Blog
About

  • Record: found
  • Abstract: found
  • Article: not found

Emphysematous pyelonephritis: the impact of urolithiasis on disease severity

Read this article at

ScienceOpenPublisherPMC
Bookmark
      There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.

      Abstract

      BackgroundEmphysematous pyelonephritis is a severe infection of the kidney associated with formation of gas in the renal parenchyma and/or collecting system. The purpose of this study was to evaluate outcomes of patients with emphysematous pyelonephritis in a contemporary cohort and to evaluate the impact of urolithiasis on disease severity.MethodsA search of all imaging reports at University of California San Francisco (UCSF) for the term “emphysematous pyelonephritis” was undertaken from 2003–2014. Patients were included if there was clinical evidence of infection, no recent urologic instrumentation, and computerized tomography (CT) demonstrating gas in the renal parenchyma or collecting system. Clinical and laboratory variables were obtained from medical records.ResultsA total of 14 cases were identified. The majority of patients (57%) had gas confined to the collecting system. Three patients (21%) had gas in the renal parenchyma and 3 patients (21%) had gas extending into perirenal tissues. A total of 8 patients (57%) had concomitant urolithiasis. Seven patients (50%) were managed with antibiotic therapy alone while 6 patients (43%) required percutaneous drainage. No patients required immediate nephrectomy. There were no deaths. Patients with urolithiasis had less severe emphysematous pyelonephritis than patients without urolithiasis (P<0.05).ConclusionsThe majority of patients in this study had gas contained within the collecting system and were treated successfully with antibiotics alone. Percutaneous drainage was successfully utilized in patients with more advanced disease. No patients required emergent nephrectomy. Emphysematous pyelonephritis in patients with urolithiasis was less severe than in patients without urolithiasis.

      Related collections

      Most cited references 15

      • Record: found
      • Abstract: found
      • Article: not found

      Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis.

      Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and its surrounding areas. The radiological classification and adequate therapeutic regimen are controversial and the prognostic factors and pathogenesis remain uncertain. To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management (ie, antibiotic treatment alone, percutaneous catheter drainage combined with antibiotic treatment, or nephrectomy) and outcome among the various radiological classes of EPN; and to clarify the gas-forming mechanism and pathogenesis of EPN by gas analysis and pathological findings. Forty-eight EPN cases from our institution were enrolled between August 1,1989, and November 30, 1997. According to the radiological findings on computed tomographic scan, they were classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN. The clinical manifestations, management, and outcome were compared. The gas contents of specimens from 6 patients were analyzed. The pathological findings from 8 patients who received nephrectomy were reviewed. The statistical methods consisted of the Fisher exact test (2 tailed) for categorical variables and Wilcoxon rank sum test for continuous variables to test the predictors of poor prognosis. Forty-six patients (96%) had diabetes mellitus, and 10 (22%) of the 46 also had urinary tract obstruction in the corresponding renoureteral unit. The other 2 nondiabetic patients (4%) had severe hydronephrosis. Twenty-one (72%) of the 29 patients with diabetes mellitus also had a glycosylated hemoglobin A(1c) level higher than 0.08. Escherichia coli (69%) and Klebsiella pneumoniae (29%) were the most common pathogens. The mortality rate in patients who received antibiotic treatment alone was 40% (2 of 5 patients). The success rate of management by percutaneous catheter drainage (PCD) combined with antibiotic treatment was 66% (27 of 41 patients). In classes 1 and 2 EPN, all the patients who were treated using a PCD or ureteral catheter combined with antibiotic treatment survived. In extensive EPN (classes 3 and 4), 17 (85%) of the 20 patients with fewer than 2 risk factors (ie, thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment; and the patients with 2 or more risk factors had a significantly higher failure rate than those with no or only 1 risk factors (92% vs 15%, P<.001). Eight of the 14 patients who had an unsuccessful treatment using a PCD underwent subsequent nephrectomy, 7 of whom survived. Only 2 patients were managed by direct nephrectomy and survived. The overall success rate of nephrectomy was 90% (9 of 10 patients). The total mortality was 18.8% (9 of 48 patients). Five of the 6 gas samples contained hydrogen (average, 12.8%), and all had carbon dioxide (average, 14.4%). The pathological findings from 8 of 10 who underwent nephrectomy revealed poor perfusion in most cases (ie, infarction, 5 patients; vascular thrombosis, 3 patients; and arteriosclerosis and/or glomerulosclerosis, 4 patients). Acute renal infection with E coli or K pneumoniae in patients with diabetes mellitus and/or urinary tract obstruction is the cornerstone for the development of EPN. Mixed acid fermentation of glucose by Enterobacteriaceae is the major pathway of gas formation. For localized EPN (classes 1 and 2), PCD combined with antibiotic treatment can provide a good outcome. (ABSTRACT TRUNCATED)
        Bookmark
        • Record: found
        • Abstract: found
        • Article: not found

        National trends in use of computed tomography in the emergency department.

