Emphysematous Pyelonephritis: Nephrectomy is not necessary, a narrative review
Abstract
Emphysematous pyelonephritis (EPN) is a severe, life-endangering, necrotising, gas-producing infection affecting the kidney and perinephric tissue. It is associated with renal loss, high morbidity, and mortality. Diabetes, obstructive uropathy, female gender and hypertension are the most common risk factors. Escherichia coli, Klebsiella pneumoniae and Proteus mirabilis are the most common pathogens causing Emphysematous pyelonephritis. EPN presents as a clinical triad of fever, flank pain, and nausea. Non-contrast CT scan is the mainstay of early diagnosis of EPN. It is diagnosed by demonstrating gas in renal parenchyma and perinephric tissue. Huang and Sang's classification is used for the classification and management of EPN. Treatment of EPN progressed from early nephrectomy to minimally invasive treatments including newer and advanced antibiotics and percutaneous drainage along with Percutaneous nephrostomy and DJ stenting. Early nephrectomy was the treatment of choice in the last century however newer studies suggest conservative treatment is associated with renal preservation, decreased morbidity and mortality. The initial use of broad-spectrum antibiotics such as Third-or fourth generation cephalosporins and carbapenems is recommended. Emergency drainage is indicated with a larger-sized pigtail catheter as pus is thick and frequent blockage of tubes is common. Nephrectomy should be done for those patients who fail to respond to conservative therapy i.e., antibiotics and percutaneous drainage. This review aims to provide comprehensive, evidence-based recommendations for the diagnosis and management of this life-threatening urological infection Emphysematous pyelonephritis.
Keywords: Emphysematous pyelonephritis, Diabetes, Antibiotics, Conservative, Percutaneous drainage, Nephrectomy
Keywords:
Emphysematous pyelonephritis, Diabetes, Antibiotics, Conservative, Percutaneous drainage, NephrectomyDOI
https://doi.org/10.22270/jddt.v14i9.6779References
Schultz EH, Klorfein EH. Emphysematous pyelonephritis J Urol. 1962; 87:762-766 https://doi.org/10.1016/S0022-5347(17)65043-2 PMid:13909504
Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinico radiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27. 160(6):797-805 https://doi.org/10.1001/archinte.160.6.797 PMid:10737279
Partin A. W. Dmochowski R. R. Kavoussi L. R. & Peters C. Campbell-Walsh-wein urology (Twelfth). Elsevier. 2021
Lu YC, Chiang BJ, Pong YH, Chen CH, Pu YS, Hsueh PR, et al. Emphysematous pyelonephritis: clinical characteristics and prognostic factors. Int J Urol. 2014 Mar. 21 (3):277-782 https://doi.org/10.1111/iju.12244 PMid:24033515
Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011 May. 107 (9):1474-8 https://doi.org/10.1111/j.1464-410X.2010.09660.x PMid:20840327
Pontin, A., Barnes, R. Current management of emphysematous pyelonephritis. Nat Rev Urol 2009;6:272-279 https://doi.org/10.1038/nrurol.2009.51 PMid:19424175
Huang JJ, Chen KW, Ruaan MK. Mixed acid fermentation of glucose as a mechanism of emphysematous urinary tract infection. J Urol. 1991 Jul. 146(1):148-151 https://doi.org/10.1016/S0022-5347(17)37736-4 PMid:2056576
Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol. 1990 May. 143(5):960-964 https://doi.org/10.1016/S0022-5347(17)40151-0 PMid:2184258
Wan YL, Lo SK, Bullard MJ, Chang PL, Lee TY. Predictors of outcome in emphysematous pyelonephritis. J Urol 1998; 159:369-373 https://doi.org/10.1016/S0022-5347(01)63919-3 PMid:9649241
