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


OBJECTIVE
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.


METHODS
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.


RESULTS
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).


CONCLUSIONS
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)
Huang
J J
JJ
Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, Republic of China. jjhuang@mail.ncku.edu.tw
Tseng
C C
CC
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000892:Anti-Infective Agents, Urinary / Q000627:therapeutic use; D003663:Decision Trees; D003937:Diagnosis, Differential; D004322:Drainage; D004646:Emphysema / Q000382:microbiology* / Q000401:mortality / Q000503:physiopathology; D004926:Escherichia coli / Q000302:isolation & purification; D004927:Escherichia coli Infections / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D005260:Female; D006801:Humans; D007710:Klebsiella Infections / Q000150:complications / Q000175:diagnosis / Q000628:therapy; D007711:Klebsiella pneumoniae / Q000302:isolation & purification; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D011379:Prognosis; D011704:Pyelonephritis / Q000150:complications* / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000382:microbiology / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011859:Radiography; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome
D000892:Anti-Infective Agents, Urinary