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Emphysematous pyelonephritis in a renal allograft
Emphysematous Pyelonephritis in a Renal Allograft Andrew J. Crouter MD, Michael K. Abraham MD, R. Gentry Wilkerson MD PII: DOI: Reference:
S0735-6757(16)30621-0 doi: 10.1016/j.ajem.2016.09.043 YAJEM 56146
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
8 September 2016 20 September 2016
Please cite this article as: Crouter Andrew J., Abraham Michael K., Wilkerson R. Gentry, Emphysematous Pyelonephritis in a Renal Allograft, American Journal of Emergency Medicine (2016), doi: 10.1016/j.ajem.2016.09.043
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
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Emphysematous Pyelonephritis in a Renal Allograft
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Running Head: Emphysematous Pyelonephritis in a Renal Allograft
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Andrew J. Crouter, MD, Michael K. Abraham, MD, and R. Gentry Wilkerson, MD
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Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Correspondence: R. Gentry Wilkerson, MD, Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201; 410-328-8025; [email protected]
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Abstract
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Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by the presence of gas in the renal parenchyma, collecting system, and surrounding structures. It is a rare, life-threatening disease, which poses a diagnostic challenge due to its rarity and nonspecific presentation. EPN can affect both native and allograft kidneys and is often treated surgically. In this report, we describe a patient with EPN in a renal allograft, who was treated conservatively with intravenous (IV) antibiotics without percutaneous drainage or nephrectomy.
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Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by the presence of gas in the renal parenchyma, collecting system, and surrounding structures [1,2]. It is a rare, life-threatening disease, which poses a diagnostic challenge due to its rarity and non-specific presentation [3]. EPN can affect both native and allograft kidneys and is often treated surgically [4,5]. In this report, we describe a patient with EPN in a renal allograft, who was treated conservatively with intravenous (IV) antibiotics without percutaneous drainage or nephrectomy.
NU
A 61-year-old man came to the emergency department (ED) after
MA
experiencing 3 days of progressively worsening lethargy, shortness of breath, and non-productive cough. His history was significant for living donor renal
ED
transplant, diabetes mellitus, and hypertension. At triage, his vital signs were as
PT
follows: blood pressure, 176/86 mm Hg; heart rate, 145 beats/min; respiratory rate, 32 breaths/min; and temperature, 40.7 C. On examination, he appeared ill,
CE
with tachycardia, tachypnea, and dry mucous membranes. He had a soft, non-
AC
tender abdomen.
Laboratory studies demonstrated the following values: blood glucose,
518 mg/dL; bicarbonate, 15 mEq/L; lactic acid, 7.2 mg/dL; creatinine, 6.2 mg/dl; white blood cell count, 14.4 x 10³/µL; anion gap, 22 mEq/L, and pyuria—findings consistent with acute kidney injury, diabetic ketoacidosis (DKA) and sepsis due to a urinary source. Non-contrast computed tomography (CT) scan of his abdomen revealed numerous foci of gas within the parenchyma of the upper and medial lower poles of the transplanted kidney, diffuse thickening of the bladder wall,
ACCEPTED MANUSCRIPT
and pericystic soft tissue stranding (Fig. 1a and 1b). EPN was diagnosed and a
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transplant surgeon was consulted.
Treatment in the ED consisted of aggressive IV fluid resuscitation with
SC
initiation of an insulin drip. After urine and blood samples were obtained, the
NU
patient was started on vancomycin and piperacillin/tazobactam. Despite this treatment, he became persistently hypotensive and required norepinephrine
MA
infusion. The patient was admitted to the intensive care unit (ICU), where the treatment team continued the antibiotics and elected not to remove the
ED
transplanted kidney The findings of DKA also improved with medical
PT
management. At the time of discharge, the patient had adequate urine output and his creatinine had improved to 3.2. He was discharged to a subacute
CE
rehabilitation facility 16 days after initial presentation.
