Emphysematous pyelonephritis-role of conservative management and drainage procedures-institutional experience

Introduction: Emphysematous pyelonephritis is a fulminant infection of the renal parenchyma by gas forming organisms that lead to collection of gas in the renal parenchyma and collecting system. Uncontrolled diabetic status, obstruction predispose for infection. Most common organism is E.coli. Failure to diagnose at an earlier stage can lead to mortality. Early diagnosis and efficient conservative management can reduce morbidity and mortality. Materials and methods: Retrospective analysis of cases admitted and managed as emphysematous pyelonephritis over a period of 2 years. Patients admitted with renal colic, features of sepsis and radiological evidence of gas in renal parenchyma or PCS were analyzed. Out of 135 cases admitted for urosepsis 15 cases had evidence of gas in PCS. All the cases were investigated with urinalysis, urine culture, blood biochemistry, plain x-ray, and CT scan. Treatment started with Cefperazone + sulbactum and supportive measures. If there is no response within 24 - 36 hours antimicrobial changed to meropenum. Operative management was reserved for patients who do not respond to conservative treatment. Results: Of the 15 cases 9 were male and 6 female in the age group 45 to 65 years. Left renal system involved in 7 cases, right in 7 cases and 1 case had gas in both kidneys. All the patients were diabetics with poor glycemic control. Presentation was fever, loin pain and azotemia. Urine culture showed E.coli in all the cases. As per CT based classification 5 cases (33.3%) were class 1, 2 cases (13.3%) were class 2, 7 cases (46.6%) were class 3 and 1 case (6.6%) was class 4. In our series mortality was 0% (no cases), 46.6% (7 cases) needed no surgical intervention, 20% (3 cases) underwent DJ stenting alone, 13.3% (2 cases) had DJ stenting with percutaneous drainage, 13.3% (2 cases) underwent partial nephrectomy and 6.6% (1 case) was managed with nephrectomy. Stent was removed after 4 weeks and PCD 8 to 10 days. Conclusion: EPN is a life threatening infection of the kidneys was treated by primary nephrectomy earlier. Availability of newer antimicrobials effective against most of the gas forming organisms and earlier diagnosis changed the scenario from radical to conservative management saving more renal units.