Predictive factors for mortality and need for nephrectomy in patients with emphysematous pyelonephritis

Abstract

Study Type – Therapy (case series) Level of Evidence 4OBJECTIVETo analyse the factors predicting the mortality and need for nephrectomy in patients with emphysematous pyelonephritis (EPN).PATIENTS AND METHODSClinical features, laboratory variables, imaging studies, management strategy and the final outcomes were analysed in 39 consecutive patients with EPN. The mean (sd) age was 57 (7.2) years and the male to female ratio was 2:11. The baseline risk factors (clinical, laboratory and radiological) were compared among three groups; group 1, survived with renal salvage (26); group 2, survived after nephrectomy (eight); and group 3, died (five).RESULTSThe overall survival rate was 87% (34/39) and the kidney was salvaged in 67% (26) patients at a median follow‐up of 18 months. Altered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation were significantly associated with mortality rate. There was no significant difference in final outcome based on radiological classification. Extensive renal parenchymal destruction of >50% (based on computed tomography) significantly predicted the need for nephrectomy (P < 0.001) and death (P = 0.02). Early (<1 week) nephrectomy resulted in a higher mortality rate (three of seven patients) than initial conservative management. There were no deaths in selected patients who received antibiotics alone or had delayed nephrectomy (four patients each). Of 24 patients who had minimally invasive treatment alone, two (8%) died. Minimally invasive treatment resulted in high renal salvage (22/24, 92%).CONCLUSIONAltered mental status, thrombocytopenia, renal failure and severe hyponatremia at presentation are associated with higher mortality rates, whereas extensive renal parenchymal destruction is associated with a need for nephrectomy. Early nephrectomy is associated with higher mortality rates than is initial conservative management.

194 Kidney preservation protocol for management of emphysematous pyelonephritis: Treatment modalities and follow-up

“…Diabetes mellitus was the most frequently reported predisposing factor for developing EPN, as it constituted 80-100% of patients [5,14,15]. Of the present patients, 77% were diabetic, and the second predisposing factor was urolithiasis; the same was reported by Kapoor et al [12].…”

“…Factors associated with increased mortality rate were conservative treatment alone, bilateral EPN, type I EPN according to the classification of Wan et al, and thrombocytopenia. More recently, Kapoor et al [12] reported a mortality rate of 13% of 39 patients with EPN. They concluded that altered mental status, thrombocytopenia, renal failure and severe hyponatraemia at presenta- tion were significantly associated with death.…”

“…Risk factors for nephrectomy were studied by Kapoor et al [12] in a retrospective study of 39 patients. They found that extensive renal parenchymal destruction of >50% (based on CT) significantly predicted the need for nephrectomy (P < 0.001).…”

Emphysematous pyelonephritis: Changing trend of clinical spectrum, pathogenesis, management and outcome

“…Risk and benefit assessment should be done for life-saving emergency nephrectomy. [25] In our study 12 patients (16%) were managed by antibiotics only. DJ stenting was done in 18 patients (24%) among them 10 patients required pigtail catheter insertion.…”

Emphysematous pyelonephritis: Our experience in managing these cases

“…Thrombocytopenia, altered mental status, hyponatremia, severe proteinuria, severe hypoalbuminemia, and acute renal failure at EPN presentation have been associated with a poor outcome. [15][16][17] In a meta-analysis, systolic blood pressure less than 90 mmHg, serum creatinine levels greater than 2.5 mg/dL, and impairment of consciousness were also associated with increased mortality. 18 In parallel with these findings, all of our class 1 and 2 patients could be treated with medical therapy and/or drainage; our class 3a patients 20 Similarly, Flores and colleagues 21 had successfully treated acute bilateral EPN using only medical therapy.…”