conservative management of emphysema to us pyelonephritis

8/6/2019 Conservative Management of Emphysema to Us Pyelonephritis

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Is conservative managementIs conservative managementeffective in Emphysematouseffective in Emphysematous

Pyelonephritis?Pyelonephritis?Vijay Anand, Vineet, Sridharan, Venkat Ramanan,Vijay Anand, Vineet, Sridharan, Venkat Ramanan,

Sunil Shroff, M.G.Rajamanickam.Sunil Shroff, M.G.Rajamanickam.

Department of Urology & Renal transplantation,Department of Urology & Renal transplantation,SRMC & RI.SRMC & RI.


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Emphysematous pyelonephritisEmphysematous pyelonephritis

AcuteAcute necrotizingnecrotizing parenchymalparenchymal andand

perirenalperirenal infectioninfection causedcaused byby gasgasformingforming organismsorganisms. .

High morbidity & poor prognosis.High morbidity & poor prognosis.Rate of Nephrectomy: 21Rate of Nephrectomy: 21- -29%29%Mortality rate: 60Mortality rate: 60- -75%75%


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AIMAIM

T o analyze the efficacy of T o analyze the efficacy of conservative management in EPN.conservative management in EPN.


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MethodsMethodsRetrospective studyRetrospective study

Inclusion criteria: All patients of EPN managed inInclusion criteria: All patients of EPN managed inour centre in the last three years.our centre in the last three years.

Diagnosis of EPN: Based on clinical andDiagnosis of EPN: Based on clinical andradiological findingsradiological findings

T he risk factors and classification done based onT he risk factors and classification done based onstudy by Wan et alstudy by Wan et al **

Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ;Correlation between imaging finding & clinical outcome ; Liang Wan, Tze u lee ;Radiology 1996; 198: 433Radiology 1996; 198: 433- -438438


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Cla ssific a tion a ccording toCla ssific a tion a ccording to

extent of involvementextent of invo

lvement

C lass I : Renal pelvisC lass I : Renal pelvisC

lass II : Renal parenchymaC

lass II : Renal parenchymaC lass IIIC lass IIIA : Perinephric tissueA : Perinephric tissueB : Beyond Gerotas fascia.B : Beyond Gerotas fascia.

C lass IV : Bilateral involvementC lass IV : Bilateral involvementEPN in solitary kidneyEPN in solitary kidney


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R a dio logic al Cla ssific a tionR a dio logic al Cla ssific a tion

Type IType I Parenchymal destruction, absence of Parenchymal destruction, absence of

fluid collections and presence of mottled gasfluid collections and presence of mottled gas(Dry type)(Dry type) Mortality : 69%Mortality : 69%

Type IIType II Renal or perirenal collections withRenal or perirenal collections withbubbly or loculated gas or gas in collectingbubbly or loculated gas or gas in collectingsystem. (Wet type) Mortality : 18%system. (Wet type) Mortality : 18%

Wan et al 1996, Best et al 1999Wan et al 1996, Best et al 1999


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R isk f a ctorsR isk f a ctors

T hrombocytopeniaT hrombocytopenia

Acute renal insufficiencyAcute renal insufficiencyLow S. AlbuminLow S. AlbuminAltered mental statusAltered mental statusShock on presentationShock on presentation

AUA, 2005AUA, 2005

More than 2 risk factorsMore than 2 risk factors Poorer prognosisPoorer prognosis


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C onserv a tive M a na gement in EPNC onserv a tive M a na gement in EPN

AntibioticsAntibioticsSupportive measuresSupportive measures

Stenting / PerStenting / Per- -cutaneous drainagecutaneous drainageIndicationsIndications

Rising S. C reatinineRising S. C reatinineHydroureteronephrosisHydroureteronephrosisSepsisSepsisSignificant renal or periSignificant renal or peri- -renalrenal

collection (Percutaneous drainage)collection (Percutaneous drainage)


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R esu ltsR esu lts

T otal # of patients : 18T otal # of patients : 18

Male : Female : 1: 2 (6 M, 12 F)Male : Female : 1: 2 (6 M, 12 F)

AgeAge : 34: 34- -67yrs (mean 51).67yrs (mean 51).


