Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus

Yano, Toshiaki; Takada, Toshihiko; Fujiishi, Ryuto; Fujii, Kotaro; Honjo, Hitoshi; Miyajima, Masayuki; Takeshima, Takao; Hayashi, Michio; Miyashita, Jun; Azuma, Teruhisa; Fukuhara, Shunichi

doi:10.1177/0284185120988817

Cited by 7 publications

(8 citation statements)

References 29 publications

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“…There have been several studies on PRFS with hydronephrosis [9][10][11][12][13][14][15]. In general, the occurrence of PRFS with hydronephrosis can be explained by the following two reasons.…”

Section: Discussionmentioning

confidence: 99%

“…PRFS is often recognized as a linear or curvilinear area of soft-tissue attenuation in the perirenal fat space on CT. There have been reports of PRFS due to pyelonephritis and ureteral stones with hydronephrosis in benign diseases [10,11] and reports of RPFS due to UUC with hydronephrosis in cancers [9]. However, PRFS in renal pelvic urothelial carcinoma (RPUC) without hydronephrosis has not been reported.…”

Section: Introductionmentioning

confidence: 99%

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Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: A retrospective study

Yanagi

Terasaki

Kiriyama

et al. 2023

Preprint

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Background To investigate the impact of Perirenal fat stranding (PRFS) on progression after radical nephroureterectomy (RNU) for pelvic urothelial carcinoma (RPUC) without hydronephrosis and to reveal the pathological findings of PRFS. Methods Clinicopathological data, including computed tomography (CT) findings of the ipsilateral and contralateral PRFS, were collected from the medical records of 56 patients treated with RNU for renal RPUC without hydronephrosis between 2011 and 2021 at our institution. Ipsilateral PRFS on CT was classified as either low or high PRFS. The impact of PRFS on progression-free survival (PFS) after RNU was analyzed using the Kaplan-Meier method and log-rank test. In addition, specimens including sufficient perirenal fat from patients with low and with high PRFS were pathologically analyzed. Results Of the 56 patients, 31(55.4%) and 25 (44.6%) patients were classified as having low and high PRFS, respectively. Within a median follow-up of 40.6 months postoperatively, 11 (19.6%) patients showed disease progression. The Kaplan-Meier method and log-rank test revealed that patients with ipsilateral high PRFS had significantly lower PFS rates than those with ipsilateral low PRFS (3-year PFS 69.8% vs 93.3%; p=0.0393). Pathological analysis revealed that ipsilateral high PRFS specimens (n=3 patients) contained more fibrous strictures in perirenal fat than ipsilateral low PRFS specimens (n=3 patients). Conclusions PRFS of RPUC without hydronephrosis consists of collagenous fibers. The presence of ipsilateral high PRFS is a risk factor for progression after RNU for RPUC patients without hydronephrosis. Strict follow-up after surgery is thus recommended for these patients.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: A retrospective study

Yanagi

Terasaki

Kiriyama

et al. 2023

Preprint

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“…25 Lastly, for the methodology of our study we decided to validate OU in the presence of signs for recent passage of stone and to consider non-obstructing renal stones not related to the acute pain. However, uretero/hydronephrosis, perinephric edema and periureteral edema may be rather signs of pyelonephritis 34 with no OU, and rarely non-obstructing renal stone does cause some pain. This fact might have changed slightly our justification rates.…”

Section: Cuaj -Original Researchmentioning

confidence: 99%

Emergency department non-contrast computed tomography for suspicion of obstructive urolithiasis: Yield and consequences

Savin

Dekalo

Schreter

et al. 2022

CUAJ

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Introduction: We aimed to analyze patterns of referral, yield, and clinical implications of non-contrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED). Methods: The study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted. Results: NCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%. Conclusions: The yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload.

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“…Accordingly, we have recently assessed the diagnostic performance of five CT signs (perirenal fat stranding, pelvicalyceal wall thickening, enlargement of the kidney, thickening of Gerota’s fascia and decreased attenuation) for APN in older patients with a suspected infection with an unknown focus. 8 In our previous study involving 473 patients, non-contrast CT findings were evaluated in all patients, while contrast-enhanced CT findings were assessed in 101 patients. Contrast medium was withheld mainly due to concerns about contrast-induced acute kidney injury (AKI).…”

Section: Introductionmentioning

confidence: 99%

“…Even without contrast, these CT signs were especially useful for ruling in APN (positive likelihood ratio 2.5–11.3). 8 However, whether those CT findings have any added value to readily available information before CT (ie, history, physical examination, urinalysis, etc) remains unknown. Since the diagnosis of APN is always made based on all available information in clinical practice, whether CT provides added value is more important than its diagnostic performance as a sole test.…”

Section: Introductionmentioning

confidence: 99%

Added value of non-contrast CT for the diagnosis of acute pyelonephritis in older patients with suspected infection with an unknown focus: a retrospective diagnostic study

Takada,

Yano,

Fujiishi

et al. 2024

BMJ Open

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ObjectivesIn older patients, the diagnosis of acute pyelonephritis (APN) is challenging. The aim was to evaluate the added value of CT to history, physical examination and urinalysis for the diagnosis of APN in older patients with suspected infection with an unknown focus.DesignRetrospective diagnostic study.SettingDepartment of General Medicine in an acute care hospital in Japan.ParticipantsPatients aged ≥65 years who underwent blood cultures, a urine culture, and chest and abdominal CT to detect the focus of infection were included.Primary outcome measuresTwo radiologists independently reviewed four non-contrast CT signs: perirenal fat stranding, pelvicalyceal wall thickening, enlargement of the kidney and thickening of Gerota’s fascia. Findings on contrast-enhanced CT could not be evaluated due to an insufficient number of patients in whom contrast-enhanced CT was performed. An expert panel was used as the reference standard for APN. The added value of CT findings was quantified by comparing the diagnostic performance between a model based on 10 predictors available before CT and an extended model including the CT findings.ResultsOf 473 patients, 61 (14.8%) were diagnosed with APN. When the laterality of the CT findings was taken into account, the model fit was not improved by adding them. In the laterality-insensitive analysis, the model performance was significantly improved by adding the CT signs (likelihood-ratio test p=0.03; c-index 0.89 vs 0.91, p=0.03). However, their clinical utility was only to improve the classification of 11.5% of patients with APN.ConclusionsThe added value of non-contrast CT findings to history, physical examination and urinalysis was limited for the diagnosis of APN in older patients with a suspected infection with an unknown focus.

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Usefulness of computed tomography in the diagnosis of acute pyelonephritis in older patients suspected of infection with unknown focus

Cited by 7 publications

References 29 publications

Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: A retrospective study

Perirenal fat stranding as a predictor of disease progression after radical nephroureterectomy for renal pelvic urothelial carcinoma: A retrospective study

Emergency department non-contrast computed tomography for suspicion of obstructive urolithiasis: Yield and consequences

Added value of non-contrast CT for the diagnosis of acute pyelonephritis in older patients with suspected infection with an unknown focus: a retrospective diagnostic study

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