Aswathaman K, Gopalakrishnan G, Gnanaraj L, Chacko NK, Kekre NS, Devasia A. Emphysematous pyelonephritis: Outcome of conservative management. Urology 2008; 71:1007-9 https://doi.org/10.1016/j.urology.2007.12.095 PMid:18372018
Lu YC, Hong JH, Chiang BJ, Pong YH, Hsueh PR, Huang CY, et al. Recommended Initial Antimicrobial Therapy for Emphysematous Pyelonephritis: 51 Cases and 14-Year-Experience of a Tertiary Referral Center. Medicine (Baltimore). 2016 May. 95 (21):e3573 https://doi.org/10.1097/MD.0000000000003573 PMid:27227920 PMCid:PMC4902344
Atirel A, Regmi SK, Singh P, Mert A, Konety BR, Kumar R. Urological infections in the developing world: An increasing problem in developed countries World J Urol. 2020;38:2681-2691 https://doi.org/10.1007/s00345-020-03120-3 PMid:32108257
Somani BK, Nabi G, Thorpe P, Hussey J, Cook J, N'Dow J, et al Is percutaneous drainage the new gold standard in the management of emphysematous pyelonephritis? Evidence from a systematic review J Urol. 2008; 179:1844-1849 https://doi.org/10.1016/j.juro.2008.01.019 PMid:18353396
Kapoor R, Muruganandham K, Gulia AK, Singla M, Agrawal S, Mandhani A, et al Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis BJU Int. 2010;105:986-9 https://doi.org/10.1111/j.1464-410X.2009.08930.x PMid:19930181
Olvera-Posada D, García-Mora A, Culebro-García C, Castillejos-Molina R, Sotomayor M, Feria-Bernal G, et al. [Prognostic factors in emphysematous pyelonephritis]. Actas Urol Esp. 2013 Apr. 37 (4):228-232 https://doi.org/10.1016/j.acuroe.2012.03.019
Koratala A, Malpartida FR, Zeng X. Emphysematous pyelonephritis. Clin Case Rep. 2018 Feb. 6 (2):439-441 https://doi.org/10.1002/ccr3.1364 PMid:29445494 PMCid:PMC5799643
Song Y, Shen X. Diabetic ketoacidosis complicated by emphysematous pyelonephritis: a case report and literature review. BMC Urol. 2020 Jan 29. 20(1):6 https://doi.org/10.1186/s12894-020-0575-0 PMid:31996190 PMCid:PMC6990560
Li S, Wang J, Hu J, He L, Wang C. Emphysematous pyelonephritis, and cystitis: A case report and literature review. J Int Med Res. 2018 Jul. 46 (7):2954-2960 https://doi.org/10.1177/0300060518770341 PMid:29916283 PMCid:PMC6124253
Wang YC, Wang JM, Chow YC, Chiu AW, Yang S. Pneumomediastinum and subcutaneous emphysema as the manifestation of emphysematous pyelonephritis. Int J Urol. 2004 Oct. 11(10):909-11 https://doi.org/10.1111/j.1442-2042.2004.00919.x PMid:15479300
Sharma PK, Sharma R, Vijay MK, Tiwari P, Goel A, Kundu AK. Emphysematous pyelonephritis: Our experience with conservative management in 14 cases. Urol Ann. 2013 Jul. 5(3):157-162 https://doi.org/10.4103/0974-7796.115734 PMid:24049377 PMCid:PMC3764895
Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology. 1997 Mar. 49(3):343-6 https://doi.org/10.1016/S0090-4295(96)00501-8 PMid:9123695
Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol. 1997 May. 157(5):1569-1573 https://doi.org/10.1016/S0022-5347(01)64797-9 PMid:9112478
Uruc F, Yuksel OH, Sahin A, Urkmez A, Yildirim C, Verit A. Emphysematous pyelonephritis: Our experience in managing these cases. Can Urol Assoc J. 2015 Jul-Aug. 9 (7-8): E480-3 https://doi.org/10.5489/cuaj.2828 PMid:26279720 PMCid:PMC4514496
Misgar RA, Mubarik I, Wani AI, Bashir MI, Ramzan M, Laway BA. Emphysematous pyelonephritis: A 10-year experience with 26 cases. Indian J Endocrinol Metab. 2016 Jul-Aug. 20 (4):475-480 https://doi.org/10.4103/2230-8210.183475 PMid:27366713 PMCid:PMC4911836
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