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Table of Content - Volume 12 Issue 2 - November 2019

 

Clinical and management profile of diabetic patients with emphysematous pyelonephritis and sloughed renal papilla with ureteral obstruction in tertiary care hospital in Hyderabad

 

Vikas P Kadam1, Abhinandan S Jadhav2*

 

1,2Assistant Professor, Department of General Surgery, Dr Vasantrao Pawar Medical College and Research Centre, Adgaon, Nashik.

Email: abhinandanjadhav@hotmail.com

 

Abstract               Background: Diabetic epidemic is a major concern affecting around 40.9 million people in India and this is further set to rise to 69.9 million by the year 2025. Diabetic nephropathy is a major and important complication. In poorly controlled diabetes, usually urological emergencies are of infective origin. Aim: To study clinical profile and different management options of diabetic patients with emphysematous pyelonephritis, sloughed renal papilla with ureteral obstruction. Material and methods: Hospital based descriptive longitudinal study was conducted in tertiary care hospital on 30 diabetic patients with EPN and papillary necrosis. Results: Both the conditions were more common in the elderly age group having diabetes since >5 years. Male to female ratio was 1:2. HbA1C levels were >8% in 90% cases. Left kidney was affected in 60% cases. E.coli was predominant organism isolated from 53% cases. Management needed was DJ stenting (30%), unilateral nephrectomy (26.7%), PCN (16.6%) and Basketting of papilla and DJ stenting (26.7%). All EPN class 3 patients underwent nephrectomy. In papillary necrosis cases, most common management was Basketting and DJ stenting followed by unilateral PCN and no case for nephrectomy. Conclusion: High index of suspicion for EPN is must in diabetic patients with features of pyelonephritis to diagnose it in early stages to avoid nephrectomy. Ureteric obstruction due to sloughed renal papilla can be managed successfully by removing the papilla and DJ stenting under antibiotics coverage.

Key Words: EPN, Diabetic nephropathy, UTI, Nephrectomy.

 

 

INTRODUCTION
Diabetes epidemic is more pronounced in India as the World Health Organization (WHO) reports show that 32 million people had diabetes in the year 2000.1 The International Diabetes Federation (IDF) estimates the total number of diabetic subjects to be around 40.9 million in India and this is further set to rise to 69.9 million by the year 2025.2 Diabetic nephropathy is a major and important complication. In diabetic patients, usually urological emergencies are of infective origin. The presence of diabetes predisposes to much more severe infections especially in patients with poorly controlled diabetes. Emphysematous pyelonephritis, ureteral obstruction due to sloughed renal papilla are some of the emergencies seen in diabetic patients. Urinary tract is the most common site of infection in diabetic patients. Diabetic patients have been found to have fivefold increased frequency of acute pyelonephritis at autopsy than non-diabetics.3 Certain urinary tract infections including emphysematous pyelonephritis and cystitis, perinephric abscess and candidiasis show close association with diabetes mellitus. These together with papillary necrosis form the basis of UTI.4 Most urinary tract infections in diabetic patients are relatively asymptomatic and can lead to severe kidney damage and causes renal failure.5This study was done to study the different management options of diabetic patients with emphysematous pyelonephritis, sloughed renal papilla with ureteral obstruction. Along with this demographic profile of cases and organisms isolated in urine were also taken into consideration.

 

