Emphysematous Pyelonephritis Mini-topic Emphysematous Pyelonephritis R1. 추성준 xanthogranulomatous PN : chr. PN - 주로 infected renal stone에 의해 granulomatous tissue 형성(lipid-laden) > massive destruction of kidney 성인 : middle aged women : 반복적 요로감염 hx.(+) classic sx(+) unilat.★ renal mass(+) - E.coli 어린이 : kidney 전체에 영향 . tumor와 비슷, palpable abd. mass(+)- Proteus - 2nd amyloidosis(+) > NS RT 환자에게서도 생김(초반몇주~14년) -원인 : 면역억제, rejection, lymphatic blockade CT상 round low denstiy lesion + enhanced rim defect in macrophage processing of bacteria. In the case of XPN complicating renal transplantation, renal ischemia, lymphatic blockade and immunosuppression may also be important factors Tx : nephrectomy

Pathogenesis & Risk factor : poorly understood elevated tissue glucose level Risk factor :- DM > emphysematous PN : 80% > emphysematous pyelitis : 50% > emphysematous cystitis : 60~70% :- Urinary tract obstruction > emphysematous PN & cystitis : 20% :- women, old age Elevated tissue glu >> more favorable microenvironment Necrotic tissue + high glucose concentration > bac들이 glucose를 lactose, CO2, H로 변화 주로 당뇨환자에서 back pain 및 fever 있을 경우 생각해야함.

Diagnosis Causative bacteria Emphysematous pyelonephritis E.coli(69%), K. pneumonia(29%) Candida (rare) Emphysematous pyelonephritis Gas producing, necrotizing infection Renal parenchyma, perirenal tissue Plain film of abdomen Computed tomography ★ 48명 대상으로 한 study상 blood culture상 54%에서 균 동정되었고 그중 69%가 E.coli 29% K. pneumoniae 그외 다른 연구에서도 E.coli가 dominant 하게 동정됨

Clinical feature Severe APN vs Emphysematous PN Differential diagnosis Indistinguishable Abrupt or slowly(2~3 weeks) Anuric renal failure : uncommon complication Differential diagnosis Xanthogranulomatous PN Acute papillary necrosis air in Renal parenchyma air reflux from bladder air in a renal abscess entero-renal or cutaneo-renal fistula retroperitoneal perforation psoas abscess recent intervention Leukocytosis, hyperglycemia, cr상승, pyuria 관찰 Anuria 는 드물다 (bilat. Infection or unilat. Dz in solitary kidney dz에선 anuria(+)) Xanthogranulomatous : 주로 renal infected stone 에 의해, palpable abd. Mass > kidney destruction, granulomatous tissue change

Treatment Nephrectomy or open drainage + systemic antibiotics ? Systemic antibiotics + PCD (+ if present, relief of Urinary tract obstruction) Mortality?? >> 13.5%(6.6%) Vs 25% 85년~ 97년 사이만 해도 early nephrectomy + antibiotics : TOC 2000년 이후 initial treatment 로 각광받기 시작함 (lower motality-class가 낮은 군에대해서는) 안티 사용기간은 APN complicated와 동일하게 2주사용 2008년 J uro 210명 환자 대상

Treatment Prognostic classification Type I Type II Onset to Dx : renal parenchymal necrosis Type II : renal or perirenal fluid + bubbly gas pattern or gas in collecting syst. Type I Type II Onset to Dx Mortality Course Pathology 4 day 69% More fulminant Necrosis and hemorrhagic infarct 11 day 18% Diffuse infiltration of inflammatory cell, abscess formation type 1에는 vascular thrombosis 가 있음 > mor fulminant course / onset~진단까지의 기간이 짧다(4일) vs type2는 11일 type 1 higher mortality rate

Treatment Prognostic classification (CT) defined as the area between the fibrous renal capsule and the renal fascia) defined as the space beyond the renal fascia and/or extension to adjacent tissues such as the psoas muscle)

Treatment Risk factor for adverse outcomes(esp. Class 3 or 4) Thrombocytopenia Acute renal failure impaired consciousness shock Suscess rate of PCD : 85%(risk factor 0~1) vs 8%(risk factor 2~) 그외 india 에서 시행한 study상에서는 anti + PCD 넣고 3일후 CT f/u 통해 필요시 추가로 PCN insertion / clinical improve 없을때는 early nephrectomy 시행함. delayed nephrectomy (recurrent PN 발생시나 DTPA에서 kidney function 낮을때) 전체적 mortality 13% - thrombocytopenia, ARF, M/s chage severe hypoNa인 경우 mortality 상승함 renal parenchyma의 50%이상이 destruction 된경우 nephrectomy 시행 early nephrectomy 시행시 3/7 죽음 / PCD만가지고 치료했을때는 2/24 PCD에 이은 delayed nephrectomy시 다 살았음

Treatment Risk Factors for Mortality in Patients With Emphysematous Pyelonephritis: A Meta-Analysis / 07년 j of urology 그외 bilat EPN, conservative tx + anti만 사용했을 경우, type I인 경우 mortality를 높임.

