the 11 patients who were survived, only 1 had received percutaneous catheter drainage while the other 10 received nephrectomy (8 patients had staged nephrectomy). Follow-up was performed 6 months after discharge. Of the 11 surviving patients, 2 were lost to follow-up, and the remaining 9 patients had an creatine level of (118.4±29.4) μmol/L (range: 89 to 176 μmol/L). Conclusions: For patients coupled with diabetes who were initially diagnosed as acute pyelonephritis, the possibility of EPN should be considered when the disease progressed rapidly especially septic shock occurred. On the basis of empirical broad-spectrum antibiotics therapy and standardized anti-septic shock treatment, a combination of an initial percutaneous catheter drainage and second stage nephrectomy could be efficacious.

Clinical profile, management and outcomes of class IV emphysematous pyelonephritis in a tertiary care center: A retrospective descriptive study

Abstract. Class IV Emphysematous pyelonephritis (EPN) is a life-threatening infection of the kidney, and there is sparse data on immediate and long-term outcomes of medical management. The study aimed to review the clinical presentation, diagnosis, immediate and long-term outcomes of medical management, and outcome of patients presenting with class IV EPN&#x0D; Methods. This retrospective study was conducted in a tertiary care center in Dharwad, India. The study included class IV EPN patients admitted to the hospital between Jan 2012 to Dec 2019. The factors studied were demographics, comorbidities, radiological investigations, clinical presentation, urine, blood and pus culture, and sensitivity and treatment history. Immediate and long-term outcomes of medical management were determined. Descriptive analysis of the data was conducted. Continuous variables were presented as mean ± standard deviation and discrete variables in terms of number (%).&#x0D; Results. Twenty-one patients with class IV EPN, with a mean age of 55.7 ±13.5 years, were analyzed. The majority were males (M: F 15:6). The patients were followed up for 32.70±21.12 months. Fever, flank or abdominal pain, and acute kidney injury were observed in all 21 patients, while nausea and/or vomiting and dysuria were seen in 16 (76.2%) patients. E. Coli was the most common pathogen found. Double J stenting was done in 20 (95.2%) patients; Ultrasonography guided aspiration 8(38.1%) and percutaneous drainage in 5 (23.8%) patients. One (4.8%) patient died during the first episode and 3(19%) others due to recurrent infection and end-stage renal disease.&#x0D; Conclusions. Class IV Emphysematous pyelonephritis can be managed successfully by minimally invasive modalities. However, long-term morbidity and mortality risks are still negative.

MP29-09 RISK FACTORS FOR SEPSIS AND MORTALITY IN PATIENTS WITH EMPHYSEMATOUS PYELONEPHRITIS

You have accessJournal of UrologyInfections/Inflammation/Cystic Disease of the Genitourinary Tract: Kidney & Bladder II (MP29)1 Sep 2021MP29-09 RISK FACTORS FOR SEPSIS AND MORTALITY IN PATIENTS WITH EMPHYSEMATOUS PYELONEPHRITIS Mohamed Hafedh Saadi, Ahmed Saadi, Marouene Chakroun, Mariem Jrad, Abderrazek Bouzouita, Amine Derouiche, Riadh Ben Slama, Haroun Ayed, and Mohamed Chebil Mohamed Hafedh SaadiMohamed Hafedh Saadi More articles by this author , Ahmed SaadiAhmed Saadi More articles by this author , Marouene ChakrounMarouene Chakroun More articles by this author , Mariem JradMariem Jrad More articles by this author , Abderrazek BouzouitaAbderrazek Bouzouita More articles by this author , Amine DerouicheAmine Derouiche More articles by this author , Riadh Ben SlamaRiadh Ben Slama More articles by this author , Haroun AyedHaroun Ayed More articles by this author , and Mohamed ChebilMohamed Chebil More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002026.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection of the kidney characterized by accumulation of gas in renal parenchyma. Bacteremia is present in more than 50% of the EPN patients and rapid evolution to sepsis is not uncommon. The aim of our work was to study risk factors of urosepsis and mortality in case of EPN. METHODS: Patients diagnosed with EPN between January 2010 and December 2020 were retrospectively reviewed. Patients’ age, gender, diabetes mellitus (DM), urological records, Body Mass Index (BMI), EPN type, serum creatinine, leucocytic count, lymphocytic count, platelet count, platelet to leucocytic count ratio, urine culture, EPN radiological class and the line of treatment were analyzed as risk factors of severe sepsis, septic shock and mortality. Univariate and multivariate analysis for severe sepsis, septic shock and mortality were performed. Statistical analysis was made using SPSS version 26. RESULTS: 52 patients were included in the study. Mean age was 58.63 years old [22-88]. 38 patients (73%) had Diabetes Mellitus (DM). Mean presentation delay was 5.96 days [1-30]. As per Huang and Tseng classification, 23 patients had class 1 EPN, 11 had class 2 EPN, 8 had class 3 EPN and 10 had class 4 EPN. 32 patients (61.5%) presented with severe sepsis and 9 patients (17.3%) developed a septic shock. Specific mortality rate was 3.84%. In univariate analysis, DM, higher blood sugar on admission, higher leucocytic count, higher lymphocytic count and lower PLR were associated with sepsis (p=0.02, 0.03, 0.0001, 0.0001 and 0.0001, respectively) (table1). In multivariate analysis, leucocytic count and PLR were independent risk factors (table1). DM history, blood sugar on admission, leucocytic rate, lymphocytic rate, thrombocytopenia, PLR, creatinine serum level, PNE type and EBSL-secreting bacteria were not associated with higher rate of mortality (p=0.08, p=0.015, p=0.753, p=0.533, p=0.455, p=0.093, p=0.522, p=0.421 and p=0.25 respectively). CONCLUSIONS: The accumulated and analyzed evidence suggests that leucocytic count on admission and PLR seem to be significant risk factors for sepsis in patients with emphysematous pyelonephritis. These data may be taken into consideration when treating patients with this devastating infection. Source of Funding: None to be declared © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e492-e493 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Mohamed Hafedh Saadi More articles by this author Ahmed Saadi More articles by this author Marouene Chakroun More articles by this author Mariem Jrad More articles by this author Abderrazek Bouzouita More articles by this author Amine Derouiche More articles by this author Riadh Ben Slama More articles by this author Haroun Ayed More articles by this author Mohamed Chebil More articles by this author Expand All Advertisement Loading ...

