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

Abstract

Purpose 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. Methods 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 6 months with respect to number of UTIs, glycemic control and renal parameters. Results 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. Conclusion Complications frequently occur in EPN patients as compared to pyelonephritis.

Diabetic Ketoacidosis Triggered by an Emphysematous Urinary Tract Infection: A Case Report and Mini-Review of Literature

“…A higher prevalence in the female gender has been described, as well as an average age presentation at 60 years. The main risk factors identified in case series in the literature are type 2 diabetes mellitus, up to 95% of patients with emphysematous pyelonephritis have poor glycemic control, followed by urinary tract obstruction [2,4,7].…”

“…Most type 2 diabetes patients exhibit inadequate glycemic control levels upon admission confirmed by HbA1C levels greater than 8% or presence of microvascular complications (diabetic retinopathy/ nephropathy) [7,8]. One study reported that neutrophiles´ ability to produce Neutrophil Extracellular Traps (NETs) was suppressed during hyperglycemia, leading to infection susceptibility; macrophage function is also altered.…”

“…In a cohort of 26 patients with emphysematous pyelonephritis, DKA has an incidence of 27% (7 patients) and it's associated with increased mortality rate [5]. Another comparative study showed that patients with EPN had commonly poor glycemic control, lower estimated glomerular filtration rate and complications like DKA compared with patients with pyelonephritis [7].…”

“…The most frequently isolated gas-producing organisms in urinary tract infections are Escherichia coli in 63%. Nonetheless, others agents such as: Klebsiella pneumoniae, Proteus mirabilis, Pseudomonas aeruginosa, Enterobacter aerogenes, Enterococci, Staphylococcus aureus, Streptococci, Nocardia, Clostridium perfringens and Candida albicans are also usually involved [2,7]. The management of DKA is with intravenous fluids, insulin therapy, potassium and bicarbonate when necessary, but treatment of concomitant EPN is debated.…”

“…The management of DKA is with intravenous fluids, insulin therapy, potassium and bicarbonate when necessary, but treatment of concomitant EPN is debated. Nowadays there are not international guidelines or established recommendations for EPN management and available information is poorly weighted given the low incidence reported of EPN [7,12]. Since 1980's treatment of patients with EPN was emergency nephrectomy and/or open surgical drainage together with antibiotic therapy, nowadays some studies suggest better outcomes with nonsurgical management like >90% of survival and less decline in glomerular filtration rate [13,14].…”