Review of Emphysematous pyelonephritis Department of Endocrinology and Metabolism R4 권미광

Case 1 56세 여자, 제2형 당뇨병 환자 5일전부터 발생한 fever, malaise, nausea, vomiting으로 내원,평소 당뇨병에 대해 조절 받지않음. Alcoholic, 30 pack/year smoker Ill-appearing, distressed and obese woman, Kussumaul breathing with ketone odor 110/70 mmHg- 130/min- 30/min-39°C-SaO2 96%(FiO2 0.28) P/E : bilateral expiratory wheezing, CVA tenderness(+/+) 11800/mm3-11.7 g/dL- 60000/mm3 ABGA Ph 7.36 HCO3 14 mmol/L Pco2 25 mmHg AG 20 Serum creatinine 2.0 mg/dL serum glucose 463 mg/dL UA) WBC : many RBC : many, UC) E. Coli Ampicillin + gentamicin  ceftriaxone + genatmicin

12hrs after admission  Clinical improvement with decreased in respiratory and heart rate, adequate urine output, nl. Acidemia and AG, decreased Cr and glucose 36hrs after admission  Deteriorated condition Abdominal discomfort, diarrhea, Rt. flank pain Leukocytosis 23800/mm3 s-glucose 392 mg/dL, AG 19, S-Cr 2.1 mg/dL, LDH 3428 U/L

Diabetes Research and Clinical Practice 44 (1999) 71–75 Radial nephrectomy gas in the kidney and retroperitoneal tissues, necrotic right adrenal gland Affected kidney diffusely congested and necrotic, friable and irregular non-viable parenchyma, infarcted, thrombosis of the renal artery and segmental vessels inflammatory infiltrate of mainly neutrophils in the superficial renal cortex and surrounded perinephric fat Post-op ventilator support, transfusion, inotropic agents  expired Diabetes Research and Clinical Practice 44 (1999) 71–75

Emphysematous Pyelonephritis Definition Necrotizing infection of the renal parenchyma and its surrounding areas Gas in the renal parenchyma, collecting system, or perinephric tissue Generally regarded as rare renal infection Reported in urology and radiology, rarely in IM or nephrology US or CT  more recognized recently Diabetic patients or urinary tract obstruction without DM

Radiological classification Adequate therapeutic regimen Prognostic factors Pathogenesis Unclear Controversial

Arch Intern Med. 2000;160:797-805

PATIENTS National Cheng Kung University Hospital, Taiwan, Republic of China, August 1, 1989, and November 30, 1997, 48 consecutive cases, EPN (1) symptoms and signs of upper UTI, or fever with a positive urine culture or pyuria without other identified infectious foci (2) radiological evidence by CT scan of gas accumulation in the collecting system, renal parenchyma, or perinephric or pararenal space (3) no fistula between the urinary tract and bowel (4) no recent history of trauma, urinary catheter insertion, or drainage

METHODS Class 1: gas in the collecting system only Class 2: gas in the renal parenchyma without extension to the extrarenal space Class 3 Class 3A: extension of gas or abscess to the perinephric space Class 3B: extension of gas or abscess to the pararenal space Class 4: bilateral EPN or solitary kidney with EPN

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BASELINE CHARACTERISTICS AND CLINICAL PRESENTATIONS Mean age : 60 years Female:male=41:7 DM : 96% Urinary tract obstruction : 22% Initial HbA1c > 8 g/dL : 72% Left (67%) > Right E. coli (69%), K. pneumoniae (29%), E. coli Mixed with GBS or Proteus mirabilis Bacteremia (54%) 13

PROGNOSTIC FACTORS OF MORTALITY AND POOR OUTCOME   

MANAGEMENT, RADIOLOGICAL CLASSIFICATION, AND OUTCOME Successful rate of nephrectomy : 90% Total mortality : 18.8%