Outcome of conservative and minimally invasive management in emphysematous pyelonephritis.

Context:Developing countries.Introduction:Emphysematous pyelonephritis (EPN) is a urologic emergency characterized by acute necrotizing infection with the presence of gas in the kidney, perinephric space, and/or urinary collecting system.Materials and Methods:It is a retrospective study of inpatients at the Department of Urology, RG Kar Medical College and Hospital, Kolkata, which includes twenty patients diagnosed as EPN between September of 2018 and May of 2020.Results:Patients were classified as per computed tomography (CT) severity grading proposed by Huang and Tseng. In our study, medical management with antibiotics was effective in 10% of patients. Twenty percent of patients were treated with medical management and internal ureteral stenting. Fifty percent of the patients were treated with medical management and percutaneous nephrostomy (PCN). Ten percent needed PCN drainage in addition to Double J (DJ) stenting. Ten percent needed percutaneous drainage of perinephric abscess along with PCN. Ten percent of patients were treated with open drainage in addition to DJ stenting and percutaneous drainage of perinephric collection as they failed to respond to minimally invasive intervention alone, with repeat ultrasonography showing persistent collection. There was no mortality in the group.Conclusion:EPN patients are mostly moribund with multiple comorbidities. It is vital to comprehend the management with a prompt CT imaging. Proactive hemodynamic stabilization, antimicrobial therapy, complementing it with DJ stenting and/or PCN in cases not responding to antibiotics alone, can treat most of the patients with this pathology.

Emphysematous Pyelonephritis in Type 2 Diabetes – Clinical Profile and Management

Emphysematous pyelonephritis (EPN) is a rare but life-threatening acute suppurative infection of the kidney among diabetics. There is no current consensus on the management of EPN. A prospective observational study was conducted at the Department of General Surgery, RML Institute of Medical Sciences, Lucknow, as well as at Eras Lucknow Medical College, Lucknow, from 2015 to 2018 to look for clinical, microbial profile and treatment outcome of diabetic patients with EPN. A total of 76 diabetic patients diagnosed with pyelonephritis were identified, of which 15 patients were diagnosed with EPN (26.3%). The mean age of the patients was 58.4 ± 6.5 years. The mean duration of diabetes was 5.3 ± 3.3 years. 12 (82%) of the 15 patients with diabetes mellitus had a glycosylated hemoglobin level higher than 7.5. Renal dysfunction at presentation was seen in 11 (73.3%) patients. Among the unilateral involvement, the left kidney was more affected. Escherichia coli in 11 (73.3%), Klebsiella sp. in one (6.6%), Pseudomonas in one (6.6%), and one each with polymicrobial and fungal urinary tract infection, respectively. Of 15 EPN patients, 13 (86.6 %) survived, and one (6.6 %) expired. Two of them underwent nephrectomy both survived. All patients with Stage I, II, and IIIa EPN (n = 12) were managed with antibiotics with or without percutaneous catheter drainage (PCD). In EPN Stage IIIb/IV (n = 3), all the three (20%) patients were managed with antibiotics and PCD, and later two (13.3%) needed nephrectomy. Only time to diagnosis, altered sensorium, shock at presentation, and thrombocytopenia were associated with poor outcome in EPN patients (P <0.05) Multiple logistic regression tests showed shock (P = 0.04) and disturbance of consciousness (P = 0.05) on (hospital admission as being the independent factors for poor outcome. EPN in diabetics needs a high index of suspicion, timely diagnosis, and good multidisciplinary approach with adequate antibiotics and surgical management for better patient outcomes.