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P a tient c a tegoriz a tionP a tient c a tegoriz a tionC lass 1C lass 1 - - 5 patients5 patients

C lass 2C lass 2 - - 4 patients4 patients

C lass 3AC lass 3A - - 6 patients6 patients

Class 3B

Class 3B - - 1 patients1 patients

C lass 4C lass 4 - - 2 patients2 patients


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Class 1


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Class 2


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Class 3 A


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Class 3B


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Class 3B


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Class IV


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Class IV


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R a dio logic al typesR a dio logic al types

Dry T ype : 4Dry T ype : 4

Wet T ype : 14Wet T ype : 14


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T ype I - g a s r a dia tes diffuse lyNo a ssoci a ted f luid co llections a re seen

T ype II - sever al sm all foci of g a s Associ a ted regions of f luid a ttenu a tion.


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R isk F a ctorsR isk F a ctors

Low S. AlbuminLow S. Albumin 1818

Acute renal insufficiency : 16Acute renal insufficiency : 16

T hrombocytopenia: 11T hrombocytopenia: 11

Altered mental statusAltered mental status - - 33

Shock on presentationShock on presentation - - 22


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C oC o--existing Di ab etes Me llitusexisting Di ab etes Me llitus

No. of pts with DM:No. of pts with DM: 18 18

Established DMEstablished DM 16 16Incidentally diagnosed 2Incidentally diagnosed 2

Hb A1c raised ( meanHb A1c raised ( mean 12.2)12.2)


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Ca us a tive org a nismsCa us a tive org a nisms

Esch. coli : 12Esch. coli : 12

Klebsiella : 2Klebsiella : 2

C itrobacter : 1C itrobacter : 1

No growth : 3No growth : 3


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Ma na gementMa na gement

DJ StentingDJ Stenting 1111

DJ Stent+Percutaneous drainageDJ Stent+Percutaneous drainage 33

Percutaneous drainagePercutaneous drainage 22

NephrectomyNephrectomy - - 11


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Pre a nd Post StentingPre a nd Post Stenting


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Pre & post per cut a neous dr a ina gePre & post per cut a neous dr a ina ge


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Ma na gement vs Cla ss of EPNMa na gement vs Cla ss of EPNEPNEPN

classclass

MA N AG E MEN TMA N AG E MEN T

11 22 3A3A 3B3B 44

DJDJ STEN

TSTEN

T 55 44 11 11

DJ ST EN T +DJ ST EN T +P CDP CD

22 11

P CD onlyP CD only 22

NEPH R E CTOMYNEPH R E CTOMY 11


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Ma na gement & Cla ss of EPNMa na gement & Cla ss of EPN

5

0 0

4

0 01

2 2

0 0 01 1

001

2

3

4

56

7

8

9

10

Class I Class 2 Class

3A

Class

3B

Class 4

DJS

DJS+PCD

PCD


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Ma na gement vs Num b er of R iskMa na gement vs Num b er of R iskf a ctorsf a ctors

RISKRISKFACTORSFACTORS

MA N AG E MEN TMA N AG E MEN T

11 22 33 44 55

DJDJ ST EN TST EN T 22 77 22

DJ ST EN T +DJ ST EN T +P CDP CD

22 11

P CDP CD 11 11

NEPH R E CTOMYNEPH R E CTOMY 11


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Mort al ityMort al ity -- 11

C lass 3BC lass 3B

Radiological typeRadiological type II

Number of risk factorsNumber of risk factors 55

OutcomeOutcome expired within few hoursexpired within few hours


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Effectiveness of C onserv a tiveEffectiveness of C onserv a tivem a na gementm a na gement

Risk factor > 2Risk factor > 2 - - 9/16 patients9/16 patients

Patients with class 3A, 3B, 4Patients with class 3A, 3B, 4

7/16 patients7/16 patients


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Fo llow upFo llow up

Follow upFollow up 3 months to 24 months3 months to 24 monthsMeanMean 6 months6 months

Recurrent EPN @ 3monthsRecurrent EPN @ 3months - - 11Pyelonephritis (Non emphysematous)Pyelonephritis (Non emphysematous) - - 11


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C onc lusionC onc lusion

C onservative management is a safe,C onservative management is a safe,effective and feasible treatmenteffective and feasible treatmentoption in patients withoption in patients withEmphysematous pyelonephritis.Emphysematous pyelonephritis.


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T ha nk youT ha nk you

conservative management of emphysema to us pyelonephritis

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