conservative-management-of-emphysematous-pyelonephritis

conservative-management-of-emphysematous-pyelonephritis -...

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Unformatted text preview: 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. Emphysematous pyelonephritis Emphysematous Acute necrotizing parenchymal and perirenal infection caused by gas forming organisms. High morbidity & poor prognosis. Rate of Nephrectomy: 21­29% Mortality rate: 60­75% AIM AIM To analyze the efficacy of conservative management in EPN. Methods Retrospective study Inclusion criteria: All patients of EPN managed in our centre in the last three years. Diagnosis of EPN: Based on clinical and radiological findings 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: 433­438 Classification according to extent of involvement extent Class I : Renal pelvis Class II : Renal parenchyma Class III A : Perinephric tissue B : Beyond Gerota’s fascia. Class IV : Bilateral involvement EPN in solitary kidney Radiological Classification Radiological 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% Wan et al 1996, Best et al 1999 Risk factors Risk Thrombocytopenia Acute renal insufficiency Low S. Albumin Altered mental status Shock on presentation AUA, 2005 More than 2 risk factors – Poorer prognosis Conservative Management in EPN Conservative Antibiotics Supportive measures Stenting / Per­cutaneous drainage Indications Rising S.Creatinine Hydroureteronephrosis Sepsis Significant renal or peri­renal collection (Percutaneous drainage) Results Total # of patients : 18 Male : Female : 1: 2 (6 M, 12 F) Age : 34­67yrs (mean 51). Patient categorization Patient Class 1 ­ 5 patients Class 2 ­ 4 patients Class 3A ­ 6 patients Class 3B ­ 1 patients Class 4 ­ 2 patients Class 1 Class 2 Class 3A Class 3B Class 3B Class IV Class IV Radiological types Radiological Dry Type : 4 Wet Type : 14 Type I - gas radiates diffusely No associated fluid collections are seen Type II - several small foci of gas Associated regions of fluid attenuation. Risk Factors Risk Low S. Albumin – 18 Acute renal insufficiency : 16 Thrombocytopenia: 11 Altered mental status ­ 3 Shock on presentation ­ 2 Co-existing Diabetes Mellitus No. of pts with DM: 18 Established DM 16 Incidentally diagnosed 2 Hb A1c raised ( mean – 12.2) Causative organisms Causative Esch. coli : 12 Klebsiella : 2 Citrobacter : 1 No growth : 3 Management Management DJ Stenting – 11 DJ Stent+Percutaneous drainage – 3 Percutaneous drainage – 2 Nephrectomy ­ 1 Pre and Post Stenting Pre Pre & post per cutaneous drainage Pre Management vs Class of EPN Management EPN class MANAGEMENT DJ STENT DJ STENT + PCD 1 2 3A 5 4 3B 4 1 1 2 1 PCD only 2 NEPHRECTOMY 1 Management & Class of EPN Management 10 9 8 7 6 5 4 3 2 1 0 5 DJS DJS+PCD PCD 4 22 1 00 00 Class I Class 2 Class 3A 11 000 0 Class Class 4 3B Management vs Number of Risk factors factors RISK FACTORS MANAGEMENT DJ STENT 1 2 DJ STENT + PCD PCD NEPHRECTOMY 4 5 2 7 2 3 2 1 1 1 1 Mortality - 1 Mortality Class 3B Radiological type – I Number of risk factors – 5 Outcome – expired within few hours Effectiveness of Conservative management management Risk factor > 2 ­ 9/16 patients Patients with class 3A, 3B, 4 – 7/16 patients Follow up Follow up – 3 months to 24 months Mean – 6 months Recurrent EPN @ 3months ­ 1 Pyelonephritis (Non emphysematous) ­ 1 Conclusion Conclusion Conservative management is a safe, effective and feasible treatment option in patients with Emphysematous pyelonephritis. Thank you Thank ...
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This note was uploaded on 12/27/2011 for the course STEP 1 taught by Professor Dr.aslam during the Fall '11 term at Montgomery College.

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