Emphysematous Pyelonephritis: Role and Factors Affecting Renal Conservation- ACross-sectional Study

Introduction: Emphysematous Pyelonephritis (EPN) is a serious life threatening, necrotising infection which can affect renal parenchyma, collecting system and nearby tissue with presence of gas within renal system Aim: To check likelihood of kidney salvagibility by minimally invasive approaches in EPN and to see the prognostic factors that support kidney salvagibility in EPN. Materials and Methods: The cross-sectional study was conducted during October 2018 to June 2020 on 30 patients who were admitted in Department of Urology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha,India with features of EPN.Thirty patients with clinical and radio-logical features (Huang Tseng Classification) of EPN were enrolled in the study. All the biochemical parameters, clinical features and outcomes (patient who managed conservatively included in good outcome group while the patients who required nephrectomy were included in poor outcome group) continuous variables were analysed with the Unpaired t-test and categorical variables were analysed with fisher-exact test and multiple logistic regression test. Results were considered statistical significance when p-value was &lt;0.05. Results: EPN was associated with diabetes mellitus in 80% of cases, 80% presented with complain of fever and loin pain was a presentation in 70% of cases. Mean serum Creatinine for good outcome was 1.4 and serum creatinine 2.5 or more was associated with poor outcome. Reduced platelet count (p-value=0.0143), altered mental status (p-value=0.0073), severe proteinuria (p-value=0 .0213), renal function impairment (p-value=0 .0493) and shock (p-value=0.0127) were statistically significant and associated with poor outcome. A 76% (n=21)cases were classified as good outcome group and 24% (n=9) cases classified as poor outcome group for which nephrectomy was done. Open nephrectomy was done in nine patients. Conclusion: There is a definite possibility of renal salvagibility by minimally invasive approaches in EPN in properly selected patients of EPN. Shock, altered mental status, raised serum creatinine, platelet count &lt;120000/cmm, severe proteinuria are poor outcome factors which can lead to nephrectomy in conservatively managed cases of EPN.

A Prospective study of Emphysematous Pyelonephritis in Patients with Type 2 Diabetes.

Introduction:Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma. There is a lack of studies on follow up of EPN patients. The study aimed to explore the effect of EPN in patients with type 2 diabetes (T2D) on glycemic and renal parameters on follow up, and factors suggesting the failure of medical treatment.Methods:This was a hospital-based prospective study done over a period of 3 years on newly diagnosed consecutive 20 patients of emphysematous pyelonephritis (EPN) with T2D. Study analyzed the clinical, laboratory, radiological, microbiological findings, complications, treatment modality, and outcome. All patients were followed up for 6 months with respect to the number of urinary tract infections (UTIs), glycemic control, and renal parameters.Results:Most of the patients were postmenopausal females with longer duration of diabetes and complicated by triopathy. Fever and renal angle tenderness were the most common clinical finding. The majority of our patients 12 (60%) had EPN (class 1 and 2). Severe hyperglycemia was present in 19 (95%), hyperosmolar hyperglycemic state (HHS) in 5 (25%), diabetic ketoacidosis (DKA) in 3 (15%), and acute kidney injury (AKI) in 15 (75%). Bacteriuria was present in 90% and bacteremia in 30%. E. coli was the most common organism isolated (80%). The survival rate was 90%, with failure of medical treatment in 30%. Renal obstruction and worsening azotemia predicted the failure of medical management. The significant number (11, 55%) of patients developed recurrent UTI on follow up. Factors that increased the risk of recurrent UTI in EPN were chronic kidney disease, poor glycemia, and renal obstruction. The recurrent UTI patients had significantly higher glycosylated hemoglobin A1c (HbA1c) at follow up than at baseline, but renal parameters did not differ.Conclusions:We recommend early aggressive medical treatment of EPN. Altered sensorium, renal obstruction, and deteriorating renal function may suggest the failure of medical treatment.

Comparative study of emphysematous pyelonephritis and pyelonephritis in type 2 diabetes: a single-centre experience.