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EPN is a life threatening process that can progress to sepsis, shock, and multiple organ failure, with a mortality rate of 40% to 50% [6]. It has a female-tomale ratio of 4 to 1 [2,3,7]. Multiple factors are thought to contribute to its pathogenesis, including elevated levels of glucose in renal tissues, immunosuppression, urinary tract obstruction, and impaired vascular supply [7]. Diabetes is almost universally present in patients with EPN [2,8]. EPN is typically caused by gas-producing bacteria such as Escherichia coli and Klebsiella pneumonia [9]. Diagnosis can be challenging due to the
ACCEPTED MANUSCRIPT
nonspecific symptomatology and laboratory findings. Physical examination
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T
findings are nonspecific and unreliable; therefore, EPN is usually diagnosed by imaging [5]. Computed tomography is superior to ultrasonography in
SC
establishing the presence of gas-producing infection in the kidneys. Renal
NU
ultrasound as a stand-alone test can miss the presence of gas in the urinary system [6,9].
MA
Treatment of EPN in a renal allograft is controversial. The treating team must weigh the preservation of transplanted kidney against potentially
ED
increasing the risk of death by allowing the affected organ to remain [2]. Few
PT
treatment algorithms have been published [10]. In 2000, Haung and Tseng published a classification system based on the extension of gas into the patient’s
CE
renal parenchyma, as seen on CT imaging [2]. They recommended escalation of
AC
treatment including nephrectomy as the radiographic findings of EPN advanced. In 2010, Al-Geizawa et al developed a similar classification system for patients with renal allografts affected by EPN based on the extent of renal gas formation on CT imaging and other clinical factors. As with Haung and Tseng, patients were stratified into groups based on disease severity, with corresponding treatment recommendations ranging from antibiotics alone to radical nephrectomy [4]. In this report, we describe a patient with EPN in a renal allograft who was treated conservatively with IV antibiotics without percutaneous drainage or
ACCEPTED MANUSCRIPT
nephrectomy. Emergency physicians must have a low threshold for pursuing
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T
advanced imaging in transplant patients whose presentation suggests EPN, due to their increased risk of infection and unreliable physical examination findings
SC
[2,7]. CT can be used to confirm the diagnosis and to determine optimal
NU
management approaches for native and transplanted kidneys. [2,4]. After the diagnosis is made, the emergency physician should focus on patient stabilization,
MA
initiation of broad-spectrum antibiotics, consultation with appropriate subspecialties, and coordination of care between medical and surgical
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PT
ED
subspecialties for hospital admission.
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References
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1. Tienza A, Hevia M, Merino I, Velis JM, Algarra R, Pascual JI, et al. Case of emphysematous pyelonephritis in kidney allograft: conservative treatment.
SC
Can Urol Assoc J 2014;8:E256‒9.
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2. Huang JJ, Tseng CC. Emphysematous pyelonephritis; clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med
MA
2000; 160:797‒805.
3. Agreda Castañeda F, Lorente D, Trilla Herrera E, Gasanz Serrano C, Servian
ED
Vives P, Iztueta Saavedra I, et al. Extensive emphysematous pyelonephritis in
2014;16:642‒7.
PT
a renal allograft: case report and review of literature. Transpl Infect Dis
CE
4. Al-Geizawa SM, Farney AC, Rogers J, Assimos D, Requarth JA, Doares W, et al.
AC
Renal allograft failure due to emphysematous pyelonephritis: successful nonoperative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543‒50. 5. Schmidt S, Foert E, Zidek W, van der Giet M, Westhof TH. Emphysematous pyelonephritis in a kidney allograft. Am J Kidney Dis 2009;53:895‒7. 6. Tsu JH, Chan CK, Chu RW, Law IC, Kong CK,Liu PL, et al. Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals. Asian J Surg 2013;36: 121‒5.
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7. Kangjam SM, Irom KS, Khumallambam IS, Sinam RS. Role of conservative
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T
management in emphysematous pyelonephritis - a retrospective study. J Clin Diagn Res 2015;9:PC09‒11.
SC
8. Arai S, Makino T, Okugi H, Hasumi M, Shibata Y, Hatori M, et al. A case of
NU
emphysematous pyelonephritis in a renal allograft. Transplantation 2006;81:296‒7.
MA
9. Uruc F, Yuksel OH, Sahin A, Urkmez A, Yildirim C, Verit A. Emphysematous pyelonephritis: our experience in managing these cases. Can Urol Assoc J
ED
2015;9:E480‒3.
PT
10. Bansal RK, Lambe S, Kapoor A. Emphysematous pyelonephritis in failed renal
AC
CE
allograft: case report and review of literature. Urol Ann 2016;8:111‒3.
