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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2019  |  Volume : 30  |  Issue : 6  |  Page : 1485-1487
Emphysematous Pyelonephritis


1 Department of Nephrology Dialysis and Renal Transplantation, Civico and Di Cristina Hospital, Palermo, Italy
2 Department of Radiology, Civico and Di Cristina Hospital, Palermo, Italy

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Date of Submission10-Jan-2019
Date of Acceptance14-Jan-2019
Date of Web Publication9-Jan-2020
 

How to cite this article:
Cavol GL, Finazzo F, Carollo C, Li Cavoli TV, Zagarrigo C, Azzolina V, Mongiovi R, Amato A, Oliva B, Servillo F, Tortorici C, Schillaci O, Tralongo A, Turdo R, Bono L, Giammarresi C, Caputo F. Emphysematous Pyelonephritis. Saudi J Kidney Dis Transpl 2019;30:1485-7

How to cite this URL:
Cavol GL, Finazzo F, Carollo C, Li Cavoli TV, Zagarrigo C, Azzolina V, Mongiovi R, Amato A, Oliva B, Servillo F, Tortorici C, Schillaci O, Tralongo A, Turdo R, Bono L, Giammarresi C, Caputo F. Emphysematous Pyelonephritis. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2020 Jan 18];30:1485-7. Available from: http://www.sjkdt.org/text.asp?2019/30/6/1485/275499


To the Editor,

Emphysematous pyelonephritis (EPN) is a rare gas-forming necrotizing infection in the renal parenchyma and its surrounding areas. EPN involves both kidneys in <10% of the cases; the clinical behavior is aggressive and the infection can rapidly progress to multiorgan failure with high mortality rate.[1] The major reported risk factors are female gender (male-to-female ratio = 1:4), diabetes mellitus, and urological comorbidity (hydronephrosis, urinary tract obstruction, and neurogenic bladder). Other reported factors are urologic anatomic changes, alcoholism, and drug abuse.[2],[3] According to the reported cases, bacteria such as  Escherichia More Details coli and Klebsiella pneumoniae are the most common identified pathogens.[4],[5] These Gram-negative facultative anaerobic microorganisms are responsible for gas production via the fermentation of glucose and lactate. According to the presence of gas in the kidneys and surrounding areas, Huang and Tseng classified EPN in four categories based on the extent of gas on computed tomography (CT).[6] There are few reports regarding EPN in patients with autosomal dominant polycystic disease (ADPKD). Here, we report our experience of a 58-year-old male suffering from ADPKD and chronic renal failure, who received a deceased donor kidney after six years of chronic hemodialysis. Hepatitis B virus, human immunodeficiency virus, and hepatitis C virus tests were negative, and parameters of liver function were within the normal range. The induction immunosuppressive therapy involved basiliximab, and the maintenance was held with tacrolimus, mycophenolate sodium, and prednisone. The follow-up was troublesome due to hydronephrosis and lymphocele in the surgical site, which were treated with temporary drenages, and post-transplant diabetes mellitus. The patient had recurrent urinary tract infections caused by extended spectrum betalactamase (ESBL) + K. pneumoniae and was treated initially with levofloxacin and meropenem, and then with amikacin, but these treatments were not able to eradicate the infections. The Doppler ultrasound of renal graft ruled out any vascular complications. The patient had a poor outcome: 10 months after the renal transplant, the patient went to the emergency facility presenting severe sepsis due to urinary infection (ESBL + K. pneumoniae were isolated from both urine and blood cultures). The immuno-suppressive therapy was terminated. Abdomen emergency noncontrast CT showed bilateral air collection in the native policystic kidneys and in the wall of the intestinal loop near the right kidney [Figure 1] and [Figure 2]. The transplanted kidney showed normal findings. This picture was consistent with Class 4 EPN according to the Huang and Tseng classification. A bilateral nephrectomy was needed. The macroscopic examination of the kidneys, measuring approximately 20 cm × 11 cm × 12 cm, showed numberless cysts and multiple small abscesses. The pathological analysis of kidneys was consistent with the diagnosis of chronic suppurative pyelonephritis with flogosis of peritoneal membrane. The cultures of pus and urine yielded ESBL + K. pneumoniae. The patient underwent septic shock and died after 30 days. From this experience, it was found that the following four main pathogenetic factors were responsible for the EPN: the presence of gas-forming bacteria, hyperglycemia, inadequate kidney perfusion, and reduced immune response. EPN is usually seen in the native kidneys and has been reported infrequently in functioning renal allografts. EPN, bilateral or in a solitary kidney, is a lifE-threatening condition that requires prompt diagnosis and early intervention.
Figure 1: Abdominal noncontrast computed tomography showing enlarged polycystic kidneys and gas in the renal parenchyma (white arrows).

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Figure 2: Abdominal noncontrast computed tomography showing polycystic kidneys with intraparenchymal gas and air–fluid intracystic level (white arrows).

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Conflict of Interest: None declared.



 
   References Top

1.
Azzini AM, Sette P, Castellano G, Dorizzi RM. A rare association of emphysematous pyelonephritis with unrecognized diabetes and polycystic kidney. Indian J Nephrol 2009;19: 20-2.  Back to cited text no. 1
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2.
Al-Geizawi SM, Farney AC, Rogers J, et al. Renal allograft failure due to emphysematous pyelonephritis: Successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543-50.  Back to cited text no. 2
    
3.
Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int 2011; 107:1474-8.  Back to cited text no. 3
    
4.
Bansal RK, Lambe S, Kapoor A. Emphysematous pyelonephritis in failed renal allograft: Case report and review of literature. Urol Ann 2016;8:111-3.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Cosentini V, Cosaro A, Gammaro L, Lidestri V, Oldrizzi L, Maschio G. Escherichia coli-induced emphysematous pyelonephritis in a diabetic patient with polycystic kidney disease. G Ital Nefrol 2011;28:85-8.  Back to cited text no. 5
    
6.
Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med 2000;160:797-805.  Back to cited text no. 6
    

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Correspondence Address:
Gioacchino Li Cavol
Department of Nephrology Dialysis and Renal Transplantation, Civico and Di Cristina Hospital, Palermo
Italy
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DOI: 10.4103/1319-2442.275499

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