Emphysematous pyelonephritis (EPN) patients with type 2 diabetes (T2D) have severe complications and high morbidity with poor prognosis as compared to Pyelonephritis. The aim was to study clinical features, microbiological profile, complications of EPN and pyelonephritis in T2D patients. This was a hospital-based prospective study done on 200 T2D patients with upper UTI. Various clinical, biochemical parameters and urine examination and culture were monitored. Patients were followed up for 6months with respect to number of UTIs, glycemic control and renal parameters. Pyelonephritis was present in 180(90%) and EPN in 20(10%) of upper UTI patients. Longer duration of diabetes, presence of nephropathy, chronic kidney disease (CKD), hypertension (HTN), history of symptomatic UTI in a prior year, renal calculi and obstruction increase the risk of EPN. Patients with EPN commonly present with vomiting, flank pain altered sensorium and renal tenderness. Complications like diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), multiorgan dysfunction syndrome (MODS), acute kidney injury (AKI) and hypotension occur frequently in EPN as compared to pyelonephritis in T2D patients. Patients with EPN had poor glycemia and lower estimated glomerular filtration rate (eGFR) as compared to pyelonephritis. Bacteriuria was present in 90% and 66.7% of EPN and pyelonephritis patients respectively. E. coli was the most common isolate in both UTI groups. A significant number of EPN patients develop recurrent UTI. Patients with EPN have an improvement in glycemia on follow up, but renal parameters do not improve on follow up, while as pyelonephritis patients have an improvement in glycemia and renal parameters with intensive treatment. Recurrent UTI in upper UTI patients leads to worsening of glycemia and renal parameters. Complications frequently occur in EPN patients as compared to pyelonephritis.

Renal salvage, an achievable goal in patients with emphysematous pyelonephritis: Outcomes of an algorithmic renal preserving strategy.

Introduction:Emergency nephrectomy has been the time-honored treatment of choice for emphysematous pyelonephritis (EPN), a fatal gas-forming necrotizing infection. Recent years have seen a shift toward nonextirpative approach aimed to achieve higher rates of renal salvage, limiting the indications for nephrectomy to severe grades of the disease. This study aimed at analyzing the role of initial renal preserving measures algorithmically applied across grades of EPN.Materials and Methods:We prospectively analyzed the clinical data and outcome of 36 consecutive patients of EPN in 5 years' study period, treated by renal preserving measures, which include aggressive resuscitation, parenteral antibiotics, effective drainage of infected fluid/gas, and relieving the urinary tract obstruction. Huang-Tseng computed tomography-based classification system was used to categorize the patients as well as to employ suitable treatment modality.Results:The mean age of the patients was 57.5 ± 12 years with female preponderance (2:1). Diabetes mellitus (97%) was the most common associated factor. Escherichia coli was (72%) the most frequent causative organism found. Urinary tract obstruction was seen in 27 patients (75%) attributable to ureteric calculi, renal papillary necrosis, ureteric stricture, and fungal bezoar in the descending order of frequency. Only 2 (6%) out of 36 patients managed according to our hospital renal salvage protocol required salvage nephrectomy. The overall survival rate was 94%.Conclusion:Our hospital-based algorithmic renal preserving strategy not only improved the survival but also decreased the need for nephrectomy.

Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients’ need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals’ emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ2 tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.

Emphysematous pyelonephritis treatment strategies in correlation to the CT classification: have the current experience and prognosis changed?

In view of the differences in early and late management experiences based on Huang and Tseng CT classification of emphysematous pyelonephritis (EP), our study included 34 patients aimed to re-correlate the current management plans with CT classification. A retrospective review from January 2009 to December 2018, in patients with primary or final diagnosis of EP. Data included; patients' demographics, routine laboratory and imaging work-up. CT was performed for all, and images were classified based on Huang and Tseng classification. The CT classification was correlated to the laboratory parameters and the final treatment plans. Data were collected and analyzed using SPSS®. Complete data for 34 patients were analyzed. The majority (70%) had positive urine culture, and Carbapenems and Ureidopenicillin were the most commonly used antibiotics. Based on CT classification, 75% (26/34) of the patients were in class I and II, 6 cases with class IIIa, and only two with class IIIb, with no cases of class IV. All patients in class I and II responded well to the medical therapy, and eight required PCN/DJ. Four required nephrectomy in class III, with zero mortality. Patients in class I and II comprise the majority of EP patients, and respond well to medical treatment with excellent outcome. Insertion of PCN and DJ are not required routinely, but with urinary obstruction requiring drainage, and a few cases who required nephrectomy-all with class III. Our data show improvement in the overall survival in patients for EP.