1. Review of Emphysematous pyelonephritis
Department of Endocrinology and Metabolism R4 권미광

2. 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/mm g/dL /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

3. 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 U/L

5. 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

6. 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

7. Radiological classification Adequate therapeutic regimen
Prognostic factors
Pathogenesis
Unclear
Controversial

8. Arch Intern Med. 2000;160:

9. 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

10. 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

11. 11

12. 12

13. 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

14. PROGNOSTIC FACTORS OF MORTALITY AND POOR OUTCOME  

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

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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:
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

22. 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

23. 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

24. Flowchart for management of EPN

25. 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 ( g/day)
often in combination with
Aminoglycoside (GM 3-5 mg/kg/day) or iv fluoroguinolone
Severe complicated UTI
Imipenem ( 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

26. 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