MATERIAL AND METHODS

An observational descriptive longitudinal hospital-based study was conducted in Yashoda Hospital, Malakpet, Hyderabad from 1st May 2010 to June 2012. Study was conducted on 30 diabetes mellitus cases with emphysematous pyelonephritis (EPN) and sloughed renal papilla with ureteral obstruction admitted in the intensive care unit (ICU) of hospital. Institutional Ethics Committee (IEC) permission was taken. Diabetic patients of any age and sex with the diagnosis of emphysematous pyelonephritis and ureteral obstruction due to sloughed renal papilla were included in the study. Diagnosis of emphysematous pyelonephritis was done on radiological basis (USG Abdomen, Abdominal Radiograph, CT scan of abdomen). Patients with emphysematous pyelonephritis classified as per the classification proposed by Huang et al[6] in five classes. Ureteral obstruction due to sloughed renal papilla diagnosed by imaging studies (intravenous urogram, CT scan abdomen, USG Abdomen). If the imaging studies were not able to diagnose the condition cystoscopy, retrograde pyelography or ureteroscopy was done as a diagnostic and therapeutic procedure. Written valid informed consent was taken before data collection. Information about demographics, type and duration of diabetes, treatment history, personal and past history was collected. Thorough general physical, systemic and clinical examination of the patients was done. Vital parameters were recorded. Investigation like complete blood count, complete urine examination, blood sugar levels, HbA1C levels, ultrasonography (abdomen) and radiograph (KUB) were done. In all patients urine sample was sent for culture and sensitivity examination before the starting of antibiotics. Standard operational definitions and protocols were formulated beforehand and followed till end. Patients were treated according to the demand of clinical situation (grade of emphysematous pyelonephritis, severity of ureteral obstruction and hemodynamic stability). Patients were managed as – 1) Minimally invasive procedures (PCN, DJ Stenting, Basketting of papilla and DJ stenting). 2) Surgical intervention (Open surgical drainage, Nephrectomy). All patients received intravenous fluids, appropriate antibiotics treatment for diabetes mellitus and associated co-morbidities in ICU. At the time of discharge from the hospital health education was given regarding diabetes control and regular exercise. All patients were advised to come for regular follow up after 1 week, one month and whenever necessary. During the follow up diabetic status, serum creatinine was checked. Data was entered in Microsoft Excel 2007 and analysed with SPSS v.16. Tables and graphs were used to summarize results. Descriptive statistics like frequency, proportions, mean and standard deviations were used. Suitable inferential statistics were used at appropriate places.

 

RESULTS

In current study of 30 diabetic cases of emphysematous pyelonephritis and sloughed renal papilla with ureteral obstruction were studied (15 each). Distribution of various attributes of study population is shown in table no.1. Majority (73.4%) of the patients with EPN were in the age between 51 to 70 years while two peaks were seen in age groups with obstruction due to papilla one at 41 to 50 years (40%) and other at 61 to 70 years (33.4%). Male to female ratio was 1:2. Out of 15 cases, 80% patients affected with EPN were having diabetes mellitus (DM) between 11 to 20 years while 93.4% cases with ureteric obstruction with sloughed papilla were having DM since 6 to 15 years. In 93.3% and 100% cases of EPN and Ureteric obstruction were having glycosylated haemoglobin > 8% respectively, suggesting immediate action needed to control the blood sugar level. It was noted, in EPN cases only 13.3 % patients had normal level of creatinine (≤ 1.5 mg/dl) at the time of admission. This proportion of cases increases to 40% at the time of discharge. Only 13.3 % patients with EPN had serum creatinine level ≥ 2.6 mg/dl at time of discharge. In ureteric obstruction cases only 13.3 % patients had normal level of creatinine (≤ 1.5 mg/dl) at the time of admission. This proportion of cases increases to 53.3% at the time of discharge. Only 6.7% patients with ureteric obstruction had serum creatinine level ≥ 2.6 mg/dl at time of discharge. As per shown in fig. no. 1 (bar diagram), left kidney was affected in 60 % of total 30 patients. Emphysematous pyelonephritis affected left kidney in 73.3 % (11 cases) of the patients with EPN. Right and left kidney was affected equally (7 cases each) in patients with sloughed renal papilla with ureteral obstruction. One patient was having bilateral ureteral obstruction due to sloughed renal papilla. As per depicted in table no. 2, E.coli was predominant organism isolated from 53% of 30 cases. Klebsiella, proteus, pseudomonas was isolated from 17%, 10% and 7% of the patients respectively. No organism was isolated from 13 % of the patients. Same trend was observed in both diagnosis shown in tables. Predominant organism isolated from patients with EPN was E.coli (isolated in 66.6% patients) followed by Klebsiella (13.3%), Proteus (6.7%) and pseudomonas (6.7%). E.coli was isolated in 40% cases with ureteral obstruction due to sloughed renal papilla followed by Klebsiella (20%) and Proteus and pseudomonas in 13.3 % and 6.7% patient respectively. As per shown in fig. no. 2 (Composite bar diagram), maximum patients (40%) had class 3B EPN at presentation followed by 13.3% cases presented with class 3A EPN, 20% cases with class 1 EPN and 26.7% presented with class 2 EPN. All EPN class 3 patients underwent nephrectomy. EPN class 2 patients needed DJ stenting in 3 patients (20%) and PCN in 1 patient (6.7%). All patients in EPN class 1 underwent DJ stenting. As depicted in the table no. 3, Out of total 30 cases, 30% cases needed DJ stenting, 26.7% underwent unilateral nephrectomy, five patients (16.6%) underwent PCN (4 unilateral and 1 bilateral) and 26.7% cases needed basketting of papilla and DJ stenting. In EPN cases, Nephrectomy was most common management (8 cases) followed by DJ stenting (6 cases) and unilateral PCN (1 case) with no case for bilateral PCN and basketting and DJ stenting. In ureteral obstruction due to sloughed papilla cases, most common management was basketting and DJ stenting (8 cases) followed by unilateral PCN (3 cases, DJ stenting (3 cases) and bilateral PCN with no case for nephrectomy. Basketting and DJ stenting needed in 8 patients with ureteral obstruction due to sloughed papilla.

