[Diagnosis and treatment for emphysematous pyelonephritis: analysis of 14 cases from a single centre].

Objective: To examine the modalities of treatment and clinical outcomes of emphysematous pyelonephritis (EPN), in order to improve the survival rate of EPN patients. Methods: Totally 14 patients diagnosed as EPN between October 2011 and November 2020 at Department of Urology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine were included in this article. Data collection including patient demographics, clinical manifestations, management and clinical outcomes were conducted by retrospective charts review, after receiving the institutional review board's approval. There were 11 females and 3 males with a median age of 59 years (range: 52 to 73 years). The lesions were located on the left side in 10 patients and right side in 4 patients. All the 14 patients suffered from fever, and present with severe sepsis or septic shock. The median time from symptom onset to admission to hospital was 3 days(range: 2 to 5 days). All cases had diabetes mellitus. Escherichia coli was the most common organism been cultured (11 cases), while Klebsiella pneumonia was the second (3 cases). CT scan showed bubbly or located gas in the renal parenchyma in 5 cases and presence of steaky or mottled gas in the renal parenchyma in 9 cases. All patients had been admitted to ICU for anti-septic shock therapy. Three patients had undergone percutaneous catheter drainage along with broad-spectrum antibiotics therapy while 3 patients had immediate nephrectomy, the other 8 cases had a combination of an initial percutaneous catheter drainage and second stage nephrectomy. Results: In this case series, 3 patients were died from EPN while the other 11 were survived. The median ICU stay time was 6 days (range: 3 to 11 days). Of the 3 patients died from EPN, 2 had undergone percutaneous catheter drainage along and 1 had received immediate nephrectomy. Among the 11 patients who were survived, only 1 had received percutaneous catheter drainage while the other 10 received nephrectomy (8 patients had staged nephrectomy). Follow-up was performed 6 months after discharge. Of the 11 surviving patients, 2 were lost to follow-up, and the remaining 9 patients had an creatine level of (118.4±29.4) μmol/L (range: 89 to 176 μmol/L). Conclusions: For patients coupled with diabetes who were initially diagnosed as acute pyelonephritis, the possibility of EPN should be considered when the disease progressed rapidly especially septic shock occurred. On the basis of empirical broad-spectrum antibiotics therapy and standardized anti-septic shock treatment, a combination of an initial percutaneous catheter drainage and second stage nephrectomy could be efficacious.目的： 总结气肿性肾盂肾炎病例的临床表现和诊治策略。 方法： 回顾性分析浙江大学医学院附属邵逸夫医院泌尿外科2011年10月至2020年11月连续收治的14例气肿性肾盂肾炎患者的病例资料。男性3例，女性11例。中位年龄59岁（范围：52~73岁）。病变位于左肾者10例，右肾者4例。出现症状到就诊的中位时间3 d（范围：2~5 d）。所有患者均合并2型糖尿病。14例患者均有发热，均出现脓毒性休克症状。致病菌主要为大肠埃希菌11例和肺炎克雷伯菌3例。CT检查主要表现为患侧肾实质内分叶状或气泡状积气5例、斑点状或条纹状积气者9例、积液3例，肾周组织内积液1例。所有患者均于ICU接受抗休克、抗感染治疗，3例患者单纯行经皮穿刺引流术，3例患者行急诊患侧肾切除术，8例患者先行经皮穿刺引流术，病情稳定后再二期行患侧肾切除术。 结果： 3例死亡，11例存活。中位ICU停留时间6 d（范围：3~11 d）。3例死亡患者中，2例接受经皮穿刺引流术，1例接受急诊肾切除术。11例治愈患者中，1例接受经皮穿刺引流术，10例接受肾切除术（8例先行经皮穿刺引流术）。11例存活患者出院后6个月时随访，2例失访，其余9例血肌酐为（118.4±29.4）μmol/L（范围：89~176 μmol/L）。 结论： 对于合并糖尿病、初诊为急性肾盂肾炎的患者，在病情迅速进展、出现脓毒性休克时应考虑气肿性肾盂肾炎的可能。CT检查显示肾脏及肾周感染性病变伴肾实质内积气可明确诊断。在积极抗感染、规范化抗脓毒性休克治疗的基础上，一期先行经皮穿刺引流术，病情稳定后二期行患侧肾切除术可以取得良好的效果。.