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Background: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and the surrounding tissues associated with considerable mortality. We aimed to formulate a score that classifies the risk of mortality in patients with EPN at hospital admission. Materials and methods: Patients diagnosed with EPN between 2013 and 2020 were retrospectively included. Data from 15 centers (70%) were used to develop the scoring system, and data from 7 centers (30%) were used to validate it. Univariable and multivariable logistic regression analyses were performed to identify independent factors related to mortality. Receiver operating characteristic curve analysis was performed to construct the scoring system and calculate the risk of mortality. A standardized regression coefficient was used to quantify the discriminating power of each factor to convert the individual coefficients into points. The area under the curve was used to quantify the scoring system performance. An 8-point scoring system for the mortality risk was created (range, 0-7). Results: In total, 570 patients were included (400 in the test group and 170 in the validation group). Independent predictors of mortality in the multivariable logistic regression were included in the scoring system: quick Sepsis-related Organ Failure Assessment score ≥2 (2 points), anemia, paranephric gas extension, leukocyte count >22,000/µL, thrombocytopenia, and hyperglycemia (1 point each). The mortality rate was <5% for scores ≤3, 83.3% for scores 6, and 100% for scores 7. The area under the curve was 0.90 (95% confidence interval, 0.84-0.95) for test and 0.91 (95% confidence interval, 0.84-0.97) for the validation group. Conclusions: Our score predicts the risk of mortality in patients with EPN at presentation and may help clinicians identify patients at a higher risk of death.
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Xanthogranulomatous pyelonephritis (XGP) is an uncommon chronic granulomatous infection of renal parenchyma. XGP is often associated with long-term urinary tract obstruction due to stones and infection. We aimed to analyze the clinical, laboratory, and microbial culture profiles from bladder and kidney urine of patients who were diagnosed with XGP. Databases of patients with histopathological diagnosis of XGP from 10 centers across 5 countries were retrospectively reviewed between 2018 and 2022. Patients with incomplete medical records were excluded. A total of 365 patients were included. There were 228 (62.5%) women. The mean age was 45 ± 14.4 years. The most common comorbidity was chronic kidney disease (71%). Multiple stones were present in 34.5% of cases. Bladder urine culture results were positive in 53.2% of cases. Kidney urine culture was positive in 81.9% of patients. Sepsis and septic shock were present in 13.4% and 6.6% of patients, respectively. Three deaths were reported. Escherichia coli was the most common isolated pathogen in both urine (28.4%) and kidney cultures (42.4%), followed by Proteus mirabilis in bladder urine cultures (6.3%) and Klebsiella pneumoniae (7.6%) in kidney cultures. Extended-spectrum beta-lactamases producing bacteria were reported in 6% of the bladder urine cultures. On multivariable analysis, urosepsis, recurrent urinary tract infections, increased creatinine, and disease extension to perirenal and pararenal space were independent factors associated with positive bladder urine cultures. On multivariable analysis, only the presence of anemia was significantly more frequent in patients with positive kidney cultures. Our results can help urologists counsel XGP patients undergoing nephrectomy.
RESUMEN
BACKGROUND: Emphysematous pyelonephritis (EPN) is a necrotizing infection of the kidney and surrounding tissues with significant mortality. We aimed to assess the clinical factors and their influence on prognosis in patients being managed for EPN with and without ESBL-producing bacteria and to identify if those with EPN due to ESBL infections fared any different. METHODS: A retrospective analysis was performed on patients with EPN diagnosis from 22 centers across 11 countries (between 2013 and 2020). Demographics, clinical presentation, biochemical parameters, radiological features, microbiological characteristics, and therapeutic management were assessed. Univariable and multivariable analyses were performed to determine the independent variables associated with ESBL pathogens. A comparison of ESBL and non-ESBL mortality was performed evaluating treatment modality. RESULTS: A total of 570 patients were included. Median (IQR) age was 57 (47-65) years. Among urine cultures, the most common isolated pathogen was Escherichia coli (62.2%). ESBL-producing agents were present in 291/556 urine cultures (52.3%). In multivariable analysis, thrombocytopenia (OR 1.616 95% CI 1.081-2.413, p = 0.019), and Huang-Tseng type 4 (OR 1.948 95% CI 1.005-3.778, p= 0.048) were independent predictors of ESBL pathogens. Patients with Huang-Tseng Scale type 1 had 55% less chance of having ESBL-producing pathogens (OR 1.616 95% CI 1.081-2.413, p = 0.019). Early nephrectomy (OR 2.3, p = 0.029) and delayed nephrectomy (OR 2.4, p = 0.015) were associated with increased mortality in patients with ESBL infections. Conservative/minimally invasive management reported an inverse association with mortality (OR 0.314, p = 0.001). CONCLUSIONS: ESBL bacteria in EPN were not significantly associated with mortality in EPN. However, ESBL infections were associated with poor prognosis when patients underwent nephrectomy compared conservative/minimally invasive management.
