Is conservative management Is conservative management effective in Emphysematous effective in Emphysematous

Pyelonephritis?Pyelonephritis?

Vijay Anand, Vineet, Sridharan, Venkat Ramanan, Vijay Anand, Vineet, Sridharan, Venkat Ramanan, Sunil Shroff, M.G.Rajamanickam.Sunil Shroff, M.G.Rajamanickam.

Department of Urology & Renal transplantation,Department of Urology & Renal transplantation,

SRMC & RI.SRMC & RI.

Emphysematous pyelonephritisEmphysematous pyelonephritis

Acute necrotizing parenchymal and Acute necrotizing parenchymal and perirenal infection caused by gas perirenal infection caused by gas forming organisms.forming organisms.

High morbidity & poor prognosis.High morbidity & poor prognosis. Rate of Nephrectomy: 21-29% Rate of Nephrectomy: 21-29% Mortality rate: 60-75%Mortality rate: 60-75%

AIMAIM

To analyze the efficacy of To analyze the efficacy of conservative management in EPN.conservative management in EPN.

Methods Methods Retrospective studyRetrospective study

Inclusion criteria: All patients of EPN managed in Inclusion criteria: All patients of EPN managed in our centre in the last three years.our centre in the last three years.

Diagnosis of EPN: Based on clinical and Diagnosis of EPN: Based on clinical and radiological findingsradiological findings

The risk factors and classification done based on The risk factors and classification done based on study by Wan et al study by Wan et al **

Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ; Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ; Radiology 1996; 198: 433-438Radiology 1996; 198: 433-438

Classification according to Classification according to extent of involvementextent of involvement

Class I : Renal pelvisClass I : Renal pelvis Class II : Renal parenchymaClass II : Renal parenchyma Class III Class III

A : Perinephric tissueA : Perinephric tissueB : Beyond Gerota’s fascia. B : Beyond Gerota’s fascia.

Class IV : Bilateral involvement Class IV : Bilateral involvement EPN in solitary kidney EPN in solitary kidney

Radiological ClassificationRadiological Classification

Type IType I – Parenchymal destruction, absence of – Parenchymal destruction, absence of fluid collections and presence of mottled gas fluid collections and presence of mottled gas (Dry type) – Mortality : 69%(Dry type) – Mortality : 69%

Type IIType II – Renal or perirenal collections with – Renal or perirenal collections with bubbly or loculated gas or gas in collecting bubbly or loculated gas or gas in collecting system. (Wet type) Mortality : 18%system. (Wet type) Mortality : 18%

Wan et al 1996, Best et al 1999Wan et al 1996, Best et al 1999

Risk factorsRisk factors

ThrombocytopeniaThrombocytopenia Acute renal insufficiencyAcute renal insufficiency Low S. AlbuminLow S. Albumin Altered mental statusAltered mental status Shock on presentationShock on presentation

AUA, 2005AUA, 2005

More than 2 risk factors – Poorer prognosisMore than 2 risk factors – Poorer prognosis

Conservative Management in EPNConservative Management in EPN

AntibioticsAntibiotics Supportive measuresSupportive measures Stenting / Per-cutaneous drainage Stenting / Per-cutaneous drainage

Indications Indications Rising S.Creatinine Rising S.Creatinine HydroureteronephrosisHydroureteronephrosis SepsisSepsis Significant renal or peri-renal Significant renal or peri-renal

collection (Percutaneous drainage)collection (Percutaneous drainage)

Results Results

Total # of patients : 18 Total # of patients : 18

Male : Female : 1: 2 (6 M, 12 F)Male : Female : 1: 2 (6 M, 12 F)

Age Age : 34-67yrs (mean 51). : 34-67yrs (mean 51).

Patient categorizationPatient categorization

Class 1 Class 1 - 5 patients - 5 patients

Class 2 Class 2 - 4 patients- 4 patients

Class 3A Class 3A - 6 patients- 6 patients

Class 3B Class 3B - 1 patients- 1 patients

Class 4 Class 4 - 2 patients- 2 patients

Class 1

Class 2

Class 3A

Class 3B

Class 3B

Class IV

Class IV

Radiological typesRadiological types

Dry Type : 4 Dry Type : 4

Wet Type : 14Wet Type : 14

Type I - gas radiates diffusely No associated fluid collections are seen

Type II - several small foci of gasAssociated regions of fluid attenuation.

Risk FactorsRisk Factors

Low S. Albumin – 18Low S. Albumin – 18

Acute renal insufficiency : 16 Acute renal insufficiency : 16

Thrombocytopenia: 11Thrombocytopenia: 11

Altered mental status - 3Altered mental status - 3

Shock on presentation - 2Shock on presentation - 2

Co-existing Diabetes Mellitus Co-existing Diabetes Mellitus

No. of pts with DM: No. of pts with DM: 18 18

Established DM Established DM 16 16

Incidentally diagnosed 2Incidentally diagnosed 2

Hb A1c raised ( mean – 12.2)Hb A1c raised ( mean – 12.2)

Causative organismsCausative organisms

Esch. coli : 12Esch. coli : 12

Klebsiella : 2Klebsiella : 2

Citrobacter : 1Citrobacter : 1

No growth : 3No growth : 3

ManagementManagement

DJ Stenting – 11DJ Stenting – 11

DJ Stent+Percutaneous drainage – 3 DJ Stent+Percutaneous drainage – 3

Percutaneous drainage – 2Percutaneous drainage – 2

Nephrectomy - 1Nephrectomy - 1

Pre and Post StentingPre and Post Stenting

Pre & post per cutaneous drainagePre & post per cutaneous drainage

Management vs Class of EPNManagement vs Class of EPN

EPNEPN

classclass

MANAGEMENTMANAGEMENT

11

2 2

3A3A 3B3B 44

DJ DJ STENTSTENT 5 5

44 11 11

DJ STENT + DJ STENT + PCDPCD

22 11

PCD onlyPCD only 22

NEPHRECTOMYNEPHRECTOMY 11

Management & Class of EPNManagement & Class of EPN

5

00

4

001

22

0 001 1

00123456789

10

Class I Class 2 Class3A

Class3B

Class 4

DJS

DJS+PCD

PCD

Management vs Number of Risk Management vs Number of Risk factorsfactors

RISK RISK

FACTORSFACTORS

MANAGEMENTMANAGEMENT

11

2 2

33 44 55

DJ DJ STENTSTENT 22 77 22

DJ STENT + DJ STENT + PCDPCD

22 11

PCDPCD 1 1 11

NEPHRECTOMYNEPHRECTOMY 11

Mortality - 1Mortality - 1

Class 3BClass 3B

Radiological type – IRadiological type – I

Number of risk factors – 5Number of risk factors – 5

Outcome – expired within few hoursOutcome – expired within few hours

Effectiveness of Conservative Effectiveness of Conservative managementmanagement

Risk factor > 2 - 9/16 patientsRisk factor > 2 - 9/16 patients

Patients with class 3A, 3B, 4 Patients with class 3A, 3B, 4

– – 7/16 patients 7/16 patients

Follow up Follow up

Follow up – 3 months to 24 monthsFollow up – 3 months to 24 months

Mean – 6 monthsMean – 6 months

Recurrent EPN @ 3months - 1Recurrent EPN @ 3months - 1 Pyelonephritis (Non emphysematous) - 1Pyelonephritis (Non emphysematous) - 1

ConclusionConclusion

Conservative management is a safe, Conservative management is a safe, effective and feasible treatment effective and feasible treatment option in patients with option in patients with Emphysematous pyelonephritis.Emphysematous pyelonephritis.

Thank youThank you