Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature

Abstract

Emphysematous pyelonephritis (EPN) is a life-threatening condition most commonly observed in diabetes, with nephrectomy believed to be the treatment of choice. However, nephrectomy in EPN is associated with increased risk of complications secondary to associated hemodynamic instability and may result in lifelong hemodialysis in case of bilateral EPN. We present three patients of severe bilateral EPN and one patient of unilateral EPN with diabetic ketoacidosis (DKA) successfully managed conservatively. Patient 1 (severe bilateral EPN) and patient 4 (unilateral EPN with DKA) responded to aggressive broad spectrum antibiotics, whereas patients 2 and 3 (severe bilateral EPN) responded to broad spectrum antibiotics along with percutaneous catheter drainage (PCD). PCD resulted in initial drainage of 300 and 200 ml of pus, respectively. All patients had associated uncontrolled hyperglycemia, poor glycemic control (HbA1c >8.5%), prerenal and intrinsic renal failure, leukocytosis, and dyselectrolytemia which responded to aggressive supportive management and insulin. There are several reports of successful medical management of severe bilateral EPN. Nephrectomy might no longer be the preferred treatment of severe bilateral EPN and may be reserved for patients’ refractory to antibiotics and PCD. Urgent randomized controlled trials are warranted in EPN to optimize the treatment protocols.

Emphysematous pyelonephritis: Is nephrectomy warranted?

“…In contrast, other studies suggested that PCD is a quite effective and adequate approach with a high success rate even in extensive EPN. [ 3 4 11 12 13 14 15 16 22 23 ] which is in accordance with our study where patients managed conservatively had a good outcome and survived. Furthermore, two patients with class I and class IV treated primarily with DJ stent showed improvement similar to those treated with nephrostomy.…”

“…[ 1 6 7 9 10 17 18 ] Recent articles revealed that nephrectomy is associated with higher morbidity and mortality one of which was a systematic review that demonstrated 13.5% mortality in patients treated with PCD compared with 50% mortality for emergency nephrectomy. [ 3 5 7 8 16 22 ] In our series, the mortality was definitely higher with those who underwent nephrectomy. The overall mortality was 37.5% which was associated with those who had undergone nephrectomy, while those who were treated conservatively had a good outcome compared to those who had undergone nephrectomy.…”

“…With this evidence of higher mortality and morbidity associated with nephrectomy,[ 3 5 7 8 16 22 ] we need to reconsider and direct our management toward kidney preservation and improvement of the quality of patients' life, not rendering them dialysis-dependent when they could have the chance to retain their kidney, PCD is the best preferred initial management, and stents can be used when indicated. There is no place for immediate nephrectomy keeping nephrectomy for those refractory to conservative management.…”

“…Seventy to ninety percent of cases occur in diabetic females. [ 3 ] Furthermore, it is commonly seen in patients with obstructive uropathy, polycystic kidney, and end-stage renal disease. [ 4 ] With a mortality rate of 25%;[ 5 ] it is considered life-threatening, which, necessitates early and aggressive management.…”

“…Despite the morbidity and mortality of EPN [ 5 7 8 ] there is still conflicting reports regarding the most appropriate management. [ 1 3 4 6 9 10 11 12 13 14 15 16 17 18 ] Early interference with nephrectomy was almost a mandatory approach due to increased mortality with medical therapy favoring interventional approach, leaving PCD for inoperable cases. [ 1 6 9 10 17 18 ] This approach has been changed recently due to early detection of patients with EPN with the aid of advanced radiological modalities, alongside early management with potent antibiotics, reserving nephrectomy for patients refractory to conservative measures.…”