Is conservative management
effective in Emphysematous
Pyelonephritis?
Vijay Anand, Vineet, Sridharan, Venkat Ramanan,
Sunil Shroff, M.G.Rajamanickam.
Department of Urology & Renal transplantation,
SRMC & RI.
Emphysematous pyelonephritis
 Acute
necrotizing parenchymal and
perirenal infection caused by gas
forming organisms.
 High


morbidity & poor prognosis.
Rate of Nephrectomy: 21-29%
Mortality rate: 60-75%
AIM

To analyze the efficacy of
conservative management in EPN.
Methods

Retrospective study

Inclusion criteria: All patients of EPN managed in
our centre in the last three years.

Diagnosis of EPN: Based on clinical and
radiological findings

The risk factors and classification done based on
study by Wan et al *
Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ;
Radiology 1996; 198: 433-438
Classification according to
extent of involvement
 Class
I
 Class II
 Class III
A
B
 Class
IV
: Renal pelvis
: Renal parenchyma
: Perinephric tissue
: Beyond Gerota’s fascia.
: Bilateral involvement
EPN in solitary kidney
Radiological Classification
 Type I – Parenchymal destruction, absence of
fluid collections and presence of mottled gas
(Dry type) – Mortality : 69%
 Type II – Renal or perirenal collections with
bubbly or loculated gas or gas in collecting
system. (Wet type) Mortality : 18%

Wan et al 1996, Best et al 1999
Risk factors





Thrombocytopenia
Acute renal insufficiency
Low S. Albumin
Altered mental status
Shock on presentation
AUA, 2005
More than 2 risk factors – Poorer prognosis
Conservative Management in EPN
 Antibiotics
 Supportive
measures
 Stenting / Per-cutaneous drainage
Indications
Rising S.Creatinine
 Hydroureteronephrosis
 Sepsis
 Significant renal or peri-renal
collection (Percutaneous drainage)

Results

Total # of patients : 18

Male : Female
: 1: 2 (6 M, 12 F)

Age
: 34-67yrs (mean 51).
Patient categorization
Class
1
- 5 patients
Class
2
- 4 patients
Class
3A
- 6 patients
Class
3B
- 1 patients
Class
4
- 2 patients
Class 1
Class 2
Class 3A
Class 3B
Class 3B
Class IV
Class IV
Radiological types

Dry Type : 4

Wet Type : 14
Type I - gas radiates diffusely
No associated fluid collections are seen
Type II - several small foci of gas
Associated regions of fluid attenuation.
Risk Factors
 Low S. Albumin – 18
 Acute renal insufficiency : 16
 Thrombocytopenia: 11
 Altered mental status - 3
 Shock on presentation - 2
Co-existing Diabetes Mellitus
 No.
of pts with DM:
Established DM
Incidentally diagnosed
 Hb
18
16
2
A1c raised ( mean – 12.2)
Causative organisms
Esch. coli
: 12
Klebsiella
: 2
Citrobacter
: 1
No growth
: 3
Management
 DJ
Stenting – 11
 DJ
Stent+Percutaneous drainage – 3
 Percutaneous
drainage – 2
 Nephrectomy
-1
Pre and Post Stenting
Pre & post per cutaneous drainage
Management vs Class of EPN
1
2
3A
5
4
1
1
DJ STENT +
PCD
2
1
PCD only
2
NEPHRECTOMY
1
EPN
class
3B
4
MANAGEMENT
DJ STENT
Management & Class of EPN
10
9
8
7
6
5
4
3
2
1
0
5
DJS
DJS+PCD
PCD
4
22
1
00
00
Class I Class 2 Class
3A
11
0 00
0
Class Class 4
3B
Management vs Number of Risk
factors
RISK
FACTORS
1
2
3
4
2
7
2
2
1
MANAGEMENT
DJ STENT
DJ STENT +
PCD
PCD
1
NEPHRECTOMY
1
1
5
Mortality - 1

Class 3B

Radiological type – I

Number of risk factors – 5

Outcome – expired within few hours
Effectiveness of Conservative
management
 Risk
factor > 2 - 9/16 patients
 Patients
with class 3A, 3B, 4
– 7/16 patients
Follow up

Follow up – 3 months to 24 months
Mean – 6 months
Recurrent EPN @ 3months - 1
 Pyelonephritis (Non emphysematous) - 1

Conclusion
Conservative management is a safe,
effective and feasible treatment
option in patients with
Emphysematous pyelonephritis.
Thank you