Emphysematous pyelonephritis: Time for a management plan with an evidence-based approach

Abstract

IntroductionEmphysematous pyelonephritis (EPN) is a life-threatening necrotising kidney infection, but there is no consensus on the best management.MethodsWe systematically reviewed previous articles published from 1980 to 2013 that included studies reporting on EPN, and applying the Cochrane guidelines, we conducted a meta-analysis of the results.ResultsIn all, 32 studies were included, with results for 628 patients (mean age 56.6 years, range 33.8–79.9). There were 462 women, outnumbering men by 3:1. Diabetes was present in 85% of the cases. Fevers and rigor (74.7%), pyuria (78.2%) and pain (70.4%) were the most common symptoms. Shock was associated with 54.4% of deaths while obstructive uropathy was associated with 15.1% of deaths. Computed tomography was diagnostic in all the cases. Percutaneous drainage (PCD) and medical management (MM) alone were associated with a significantly lower mortality rate than was emergency nephrectomy (EN), with an odds ratio (95% confidence interval) for PCD vs. EN of 3.13 (1.89–5.16; P < 0.001), for EN vs. MM of 2.84 (1.62–4.99; P = 0.001), and of 0.91 (0.53–1.56; P = 0.73, i.e., no difference) for PCD vs. MM. Open drainage also had a significantly lower mortality rate than EN, with a ratio of 0.12 (0.02–0.91; P < 0.04).ConclusionThe overall mortality rate was ≈18%; shock was associated with a high mortality rate and therefore should be managed aggressively. PCD and MM were associated with significantly higher survival rates than EN, and therefore EN should only be considered if the patient does not improve despite other treatments.

Emphysematous pyelonephritis – A case series from a single centre in Southern India

“…A systematic review of 10 retrospective studies including 210 patients with emphysematous pyelonephritis regarding the timing and nature of interventions noted that mortality associated with medical management plus percutaneous drainage was signi icantly lower than medical management plus emergency nephrectomy (13.5%vs 25% respectively) [14]. A more recent meta-analysis has also associated nephrectomy with increased patient mortality and has reemphasized the relevance of conservative and minimally invasive procedures [15].…”

Emphysematous pyelonephritis-role of conservative management and drainage procedures-institutional experience

“…In the last two decades, CT scan made earlier diagnosis possible and helps in assessing the extent or spread of the disease (2) . Availability of broad spectrum antimicrobials helped in efficient control of infection (3) Minimally invasive procedures enabled drainage of pus and necrotic materials feasible and reduced the morbidity and mortality of major surgical interventions with good prognosis (4) . Although nephrectomy may be the quickest way of treating the infection source, renal function is compromised in many patients; therefore, a strategy to save nephrons may be very desirable.…”

Emphysematous Pyelonephritis, Case Report and Review of the Literature

“…When septic shock was present it was associated with a mortality of 54.4% in some studies and it should be managed promptly with a multidisciplinary approach. 3 Mortality rate is about 18% and must be suspected in Diabetic patients with acute pyelonephritis poor response to medical treatment, otherwise the clinical course may be life-threatening if not recognized. 2 The presentation of this entity in Diabetic patients is secondary to the hydrogen and carbon dioxide release through sugar fermentation by the higher glucose concentrations in tissues, which favors the growth of microorganisms 4 including E. coli in 51%, followed by Klebsiella 18% and Pseudomonas 13%5.…”

“…Mechanic ventilatory support and use of norepinephrine were adhere to therapy. Laboratories report with blood cells 8400/ mm 3 , neutrophils 82%, Hemoglobin 9.5g/dL, Platelets 57000, Glucose 595mg/dL, Cr 2mg/dL, total bilirubin 6.3mg/dL, lactic dehydrogenase 572 U/l, alanine aminotransferase 352 U/l. This case was present in a rural hospital and the unique imaging auxiliary available was an …”