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Is conservative management effective in Emphysematous Pyelonephritis? Vijay Anand, Vineet, Sridharan, Venkat Ramanan, Sunil Shroff, M.G.Rajamanickam. Department.

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Presentation on theme: "Is conservative management effective in Emphysematous Pyelonephritis? Vijay Anand, Vineet, Sridharan, Venkat Ramanan, Sunil Shroff, M.G.Rajamanickam. Department."— Presentation transcript:

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. Acute necrotizing parenchymal and perirenal infection caused by gas forming organisms. High morbidity & poor prognosis. High morbidity & poor prognosis. Rate of Nephrectomy: 21-29% Rate of Nephrectomy: 21-29% Mortality rate: 60-75% Mortality rate: 60-75%

3 AIM To analyze the efficacy of conservative management in EPN. To analyze the efficacy of conservative management in EPN.

4 Methods Retrospective study Retrospective study Inclusion criteria: All patients of EPN managed in our centre in the last three years. Inclusion criteria: All patients of EPN managed in our centre in the last three years. Diagnosis of EPN: Based on clinical and radiological findings Diagnosis of EPN: Based on clinical and radiological findings The risk factors and classification done based on study by Wan et al * 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:

5 Classification according to extent of involvement Class I : Renal pelvis Class I : Renal pelvis Class II : Renal parenchyma Class II : Renal parenchyma Class III Class III A : Perinephric tissue B : Beyond Gerotas fascia. Class IV : Bilateral involvement EPN in solitary kidney 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 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% 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 Wan et al 1996, Best et al 1999

7 Risk factors Thrombocytopenia Thrombocytopenia Acute renal insufficiency Acute renal insufficiency Low S. Albumin Low S. Albumin Altered mental status Altered mental status Shock on presentation Shock on presentation AUA, 2005 More than 2 risk factors – Poorer prognosis

8 Conservative Management in EPN Antibiotics Antibiotics Supportive measures Supportive measures Stenting / Per-cutaneous drainage Stenting / Per-cutaneous drainage Indications Indications Rising S.Creatinine Rising S.Creatinine Hydroureteronephrosis Hydroureteronephrosis Sepsis Sepsis Significant renal or peri-renal collection (Percutaneous drainage) Significant renal or peri-renal collection (Percutaneous drainage)

9 Results Total # of patients : 18 Total # of patients : 18 Male : Female : 1: 2 (6 M, 12 F) Male : Female : 1: 2 (6 M, 12 F) Age : 34-67yrs (mean 51). Age : 34-67yrs (mean 51).

10 Patient categorization Class patients Class patients Class patients Class patients Class 3A - 6 patients Class 3A - 6 patients Class 3B - 1 patients Class 3B - 1 patients Class patients Class patients

11 Class 1

12 Class 2

13 Class 3A

14 Class 3B

15

16 Class IV

17

18 Radiological types Dry Type : 4 Dry Type : 4 Wet Type : 14 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 Low S. Albumin – 18 Acute renal insufficiency : 16 Acute renal insufficiency : 16 Thrombocytopenia: 11 Thrombocytopenia: 11 Altered mental status - 3 Altered mental status - 3 Shock on presentation - 2 Shock on presentation - 2

21 Co-existing Diabetes Mellitus No. of pts with DM: 18 No. of pts with DM: 18 Established DM 16 Incidentally diagnosed 2 Hb A1c raised ( mean – 12.2) Hb A1c raised ( mean – 12.2)

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

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

24 Pre and Post Stenting

25 Pre & post per cutaneous drainage

26 Management vs Class of EPN EPN class classMANAGEMENT 1 2 3A 3A 3B 3B 4 DJ STENT DJ STENT + PCD 2 1 PCD only 2 NEPHRECTOMY 1

27 Management & Class of EPN

28 Management vs Number of Risk factors RISK RISK FACTORS FACTORSMANAGEMENT DJ STENT DJ STENT + PCD 2 1 PCD 1 1 NEPHRECTOMY 1

29 Mortality - 1 Class 3B Class 3B Radiological type – I Radiological type – I Number of risk factors – 5 Number of risk factors – 5 Outcome – expired within few hours Outcome – expired within few hours

30 Effectiveness of Conservative management Risk factor > 2 - 9/16 patients Risk factor > 2 - 9/16 patients Patients with class 3A, 3B, 4 Patients with class 3A, 3B, 4 – 7/16 patients

31 Follow up Follow up – 3 months to 24 months Follow up – 3 months to 24 months Mean – 6 months Mean – 6 months Recurrent 3months - 1 Recurrent 3months - 1 Pyelonephritis (Non emphysematous) - 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


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