Emphysematous Pyelonephritis Treatment & Management
- Author: Sugandh Shetty, MD, FRCS; Chief Editor: Edward David Kim, MD, FACS more...
Prompt hydration, fluid resuscitation, and treatment with systemic antibiotics are the mainstays of management. A monitored-care facility may be needed for patients in shock. Control of diabetes and maintenance of adequate fluid balance should be achieved quickly. Initial antibiotic therapy consists of intravenous ampicillin, gentamicin, and metronidazole and is administered until the culture sensitivities are available. In patients with penicillin allergies, vancomycin is used in place of ampicillin. In patients with renal compromise, doses must be adjusted according to creatinine clearance.
Start imaging studies immediately. Any obstruction found should be relieved with either percutaneous drainage or stent placement. The decision regarding the percutaneous drainage versus a double-J stent probably depends on the patient's condition (see Surgical Therapy). Placement of a stent requires mild sedation or general anesthesia, whereas a percutaneous procedure can be performed with only a local anesthetic. In cases of bilateral emphysematous pyelonephritis (EPN) or in cases of EPN in a solitary kidney, percutaneous drainage has been useful. EPN with gas in the collecting system alone or gas and fluid in the perinephric space may respond well to percutaneous drainage.
Patients with EPN are extremely ill and need resuscitative measures in the intensive care unit. Surgical intervention should be performed only after stabilization of the cardiorespiratory status.
Patients with stones and EPN deserve special mention. The presence of a stone often leads to obstruction, which must be urgently relieved with percutaneous drainage or stenting. Definitive treatment for stones should be deferred until later.
Huang et al reported an overall EPN mortality rate of 19%. They reported significant success with percutaneous drainage and antibiotics (66%).
Wan et al reported a mortality rate of 40%. Furthermore, Wan et al reported a high risk of death in patients with serum creatinine levels greater than 1.4 mg/dL and platelet count of less than 60,000/μL. Huang et al analyzed 46 cases and concluded that class 1 and class 2 EPN could be managed with percutaneous drainage and antibiotics. In class 3 and class 4 EPN, the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock) indicated that percutaneous drainage and antibiotics could also be used. However, in the presence of more than 2 risk factors, nephrectomy yielded better results.
Nephrectomy is the treatment of choice in most patients with EPN.
A retroperitoneal flank incision is the preferred approach to avoid peritoneal contamination. Nephrectomy may be associated with significant bleeding and injury to surrounding structures. The initial procedure should often be conservative with care to drain the abscess. Patients may require intensive-care management. In a series in which nephrectomy was the exclusive treatment after stabilization, the mortality rate was low, suggesting that an aggressive surgical option should be chosen. However, less-invasive options, such as percutaneous drainage, have also been used with success.
Surgical intervention should be performed only after stabilization of the cardiorespiratory status.
Gas in the renal parenchyma or dry-type EPN should be treated immediately with nephrectomy. Bilateral nephrectomy may be necessary in patients with bilateral EPN. Mortality rates were 15-20% in 2 series in which nephrectomy was the treatment of choice.[6, 5]
Huang et al analyzed 46 cases and concluded that class 1 and class 2 EPN could be managed with percutaneous drainage and antibiotics. In class 3 and class 4 EPN, the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock) indicated that percutaneous drainage and antibiotics could also be used. However, in the presence of more than 2 risk factors, nephrectomy yielded better results.
In a recent review, Aswathaman et al (2008) reported on 41 patients with EPN; 80% of those patients were successfully treated with antibiotics and percutaneous drainage without requiring nephrectomy.
For patient education resources, see the patient education article Urinary Tract Infections.
Untreated cases of emphysematous pyelonephritis (EPN) result in death. Medical treatment of EPN may lead to uncontrollable sepsis that requires surgical intervention. Perinephric abscess and renal failure are other complications. Nephrectomy complications include injury to the colon, duodenum, and great vessels. Postoperative wound infection is common because wound healing in these patients is compromised.
Outcome and Prognosis
Patients with emphysematous pyelonephritis (EPN) should be treated with aggressive medical management and prompt surgical intervention. Conservative treatment, such as percutaneous drainage with antibiotics, should be reserved only for patients with unilateral EPN or bilateral EPN or those with compromised renal function. Early cases of patients with EPN who have gas in the collecting system alone and who are otherwise in stable condition may be treated with antibiotics and drainage. Although nephrectomy offers the best outcome, a trial of conservative treatment with drainage should be offered. However, if access to percutaneous drainage or internal stenting is not available, nephrectomy should be considered after stabilization is achieved.
Management is based on the clinical and laboratory findings. If the patient is stable, conservative treatment with antibiotics and drainage should be tried. If the patient has gas in the renal parenchyma and perinephric tissues along with significant exudate, initial percutaneous drainage should be given a chance. Saving nephrons and the patient's life should be weighed based on the clinical situation, response to treatment, and available facilities.
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