1. Is conservative management effective in Emphysematous Pyelonephritis?
Vijay Anand, Vineet, Sridharan, Venkat Ramanan,
Sunil Shroff, M.G.Rajamanickam.
Department of Urology & Renal transplantation,
SRMC & RI.

2. Emphysematous pyelonephritis
Acute necrotizing parenchymal and perirenal infection caused by gas forming organisms.
High morbidity & poor prognosis.
Rate of Nephrectomy: 21-29%
Mortality rate: 60-75%

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

4. Methods Retrospective study
Inclusion criteria: All patients of EPN managed in our centre in the last three years.
Diagnosis of EPN: Based on clinical and radiological findings
The risk factors and classification done based on study by Wan et al *
Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ;
Radiology 1996; 198:

5. Classification according to extent of involvement
Class I : Renal pelvis
Class II : Renal parenchyma
Class III
A : Perinephric tissue
B : Beyond Gerota’s fascia.
Class IV : Bilateral involvement EPN in solitary kidney

6. Radiological Classification
Type I – Parenchymal destruction, absence of fluid collections and presence of mottled gas (Dry type) – Mortality : 69%
Type II – Renal or perirenal collections with bubbly or loculated gas or gas in collecting system. (Wet type) Mortality : 18%
Wan et al 1996, Best et al 1999

7. Risk factors Thrombocytopenia Acute renal insufficiency Low S. Albumin
Altered mental status
Shock on presentation
AUA, 2005
More than 2 risk factors – Poorer prognosis

8. Conservative Management in EPN
Antibiotics
Supportive measures
Stenting / Per-cutaneous drainage
Indications
Rising S.Creatinine
Hydroureteronephrosis
Sepsis
Significant renal or peri-renal collection (Percutaneous drainage)

9. Results Total # of patients : 18 Male : Female : 1: 2 (6 M, 12 F)
Age : yrs (mean 51).

10. Patient categorization
Class patients
Class patients
Class 3A - 6 patients
Class 3B - 1 patients
Class patients

11. Class 1

12. Class 2

13. Class 3A

14. Class 3B

15. Class 3B

16. Class IV

17. Class IV

18. Radiological types
Dry Type : 4
Wet Type : 14

19. Type I - gas radiates diffusely
No associated fluid collections are seen
Type II - several small foci of gas
Associated regions of fluid attenuation.

20. Risk Factors Low S. Albumin – 18 Acute renal insufficiency : 16
Thrombocytopenia: 11
Altered mental status - 3
Shock on presentation - 2

21. Co-existing Diabetes Mellitus
No. of pts with DM:
Established DM
Incidentally diagnosed 2
Hb A1c raised ( mean – 12.2)

22. Causative organisms Klebsiella : 2 Citrobacter : 1 No growth : 3
Esch. coli : 12
Klebsiella : 2
Citrobacter : 1
No growth : 3

23. Management DJ Stenting – 11 DJ Stent+Percutaneous drainage – 3
Nephrectomy - 1

24. Pre and Post Stenting

25. Pre & post per cutaneous drainage

26. Management vs Class of EPN1 2 3A 3B 4
DJ STENT 5
DJ STENT + PCD
PCD only
NEPHRECTOMY

27. Management & Class of EPN

28. Management vs Number of Risk factors1 2 3 4 5
DJ STENT 7
DJ STENT + PCD
PCD
NEPHRECTOMY

29. Mortality - 1 Class 3B Radiological type – I
Number of risk factors – 5
Outcome – expired within few hours

30. Effectiveness of Conservative management
Risk factor > /16 patients
Patients with class 3A, 3B, 4
– 7/16 patients

31. Follow up Follow up – 3 months to 24 months Mean – 6 months
Recurrent 3months - 1
Pyelonephritis (Non emphysematous) - 1

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

33. Thank you