Case of emphysematous pyelonephritis in kidney allograft: Conservative treatment

Tienza, Antonio; Hevia, M.; Merino, I.; Velis, J.M.; Algarra, R.; Pascual, Juan I.; Zudaire, J.J.; Robles, J.E.

doi:10.5489/cuaj.1555

Cited by 10 publications

(7 citation statements)

References 10 publications

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“…[ 2 ] The only exception to this female predominance is that males undergoing renal transplantation are more likely to suffer. [ 12 ] The most common clinical features in our series and reported by others include fever/chills, flank pain, renal angle tenderness, vomiting, and dysuria. These symptoms and signs are nonspecific and cannot differentiate EPN from the usual pyelonephritis.…”

Section: Discussionsupporting

confidence: 52%

Emphysematous pyelonephritis: A 10-year experience with 26 cases

Misgar

Mubarik

Wani

et al. 2016

Indian J Endocr Metab

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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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Section: Discussionsupporting

confidence: 52%

Emphysematous pyelonephritis: A 10-year experience with 26 cases

Misgar

Mubarik

Wani

et al. 2016

Indian J Endocr Metab

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“…From the available past literature, there is an ascendancy of EPN in females, owing to their increased perceptivity to UTI [20,21]. The female to male ratio of our cohort is in conjunction to that reported by one of the study, but much higher ratios have been reported previously [22,23]. As per other series, our maximum patients presented with fever with or without flank pain.…”

Section: Discussionsupporting

confidence: 86%

Emphysematous Pyelonephritis: A Correlation of Clinical Characteristics With Serum Parameters and Its Contribution in Determination of Prognostic Factors

T.P¹,

Singh²,

Barua³

et al. 2018

Clin Infect Immun

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Background: Emphysematous pyelonephritis (EPN) is a severe lifethreatening infection of renal parenchyma, peri-renal tissue and collecting system primarily caused by gas forming bacteria and carries a significant mortality of 80% when primarily treated non-surgically. Early identification of the disease process along with timely surgical management is of paramount significance. In the last 2 decades evolution of surgical management has lead to a substantial decrease in mortality of up to 21%. The focus of the present study was to investigate optimal serum panel parameters and to propagate prognostic model for the optimal evaluation management of EPN. Methods: The present study was conducted at the Department of Urology at GMCH, Gauhati. Authors retrospectively analyzed all clinical, laboratory and radiological data along with outcome of 44 patients with EPN from January 2015 to August 2017. Chi-square analysis and Spearman tests were used to carve out significant association and correlation. Results: The overall survival rate was 86.37% (38/44). Escherichia coli (E.Coli) was the most common bacterial pathogen isolated from urine and pus culture. Uncontrolled type 2 diabetes mellitus (DM), polymicrobial infection, shock, thrombocytopenia, bacteremia, hypoalbuminemia, and hemodialysis were significantly more common in cases of death and correlated with adverse serum profile. The AUC of the ROC curve for the seven prognostic factors was 0.59 and only thrombocytopenia (TCP) (AUC = 0.78, P = 0 .033) along with liver cirrhosis (AUC = 0.76, P = 0.018) came out to be significant post ROC analysis. Conclusions: Upfront clinical factors such as uncontrolled DM type 2, polymicrobial infection, shock, thrombocytopenia, bacteremia, hy-poalbuminemia, hemodialysis along with altered serum parameters are significantly correlated with outcome in patients of EPN.

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“…Al‐Geizawi classification stage 1 tends to be treated by antibiotics and stage 2 by antibiotics plus percutaneous drainage (PCD) (Table ) . Stage 3 patients are treated either by PCD or nephrectomy, however, some stage 3 cases deteriorated too quickly to perform transplant nephrectomy .…”

Section: Discussionmentioning

confidence: 99%

Emphysematous pyelonephritis in renal allograft related to antibody‐mediated rejection: A case report and literature review

Takahashi

Malinzak

Safwan

et al. 2018

Transplant Infectious Dis

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Emphysematous pyelonephritis (EPN) is a rare condition which can rapidly progress to sepsis and multiple organ failure with high mortality. We experienced a rare case of EPN in a renal allograft related to antibody‐mediated rejection (AMR). The patient received a deceased donor kidney transplant due to end‐stage renal disease secondary to diabetes mellitus. Cross‐match test was negative but she had remote history of anti‐HLA‐A2 antibody corresponding with the donor HLA. Surgery concluded without any major events. Anti‐thymoglobulin was given perioperatively for induction. She was compliant with her immunosuppressive medications making urine of 2 L/d with serum creatinine of 1.9 mg/dL at discharge on post‐operative day (POD) 6. She did well until POD 14 when she presented to the clinic with features of sepsis, pain over the transplanted kidney area and decline in urine volume with elevated serum creatinine. CT revealed extensive gas throughout the transplanted kidney. Renal scan revealed non‐functional transplant kidney with no arterial flow. Based on these findings, a decision to perform transplant nephrectomy was made. At laparotomy, the kidney was completely necrotic. Pathology showed non‐viable kidney parenchyma with the tubules lacking neutrophilic casts suggestive of ischemic necrosis. Donor‐specific antibody (DSA) returned positive with high intensity anti‐HLA‐A2 antibody. This is the first case of early EPN in allograft considered to have occurred as a result of thrombotic ischemia secondary to AMR. This case suggests consideration of perioperative anti‐B‐cell and/or anti‐plasma cell therapies for historical DSA and strict post‐operative follow‐up in immunologically high‐risk recipients to detect early signs of rejection and avoid deleterious outcomes.

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Case of emphysematous pyelonephritis in kidney allograft: Conservative treatment

Cited by 10 publications

References 10 publications

Emphysematous pyelonephritis: A 10-year experience with 26 cases

Emphysematous pyelonephritis: A 10-year experience with 26 cases

Emphysematous Pyelonephritis: A Correlation of Clinical Characteristics With Serum Parameters and Its Contribution in Determination of Prognostic Factors

Emphysematous pyelonephritis in renal allograft related to antibody‐mediated rejection: A case report and literature review

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