Treatment Suggested approach Renal allografts parenteral antibiotics Class 1 : antibiotics alone(pyelitis) Class 2 : antibiotics + PCD Class 3A or 3B at low risk : Antibiotics + PCD // early nephrectomy? PCD is unsuccessful : Nephrectomy Class 3A or 3B at 2 more risk : anitbiotics + nephrectomy Class 4 : bilateral PCD insertion / nephrectomy : last option Renal allografts No Gerota’s fasica 80%↑ DM E.coli > K. pneumoniae Stage 1-2 : antibiotics with or without PCD Stage 3 : allograft nephrectomy ★ Glycemic control 아직까지는 치료법이 명확하게 정립되어 있지 Arch Intern Med. 2000;160(6):797. EPN 치료 class 1, 2의 경우 PCD + anti로 16명 중 1명 죽음(이 1명은 anti만 사용) class 3 중 PCD + anti 사용 > 28명중 21% 사망- 6, 39%는 PCD로도 치료 중분하지 않음(progressive or persistent lesion) > nephrectomy 시행받음 (11명중 7명만 nephrectomy 했고 그중 6명 살고 1명 죽음) class 4는 PCD 사용시 66% 죽음(4명중 1명만 나음 3명은 불충분 그중 2명은 죽음) 않아요

CASE M/84 C.C Present illness General weakness Onset) 8일전 80세 남자환자 7년전 위암수술, 20년전 당뇨(본원) 고혈압(강남세브란스) 4년전 대상포진(강남세브란스) 4년전 PCI (영동 세브란스) 시행하고 medication 중인 분으로 내원 8일 전부터 general weakness 및 fever 있었으며 이후 간헐적으로 fever, chilling, 허리통증 호소하여 9월 18 ER 내원하여 APN 얘기 듣고 입원 권유 받았으나 환자 refuse 후 퇴원하였던 분으로, general weakness 지속되어 외래 통해 입원함.

CASE Review of system General weakness(+) Fatigue(+) Chilling(+) Abdominal pain(+) LBP(+)

CASE Vital sign General appearance Chest Abdomen Back & Extremities BP : 150/70 mmHg BT : 36.4℃ PR : 60 회/min RR : 32 회/min General appearance Acute ill-looking appearance with alert mental state Chest Normal breathing sound Wheezing (-), Rale (-) Abdomen Tenderness/Rebound tenderness(-/-) Both CVA Td(+) Back & Extremities Pretibial pitting edema(-/-)

CASE Lab(HAD#1) CBC : 23500- 10.7/32.0 – 12k PT 1.21 aPTT 34.9 D-dimer 896.0 F.D.P 5.9 antithrombin III 43.0 Alb 2.3 OT/PT 22/11 BUN/Cr 100.5/3.33[16.5] (2013/10월 BUN/Cr 11.8/0.86) Electrolyte : 126 – 4.7 – 95 – 12 CRP 20.35 aBGA : 7.384 – 24.0 – 71.8 – 14 FENa 2.07

CASE

CASE

CASE Class 3A or 4

CASE HAD #3 S) 전신이 아파요 O) v/s stable BUN/Cr 104.0/4.12 CBC 17100-8.9/26.8-46k A & P) # Emphysematous PN # AKI # pneumonia PCN insertion, anti(meropenem) Femoral catheter insertion : CRRT # DIC - Antithrombin III, SDP 수혈 # r/o Rt. thigh abscess general condition 호전시 I & D 시행 고려

CASE HAD #4 S) LBP O) v/s stable BUN/Cr 69.8/2.96 CBC 26600-10.0/30.6-46k CRP 10.16 A & P) # Emphysematous PN # AKI # pneumonia Urine culture : E. Coli / blood culture : E.coli meropenem > ciprofloxacin

CASE HAD #7 S) LBP O) v/s stable BUN/Cr 50.8/2.86 CBC 17900-9.4/27.9-75k CRP 12.59 A & P) # Emphysematous PN # AKI # pneumonia CRP, WBC 상승 > ciprofloxacin >> tabaxin f/u APCT : 변화없음 > nephrectomy 권유 CRRT > perm catheter insertion > HD

CASE Class 3A

CASE HAD #11 S) O) v/s stable BUN/Cr 43.9/3.96 CBC 11800 – 8.8/26.0 – 113k CRP 5.41 e’ 139 – 3.9 – 101 - 24 A & P) # Emphysematous PN # AKI # pneumonia USG 시행함 : 나이 및 전신상태 고려하여 nephrectomy는 보류

CASE