Table 1: Distribution of various variables among EPN and Ureteral obstruction d/t sloughed renal papilla cases

Diagnosis--->

EPN

(Emphysematous Pyelonephritis)

Ureteral obstruction d/

t sloughed renal papilla

Variables

Frequency

Percentage

Frequency

Percentage

Age(years)

41-50

2

13.30%

6

40%

51-60

5

33.40%

2

13.30%

61-70

6

40%

5

33.40%

71-80

2

13.30%

2

13.30%

Gender

Female

10

66.70%

10

66.70%

Male

5

33.30%

5

33.30%

Diabetes duration(years)

New case

1

6.70%

1

6.67%

6 to 10

2

13.30%

7

46.67%

11 to 15

9

60%

7

46.67%

16 to 20

3

20%

0

0%

Glycosylated haemoglobin

>8%

14

93.30%

15

100%

7.1-7.9%

1

6.70%

0

0%

Serum creatinine at admission (mg/dl)

≤ 1.5

2

13.30%

2

13.30%

1.6 to 2.5

7

46.70%

9

60%

≥ 2.6

6

40%

4

26.70%

Serum creatinine one month after discharge (mg/dl)

≤ 1.5

6

40.00%

8

53.30%

1.6 to 2.5

7

46.70%

6

40%

≥ 2.6

2

13.30%

1

6.70%

 

Table 2: Organisms isolated in EPN and Ureteral obstruction d/t sloughed renal papilla cases

Organism

EPN

(Emphysematous Pyelonephritis)

Ureteral obstruction d/

t sloughed renal papilla

Total

No. of patients (%)

No. of patients (%)

No.

%

E.coli

10(66.6%)

6 (40%)

16

53.30%

Klebsiella

2 (13.3%)

3 (20%)

5

16.70%

Proteus

1 (6.7%)

2 (13.3%)

3

10%

Pseudomonas

1(6.7%)

1(6.7%)

2

6.70%

Sterile

1 (6.7%)

3 (20%)

4

13.30%

Total

15 (100%)

15 (100%)

30

100%

 

 

 

 

Table 3: Management of cases with EPN and Ureteral obstruction d/t sloughed renal papilla

Procedures

EPN (Emphysematous Pyelonephritis)

Ureteral obstruction d/t sloughed renal papilla

Total

No. of patients (%)

No. of patients (%)

No. of patients

%

Basketting and DJ Stenting

0(0)

8(100)

8

26.70%

Bilateral PCN

0(0)

1(100)

1

3.30%

DJ stenting

6(66.7)

3(33.4)

9

30.00%

Nephrectomy

8(100)

0(0)

8

26.70%

PCN

1(25)

3(75)

4

13.30%

Total

15(50)

15(50)

30

100.00%

DJ stent: Double J stent; PCN: Percutaneous nephrostomy

 