CE
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Fig. 1A
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Fig. 1B
S0735-6757(16)30621-0 doi: 10.1016/j.ajem.2016.09.043 YAJEM 56146
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
8 September 2016 20 September 2016
Please cite this article as: Crouter Andrew J., Abraham Michael K., Wilkerson R. Gentry, Emphysematous Pyelonephritis in a Renal Allograft, American Journal of Emergency Medicine (2016), doi: 10.1016/j.ajem.2016.09.043
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
T
Emphysematous Pyelonephritis in a Renal Allograft
RI P
Running Head: Emphysematous Pyelonephritis in a Renal Allograft
SC
Andrew J. Crouter, MD, Michael K. Abraham, MD, and R. Gentry Wilkerson, MD
NU
Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
AC
CE
PT
ED
MA
Correspondence: R. Gentry Wilkerson, MD, Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201; 410-328-8025; [email protected]
ACCEPTED MANUSCRIPT
Abstract
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PT
ED
MA
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SC
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T
Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by the presence of gas in the renal parenchyma, collecting system, and surrounding structures. It is a rare, life-threatening disease, which poses a diagnostic challenge due to its rarity and nonspecific presentation. EPN can affect both native and allograft kidneys and is often treated surgically. In this report, we describe a patient with EPN in a renal allograft, who was treated conservatively with intravenous (IV) antibiotics without percutaneous drainage or nephrectomy.
ACCEPTED MANUSCRIPT
SC
RI P
T
Emphysematous pyelonephritis (EPN) is a necrotizing infection characterized by the presence of gas in the renal parenchyma, collecting system, and surrounding structures [1,2]. It is a rare, life-threatening disease, which poses a diagnostic challenge due to its rarity and non-specific presentation [3]. EPN can affect both native and allograft kidneys and is often treated surgically [4,5]. In this report, we describe a patient with EPN in a renal allograft, who was treated conservatively with intravenous (IV) antibiotics without percutaneous drainage or nephrectomy.
NU
A 61-year-old man came to the emergency department (ED) after
MA
experiencing 3 days of progressively worsening lethargy, shortness of breath, and non-productive cough. His history was significant for living donor renal
ED
transplant, diabetes mellitus, and hypertension. At triage, his vital signs were as
PT
follows: blood pressure, 176/86 mm Hg; heart rate, 145 beats/min; respiratory rate, 32 breaths/min; and temperature, 40.7 C. On examination, he appeared ill,
CE
with tachycardia, tachypnea, and dry mucous membranes. He had a soft, non-
AC
tender abdomen.
Laboratory studies demonstrated the following values: blood glucose,
518 mg/dL; bicarbonate, 15 mEq/L; lactic acid, 7.2 mg/dL; creatinine, 6.2 mg/dl; white blood cell count, 14.4 x 10³/µL; anion gap, 22 mEq/L, and pyuria—findings consistent with acute kidney injury, diabetic ketoacidosis (DKA) and sepsis due to a urinary source. Non-contrast computed tomography (CT) scan of his abdomen revealed numerous foci of gas within the parenchyma of the upper and medial lower poles of the transplanted kidney, diffuse thickening of the bladder wall,
ACCEPTED MANUSCRIPT
and pericystic soft tissue stranding (Fig. 1a and 1b). EPN was diagnosed and a
RI P
T
transplant surgeon was consulted.
Treatment in the ED consisted of aggressive IV fluid resuscitation with
SC
initiation of an insulin drip. After urine and blood samples were obtained, the
NU
patient was started on vancomycin and piperacillin/tazobactam. Despite this treatment, he became persistently hypotensive and required norepinephrine
MA
infusion. The patient was admitted to the intensive care unit (ICU), where the treatment team continued the antibiotics and elected not to remove the
ED
transplanted kidney The findings of DKA also improved with medical
PT
management. At the time of discharge, the patient had adequate urine output and his creatinine had improved to 3.2. He was discharged to a subacute
CE
rehabilitation facility 16 days after initial presentation.
AC
EPN is a life threatening process that can progress to sepsis, shock, and multiple organ failure, with a mortality rate of 40% to 50% [6]. It has a female-tomale ratio of 4 to 1 [2,3,7]. Multiple factors are thought to contribute to its pathogenesis, including elevated levels of glucose in renal tissues, immunosuppression, urinary tract obstruction, and impaired vascular supply [7]. Diabetes is almost universally present in patients with EPN [2,8]. EPN is typically caused by gas-producing bacteria such as Escherichia coli and Klebsiella pneumonia [9]. Diagnosis can be challenging due to the
ACCEPTED MANUSCRIPT
nonspecific symptomatology and laboratory findings. Physical examination
RI P
T
findings are nonspecific and unreliable; therefore, EPN is usually diagnosed by imaging [5]. Computed tomography is superior to ultrasonography in
SC
establishing the presence of gas-producing infection in the kidneys. Renal
NU
ultrasound as a stand-alone test can miss the presence of gas in the urinary system [6,9].
