Saudi Journal of Kidney Diseases and Transplantation

LETTER TO THE EDITOR
Year
: 2019  |  Volume : 30  |  Issue : 6  |  Page : 1485--1487

Emphysematous Pyelonephritis


Gioacchino Li Cavol1, Francesca Finazzo2, Camillo Carollo1, Tancredi Vincenzo Li Cavoli1, Carmela Zagarrigo1, Vitalba Azzolina1, Rosalia Mongiovi1, Antonio Amato1, Barbara Oliva1, Franca Servillo1, Calogera Tortorici1, Onofrio Schillaci1, Angelo Tralongo1, Rosanna Turdo1, Luisa Bono1, Carlo Giammarresi1, Flavia Caputo1,  
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

Correspondence Address:
Gioacchino Li Cavol
Department of Nephrology Dialysis and Renal Transplantation, Civico and Di Cristina Hospital, Palermo
Italy




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;30:1485-1487


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 Feb 20 ];30:1485-1487
Available from: http://www.sjkdt.org/text.asp?2019/30/6/1485/275499


Full Text



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 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}{Figure 2}

Conflict of Interest: None declared.

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