NDT Plus Advance Access originally published online on February 14, 2008
NDT Plus 2008 1(4):264-265; doi:10.1093/ndtplus/sfn002
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Emphysematous pyelonephritis leading to end-stage renal failure
1 Nephrology Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, NE7 7DN
2 Institute of Human Genetics, Newcastle University, International Centre for Life, Newcastle upon Tyne, NE1 3BZ, UK
Correspondence: John A. Sayer, Institute of Human Genetics, International Centre for Life, Central Parkway, Newcastle Upon Tyne, NE1 3BZ, UK. Tel: +44-191-2418608; Fax: +44-191-2418666; E-mail: j.a.sayer{at}ncl.ac.uk
Key Words: pyelonephritis • emphysematous • Escherichia coli • acute kidney injury
Received for publication December 17, 2007. Accepted for publication December 31, 2007.
A 63-year-old woman presented with a 2-day history of nausea, vomiting and abdominal pain. She deteriorated rapidly with the development of anuric acute kidney injury and respiratory failure, requiring admission to the intensive care unit for CVVH and ventilation. Her past medical history included type 2 diabetes mellitus, treated with insulin therapy and a previous right nephrectomy (12 years previously) for a renal cell carcinoma. Her pre-admission serum creatinine was 89 µmol/l, but previous HbA1c readings of 14.5% indicated suboptimal glycaemic control.
Initial investigations confirmed sepsis; Escherichia coli grown from blood cultures was treated with i.v. tazocin. An abdominal CT scan (Figures 1 and 2) demonstrated a dilated left kidney with air in the renal parenchyma, typical of emphysematous pyelonephritis, staged as Class 4 [4]. A plain AXR also demonstrated air within the left kidney (Figure 3). Treatment consisted of continuous i.v. antibiotics for 4 weeks and subsequently two percutaneous nephrostomies to facilitate drainage.
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Urine output improved following treatment, but 3 months later the patient remains dialysis dependent and continues to suffer from urinary tract infections.
Emphysematous pyelonephritis is typically seen in female diabetic patients and E. coli is the commonest isolated organism [4]. Low oxygen tension within the kidney enforces anaerobic metabolism in E. coli, which are facultative anaerobes [2]. Gas production is secondary to rapid tissue catabolism with fermentation of glucose to carbon dioxide, which is not effectively transported away and remains localized at the site of inflammation. Further ischaemia results in tissue necrosis and perpetuates an environment for gas formation. The resulting appearances on imaging are dramatic. Management should include fluid resuscitation, glycaemic control, antibiotics and drainage [3], but nephrectomy is sometimes necessary. Following recovery of the acute episode, function of the affected kidney, as in this case, is often very poor [1].
Conflict of interest statement. None declared.
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- Abdul-Halim H, Kehinde EO, Abdeen S, et al. Severe emphysematous pyelonephritis in diabetic patients: diagnosis and aspects of surgical management. Urol Int (2005) 75:123–128.[CrossRef][Web of Science][Medline]
- Blattner FR, Plunkett G 3rd, Bloch CA, et al. The complete genome sequence of Escherichia coli K-12. Science (1997) 277:1453–1474.
[Abstract/Free Full Text] - Chen MT, Huang CN, Chou YH, et al. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol (1997) 157:1569–1573.[CrossRef][Web of Science][Medline]
- Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med (2000) 160:797–805.
[Abstract/Free Full Text]
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