MANAGEMENT, RADIOLOGICAL CLASSIFICATION, AND OUTCOME At the initial presentation Thrombocytopenia Acute renal function impairment Disturbance of consciousness Shock Predicting poor response to PCD combined with antibiotic treatment classes 3 and 4 EPN cases with ≥2 : higher failure rate of PCD (92% vs 15%, P<.001) 16

PATHOLOGICAL FINDINGS class 2 : acute inflammatory cell infiltration with focal necrosis and abscess formation class 3A : abscess formation, foci of microinfarction or large infarction, vascular thrombosis, arteriosclerosis, arterionephrosclerosis, interstitial hemorrhage, and chronic pyelonephritis, empty space class 3B : similar with class 3A EPN, more extensive inflammatory lesions to the perinephric and pararenal tissue class 4 : multiple wedge-shaped necrosis surrounded by acute and chronic inflammatory cells and vascular thrombosis, implying multiple septic infarction

Glucose 495 mg/dL, creatinine 1.9 mg/dL 90/60 mmHg-39.0 °C-110 beats/min Glucose 495 mg/dL, creatinine 1.9 mg/dL 17700/mm3-7.7 g/dL- 24 %-20000/mm3 18

PATHOGENESIS OF EPN 4 factors Gas-forming bacteria Most Enterobacteriaceae High blood glucose level High tissue glucose Impaired tissue perfusion Urinary tract obstruction Infarction or vascular thrombosis ↓ Leukocyte and antibiotics into lesions Defective immune response (such as DM)

DIAGNOSIS OF EPN Simple abdomen or KUB : 33% Abdomen US Difficult to detect because of bowel gas Urinary tract obstruction Abdomen CT Confirm of diagnosis Extent of disease Follow up

RADIOLOGICAL CLASSIFICATION Langston and Pfister Am J Roentgenol 1970;110:778 3 main radiographic patterns  correlated with the stage of disease Diffuse mottling of the renal parenchyma Bubbly renal parenchyma surrounded by a crescent of gas (perinephric space) Extension through Gerota's fascia (ie, pararenal space) Michaeli et al J Urol 1984;131:203-208 Simpler descriptive classification Stage I, gas within the renal parenchyma or the perinephric tissues Stage II, the presence of gas in the kidney and its surroundings Stage III, extension of gas through Gerota's fascia or presence of bilateral EPN Did not demonstrate a significant prognostic implication in this staging system

RADIOLOGICAL CLASSIFICATION Class 1: gas in the collecting system only Class 2: gas in the renal parenchyma without extension to the extrarenal space Class 3 Class 3A: extension of gas or abscess to the perinephric space Class 3B: extension of gas or abscess to the pararenal space Class 4: bilateral EPN or solitary kidney with EPN

RADIOLOGICAL CLASSIFICATION, MANAGEMENT, AND OUTCOME Class 1 and 2 EPN Antibiotic treatment combined with PCD Class 3 or 4 with benign manifestation (<2 risk factors) PCD combined with antibiotic treatment High success rate and so preserve their kidney Class 3 or 4 with fulminant course (≥2 risk factors) Nephrectomy Class 4 EPN High risk of emergency nephrectomy in these unstable patients Tried first bilateral PCD Nephrectomy should be done if PCD fails

Flowchart for management of EPN

ANTIBIOTICS Seriously ill patients with APN (Mandell 15th) Ceftazidime (3-6 g/day), cefepime (2-4 g/day), ticarcillin-clavulanate (18 g of ticarcillin/day), aztreonam (3-6 g/day), imipenem (2 g/day), meropenem (1.5 -3 g/day) often in combination with Aminoglycoside (GM 3-5 mg/kg/day) or iv fluoroguinolone Severe complicated UTI Imipenem (250-500 mg q 6-8hr), penicillin/cephalosporin + AG F/U urine culture Within 1-2 (2-4) weeks of completion of therapy Pregnant women, children, recurrent symptomatic pyelonephritis, complicated UTI

Simple abdomen or KUB for APN Abdomen US Non-contrast abdomen CT WE SHOULD PERFORM …. Simple abdomen or KUB for APN Abdomen US Non-contrast abdomen CT