Is conservative management effective in Emphysematous Pyelonephritis?

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: 433-438

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 : 34-67yrs (mean 51).

10. Patient categorization • Class 1 - 5 patients • Class 2 - 4 patients • Class 3A - 6 patients • Class 3B - 1 patients • Class 4 - 2 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: 18 Established DM 16 Incidentally diagnosed 2 • Hb A1c raised ( mean – 12.2)

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

23. Management • DJ Stenting – 11 • DJ Stent+Percutaneous drainage – 3 • Percutaneous drainage – 2 • Nephrectomy - 1

24. Pre and Post Stenting

25. Pre & post per cutaneous drainage

26. Management vs Class of EPN

27. Management & Class of EPN

28. Management vs Number of Risk factors

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 > 2 - 9/16 patients • Patients with class 3A, 3B, 4 – 7/16 patients

31. Follow up • Follow up – 3 months to 24 months Mean – 6 months • Recurrent EPN @ 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