Correspondence

Emphysematous Pyelonephritis

N Engl J Med 2000; 342:60-61January 6, 2000

Article

To the Editor:

Eloubeidi and Fowler (Sept. 2 issue)1 describe a 47-year-old woman with emphysematous pyelonephritis. They state, “Given the high risk of death associated with conservative therapy in this disorder, we immediately performed a radical left nephrectomy.” Several authors have published case reports and reports of small series of patients with unilateral or bilateral emphysematous pyelonephritis treated with antibiotics alone or accompanied by percutaneous drainage.2-4 Although there still is controversy about optimal treatment of emphysematous pyelonephritis,3,5 published results indicate that the mortality rate in patients treated with radical nephrectomy is equivalent to that in patients given more conservative treatment.4,5 Because antibiotics alone or with percutaneous drainage may be preferable to preserve renal function, we think that radical nephrectomy should no longer be considered the standard first-line treatment for emphysematous pyelonephritis.

Bernard Goichot, M.D., Ph.D.
Emmanuel Andrès, M.D.
Centre Hospitalier Universitaire Hautepierre, 67098 Strasbourg, France

5 References

1. 1

   Eloubeidi MAS, Fowler VG Jr. Emphysematous pyelonephritis. N Engl J Med 1999;341:737-737
   Full Text | Web of Science | Medline

2. 2

   George J, Chakravarthy S, John GT, Jacob CK. Bilateral emphysematous pyelonephritis responding to nonsurgical management. Urology 1995;15:172-174
   

3. 3

   Koh KB, Lam HS, Lee SH. Emphysematous pyelonephritis: drainage or nephrectomy? Br J Urol 1993;71:609-611
   CrossRef | Medline

4. 4

   Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol 1997;157:1569-1573
   CrossRef | Web of Science | Medline

5. 5

   Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 1997;49:343-346
   CrossRef | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: We agree that nephrectomy should not be the first line of therapy for emphysematous pyelonephritis in the minority of patients who have a response to conservative management. However, our patient had had no response to several days of conservative management with intravenous hydration and antibiotics before transfer to our facility. Her need for 11 days of inotropic support after surgery underscores the severity of her illness.

Because of the rarity of this disorder, definitive guidelines for optimal management have yet to be established. Conservative management or percutaneous drainage has occasionally been advocated,1 primarily for patients for whom surgery is not a suitable option. Unfortunately, the rate of treatment failure associated with these conservative-management strategies is usually prohibitively high.2-4 Similarly, conservative surgery that spares part of the infected kidney is rarely successful.4 By contrast, nephrectomy is generally regarded as the standard of care for the management of emphysematous pyelonephritis in patients capable of undergoing surgery.5 Nephrectomy generally should not be performed in patients with bilateral emphysematous pyelonephritis or with emphysematous pyelonephritis and only one kidney, in the attempt to preserve renal function, but we believe that nephrectomy should usually be performed if the contralateral kidney is not affected. As demonstrated in our patient, nephrectomy often contributes to a complete resolution of this life-threatening infection.

On the basis of available data, and given the high mortality associated with this disorder even after aggressive medical and surgical therapy,4,5 we believe that nephrectomy is almost always indicated for patients with emphysematous pyelonephritis.

Mohamad A. Eloubeidi, M.D., M.H.S.
Vance G. Fowler, Jr., M.D., M.H.S.
Duke University Medical Center, Durham, NC 27710

5 References

1. 1

   Chen MT, Huang CN, Chou YH, Huang CH, Chiang CP, Liu GC. Percutaneous drainage in the treatment of emphysematous pyelonephritis: 10-year experience. J Urol 1997;157:1569-1573
   CrossRef | Web of Science | Medline

2. 2

   Egawa S, Utsunomiya T, Uchida T, Mashimo S, Koshiba K. Emphysematous pyelonephritis, ureteritis, and cystitis in a diabetic patient. Urol Int 1994;52:176-178
   CrossRef | Web of Science | Medline

3. 3

   Klein FA, Smith MJ, Vick CW III, Schneider V. Emphysematous pyelonephritis: diagnosis and treatment. South Med J 1986;79:41-46
   CrossRef | Web of Science | Medline

4. 4

   Ahlering TE, Boyd SD, Hamilton CL, et al. Emphysematous pyelonephritis: a 5-year experience with 13 patients. J Urol 1985;134:1086-1088
   Web of Science | Medline

5. 5

   Shokeir AA, El-Azab M, Mohsen T, El-Diasty T. Emphysematous pyelonephritis: a 15-year experience with 20 cases. Urology 1997;49:343-346
   CrossRef | Web of Science | Medline