DISCUSSION

Some of the renal complication in diabetics are of infective origin viz. Emphysematous pyelonephritis and ureteral obstruction due to sloughed renal papilla. Studies done by Dutta et al7, Derouiche et al8 and Kapoor et al9 recorded mean age (years) of EPN patients as 54.4, 54.6 and 57 years, respectively. These study findings are concurrent with finding recorded in current study i.e. 73.4% cases of EPN were in age group of 51 to 70 years. In present study, ureteral obstruction due to sloughed renal papilla was seen more commonly in 41 to 50 years (40%) and 61 to 70 years (33.4%). Study conducted by Vijayaraghavan et al10 reported papillary necrosis was seen in elderly diabetic females. This is comparable with current study finding i.e. persons in 4th to 7th decade were affected more commonly. In present study, in both the conditions (EPN and papillary necrosis) females are affected more commonly i.e. 66.7% and male to female ratio was 1:2. Studies done by Kapoor et al[9], Khaira et al[11], Derouiche et al8 and Park et al12 reported male to female ratio as 2:11, 1:5, 1:2.5 and 1:1.4. As female urethra is short the ascending infections are more common which may lead to initiation of these fatal conditions. In current study, duration of diabetes was 11 to 20 years and 6 to 15 years in most cases of EPN and papillary necrosis cases respectively. Chen et al13 observed increased susceptibility to EPN and papillary necrosis in patients with diabetes with increased duration and severity of diabetes. Dutta et al7 reported mean duration of diabetes in EPN cases was 8.6 years. These findings are concurrent with current study findings. Longer duration of diabetes makes the kidney more vulnerable to infective and ischemic insults due to microangiopathy and uncontrolled sugar level leading to EPN and papillary necrosis. Huang et al6 and Park et al12 reported 72% and 76% cases of EPN had poorly controlled HbA1C level. Present study reported 93.3% and 100% with EPN and papillary necrosis respectively with poorly controlled HbA1C levels. In current study, proportion of patients with s. creatinine level ≤ 1.5 mg/dl was increase from 13.3% (at the time of admission) to 40% and 53% (at the time of discharge) in cases with EPN and papillary necrosis, respectively. Study done by Praveen et al14 reported improvement in renal function with decrease in serum creatinine level from 5.47 (at admission) to 2.4 mg/dl (at discharge). So it was evident that, after management of the conditions creatinine dose not normalise completely as the patients usually have associated diabetic nephropathy and as the class of EPN increases more parenchyma of kidney gets involved. In the EPN study conducted by Derouiche et al8 left kidney was affected in 71.42% patients which is similar to present study finding. Right and left kidney was affected equally in patients with sloughed renal papilla with ureteral obstruction in current study. Studies done by Huang et al[6], Park et al12 and Khaira et al11 reported E.coli (69%,52% and 68.4%, respectively) followed by Klebsiella (29%, 24% and 22%, respectively) as common organism in EPN cases. As per studies conducted on papillary necrosis in diabetics good numbers of patients have sepsis but organism pattern isolated is lacking. Current study findings recorded similar trend of causative organisms. In present study EPN patients were divided as per staging system suggested by Huang et al6 into 5 classes. Dutta et al7 reported 61% cases of Class 3B followed by class 1,3A and 4 EPN with 11.1% cases each. Present study recorded maximum case of class 3B followed by EPN class 2, 1 and 3A. Trend was quite similar in both studies. Study conducted by Huang et al[6] on 46 EPN cases recorded, 17 (85%) of the 20 patients with fewer than 2 risk factors (i.e. thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment and patients who had an unsuccessful treatment using a PCD underwent subsequent nephrectomy. Only 2 patients were managed by direct nephrectomy. The overall success rate of nephrectomy was 90%. In study done by Derouiche et al8, nephrectomy was most common management (57%) followed by ureteric drainage, percutaneous drainage and pure medical management with 24% mortality. Present study reported comparable study findings indicating surgical drainage, PCN, DJ stenting as the appropriate management for class 1, class 2 and class 3A patients with no risk factors. Need of early nephrectomy in Class 3A and class 3B patients associated with risk factor was evident. In the study conducted by Vijayaraghavan et al10, out of 15 cases fourteen patients (93%) underwent cystoscopy and ureteroscopy, which in 13 revealed necrosed papillae in the ureter as the cause of obstruction, and the same were removed. In 1 patient, necrosed papillae were not seen, but the ureteric orifice was patulous, which may have suggested recent passage. In current study, in patients with ureteral obstruction due to sloughed renal papilla majority (73.30%) underwent basketting of papilla and DJ stenting followed by PCN and DJ stenting alone. This indicates removal of papilla by ureteroscopy under antibiotic coverage play important role in the management of ureteral obstruction due to sloughed renal papilla. DJ stenting for shorter duration was needed as often there was associated ureteritis, oedema of the ureteric orifice and thick purulent material in the kidney. Patients who were not fit for anaesthesia can be managed with PCN under local anaesthesia or only DJ stenting.

 

CONCLUSION

Nephrectomy is the treatment of choice in diabetic patients with class 3A and class 3B Emphysematous pyelonephritis with one or more risk factors. High index of suspicion for EPN is must in diabetic patients presented with features of pyelonephritis to diagnose it in early stages so that nephrectomy is avoided. Ureteric obstruction due to sloughed renal papilla is a urological emergency which can be managed successfully by removing the papilla and DJ stenting under antibiotics coverage.

 

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