MA
Treatment of EPN in a renal allograft is controversial. The treating team must weigh the preservation of transplanted kidney against potentially
ED
increasing the risk of death by allowing the affected organ to remain [2]. Few
PT
treatment algorithms have been published [10]. In 2000, Haung and Tseng published a classification system based on the extension of gas into the patient’s
CE
renal parenchyma, as seen on CT imaging [2]. They recommended escalation of
AC
treatment including nephrectomy as the radiographic findings of EPN advanced. In 2010, Al-Geizawa et al developed a similar classification system for patients with renal allografts affected by EPN based on the extent of renal gas formation on CT imaging and other clinical factors. As with Haung and Tseng, patients were stratified into groups based on disease severity, with corresponding treatment recommendations ranging from antibiotics alone to radical nephrectomy [4]. In this report, we describe a patient with EPN in a renal allograft who was treated conservatively with IV antibiotics without percutaneous drainage or
ACCEPTED MANUSCRIPT
nephrectomy. Emergency physicians must have a low threshold for pursuing
RI P
T
advanced imaging in transplant patients whose presentation suggests EPN, due to their increased risk of infection and unreliable physical examination findings
SC
[2,7]. CT can be used to confirm the diagnosis and to determine optimal
NU
management approaches for native and transplanted kidneys. [2,4]. After the diagnosis is made, the emergency physician should focus on patient stabilization,
MA
initiation of broad-spectrum antibiotics, consultation with appropriate subspecialties, and coordination of care between medical and surgical
AC
CE
PT
ED
subspecialties for hospital admission.
ACCEPTED MANUSCRIPT
References
RI P
T
1. Tienza A, Hevia M, Merino I, Velis JM, Algarra R, Pascual JI, et al. Case of emphysematous pyelonephritis in kidney allograft: conservative treatment.
SC
Can Urol Assoc J 2014;8:E256‒9.
NU
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis; clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med
MA
2000; 160:797‒805.
3. Agreda Castañeda F, Lorente D, Trilla Herrera E, Gasanz Serrano C, Servian
ED
Vives P, Iztueta Saavedra I, et al. Extensive emphysematous pyelonephritis in
2014;16:642‒7.
PT
a renal allograft: case report and review of literature. Transpl Infect Dis
CE
4. Al-Geizawa SM, Farney AC, Rogers J, Assimos D, Requarth JA, Doares W, et al.
AC
Renal allograft failure due to emphysematous pyelonephritis: successful nonoperative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543‒50. 5. Schmidt S, Foert E, Zidek W, van der Giet M, Westhof TH. Emphysematous pyelonephritis in a kidney allograft. Am J Kidney Dis 2009;53:895‒7. 6. Tsu JH, Chan CK, Chu RW, Law IC, Kong CK,Liu PL, et al. Emphysematous pyelonephritis: an 8-year retrospective review across four acute hospitals. Asian J Surg 2013;36: 121‒5.
ACCEPTED MANUSCRIPT
7. Kangjam SM, Irom KS, Khumallambam IS, Sinam RS. Role of conservative
RI P
T
management in emphysematous pyelonephritis - a retrospective study. J Clin Diagn Res 2015;9:PC09‒11.
SC
8. Arai S, Makino T, Okugi H, Hasumi M, Shibata Y, Hatori M, et al. A case of
NU
emphysematous pyelonephritis in a renal allograft. Transplantation 2006;81:296‒7.
MA
9. Uruc F, Yuksel OH, Sahin A, Urkmez A, Yildirim C, Verit A. Emphysematous pyelonephritis: our experience in managing these cases. Can Urol Assoc J
ED
2015;9:E480‒3.
PT
10. Bansal RK, Lambe S, Kapoor A. Emphysematous pyelonephritis in failed renal
AC
CE
allograft: case report and review of literature. Urol Ann 2016;8:111‒3.
CE
AC
Fig. 1A
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Fig. 1B