        The role of computed tomography (CT) in acute illnesses has increased substantially in recent years; however, little is known about how CT use in the emergency department (ED) has changed over time. A retrospective study was performed with the 1996 to 2007 National Hospital Ambulatory Medical Care Survey, a large nationwide survey of ED services. We assessed changes during this period in CT use during an ED visit, CT use for specific ED presenting complaints, and disposition after CT use. Main outcomes were presented as adjusted risk ratios (RRs). Data from 368,680 patient visits during the 12-year period yielded results for an estimated 1.29 billion weighted ED encounters, among which an estimated 97.1 million (7.5%) patients received at least one CT. Overall, CT use during ED visits increased 330%, from 3.2% of encounters (95% confidence interval [CI] 2.9% to 3.6%) in 1996 to 13.9% (95% CI 12.8% to 14.9%) in 2007. Among the 20 most common complaints presenting to the ED, there was universal increase in CT use. Rates of growth were highest for abdominal pain (adjusted RR comparing 2007 to 1996=9.97; 95% CI 7.47 to 12.02), flank pain (adjusted RR 9.24; 95% CI 6.22 to 11.51), chest pain (adjusted RR 5.54; 95% CI 3.75 to 7.53), and shortness of breath (adjusted RR 5.28; 95% CI 2.76 to 8.34). In multivariable modeling, the likelihood of admission or transfer after a CT scan decreased over the years but has leveled off more recently (adjusted RR comparing admission or transfer after CT in 2007 to 1996=0.42; 95% CI 0.32 to 0.55). CT use in the ED has increased significantly in recent years across a broad range of presenting complaints. The increase has been associated with a decline in admissions or transfers after CT use, although this effect has stabilized more recently. Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
          Bookmark
          • Record: found
          • Abstract: found
          • Article: not found

          Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review.

          There is no current consensus on what constitutes the ideal management of emphysematous pyelonephritis. We review the current management strategies including the role of nephron preserving percutaneous drainage in the treatment of emphysematous pyelonephritis. We searched MEDLINE, PubMed, EMBASE, CINAHL and the Cochrane Library from 1966 to 2006. Abstracts were reviewed including all types of studies from prospective randomized controlled studies to small retrospective series. All relevant English language articles reporting on at least 5 patients were reviewed. Ten retrospective studies on 210 patients with emphysematous pyelonephritis met the inclusion criteria. There were 167 females and 43 males with a mean age of 57 years (range 24 to 83). Of the patients 96% had diabetes mellitus and 29% had urinary tract obstruction. The diagnostic accuracy of computerized tomography was 100%. Escherichia coli and Klebsiella were the most common causative agents. The mortality from medical management alone was 50%, medical management combined with emergency nephrectomy was 25% and medical management combined with percutaneous drainage was 13.5%. Mortality was significantly less in patients undergoing percutaneous drainage compared to other treatments (Pearson chi-square p <0.001). Of the patients who underwent medical treatment with percutaneous drainage a small number (15) underwent elective nephrectomy and mortality was 6.6% (1 of 15). Percutaneous drainage should be part of the initial management strategy for emphysematous pyelonephritis. This strategy is associated with a lower mortality than medical management or emergency nephrectomy. Delayed elective nephrectomy may be required in some patients.
            Bookmark

            Author and article information

            Affiliations
            [1 ]Department of Urology, University of California San Francisco, San Francisco, California, USA;
            [2 ]Department of Urology, SUNY Downstate Medical Center, Brooklyn, New York, USA;
            [3 ]Department of Urology, Cleveland Clinic, Cleveland, Ohio, USA;
            [4 ]Department of Radiology, University of California San Francisco, San Francisco, California, USA
            Author notes

            Contributions: (I) Conception and design: All authors; (II) Administrative support: None; (III) Provision of study materials or patients: All authors; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: TH Sanford; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

            Correspondence to: Thomas H. Sanford. UCSF Medical Center, 400 Parnassus Avenue, Suite A-610, San Francisco, CA 94143-0330, USA. Email: thomas.sanford@ 123456nih.gov .
            Journal
            Transl Androl Urol
            Transl Androl Urol
            TAU
            Translational Andrology and Urology
            AME Publishing Company
            2223-4691
            October 2016
            October 2016
            : 5
            : 5
            : 774-779
            5071188
            tau-05-05-774
            10.21037/tau.2016.07.02
            2016 Translational Andrology and Urology. All rights reserved.
            Categories
            Original Article

            Comments

            Comment on this article