Reply by the Authors TO THE EDITOR:
As pointed out by Dr. Turunc, emphysematous pyelonephritis (EPN) is a life-threatening condition characterized by the presence of gas in renal parenchyma, collecting systems, and/or adjacent tissues. A timely diagnosis and adequate identification of prognostic factors are crucial to decision-making process and selection of optimal treatment. Unfortunately, in our opinion, radiographic appearance is not as accurate as needed to determine the prognosis of a patient with EPN. Recently, our group published a multicenter series of 62 patients with EPN.1 Surprisingly, we found that there was no difference in mortality rates when comparing Huang’s classification2 categories (P ¼ .55). Instead, a thorough clinical workup supported by radiographic evaluation is recommended. Previously, we have demonstrated that impaired consciousness, multiple organ failure, hyperglycemia, and elevated leukocyte count are independent predictors of poor outcome.3 Moreover, in our opinion, initial approach and treatment guided by strict criteria such as Surviving Sepsis Campaign recommendations4 is more reliable than radiologic criteria alone. Undoubtedly, EPN requires multidisciplinary treatment with carefully selected broad-spectrum antibiotics and fluid resuscitation. Invasive therapy should be tailored according to the severity of the disease and
UROLOGY 84 (4), 2014
clinical status. Computed tomographic scan is helpful to determine the type of minimally invasive approach. Ureteral stent placement and percutaneous drainage are excellent options to relieve obstruction (if present) and drain pus and infected urine. Among the advantages is the fact that these procedures can be repeated before open surgery. Timely reassessment of patient’s clinical condition is essential to improve results. Open drainage and nephrectomy should be reserved for critically ill patients not responding to the combination of medical management and minimally invasive techniques. Daniel Olvera-Posada, M.D. Francisco Rodriguez-Covarrubias, M.D. Department of Urology Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran Mexico City, Mexico References 1. Olvera-Posada D, Armengod-Fischer G, Vazquez-Lavista L, et al. Emphysematous pyelonephritis: multicenter clinical and therapeutic experience in Mexico. Urology. 2014;83:1280-1284. 2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160:797-805. 3. Olvera-Posada D, Garcia-Mora A, Culebro-Garcia C, et al. Prognostic factors in emphysematous pyelonephritis. Actas Urol Esp. 2013;37:228-232. 4. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296-327.
989
As pointed out by Dr. Turunc, emphysematous pyelonephritis (EPN) is a life-threatening condition characterized by the presence of gas in renal parenchyma, collecting systems, and/or adjacent tissues. A timely diagnosis and adequate identification of prognostic factors are crucial to decision-making process and selection of optimal treatment. Unfortunately, in our opinion, radiographic appearance is not as accurate as needed to determine the prognosis of a patient with EPN. Recently, our group published a multicenter series of 62 patients with EPN.1 Surprisingly, we found that there was no difference in mortality rates when comparing Huang’s classification2 categories (P ¼ .55). Instead, a thorough clinical workup supported by radiographic evaluation is recommended. Previously, we have demonstrated that impaired consciousness, multiple organ failure, hyperglycemia, and elevated leukocyte count are independent predictors of poor outcome.3 Moreover, in our opinion, initial approach and treatment guided by strict criteria such as Surviving Sepsis Campaign recommendations4 is more reliable than radiologic criteria alone. Undoubtedly, EPN requires multidisciplinary treatment with carefully selected broad-spectrum antibiotics and fluid resuscitation. Invasive therapy should be tailored according to the severity of the disease and
UROLOGY 84 (4), 2014
clinical status. Computed tomographic scan is helpful to determine the type of minimally invasive approach. Ureteral stent placement and percutaneous drainage are excellent options to relieve obstruction (if present) and drain pus and infected urine. Among the advantages is the fact that these procedures can be repeated before open surgery. Timely reassessment of patient’s clinical condition is essential to improve results. Open drainage and nephrectomy should be reserved for critically ill patients not responding to the combination of medical management and minimally invasive techniques. Daniel Olvera-Posada, M.D. Francisco Rodriguez-Covarrubias, M.D. Department of Urology Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran Mexico City, Mexico References 1. Olvera-Posada D, Armengod-Fischer G, Vazquez-Lavista L, et al. Emphysematous pyelonephritis: multicenter clinical and therapeutic experience in Mexico. Urology. 2014;83:1280-1284. 2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000;160:797-805. 3. Olvera-Posada D, Garcia-Mora A, Culebro-Garcia C, et al. Prognostic factors in emphysematous pyelonephritis. Actas Urol Esp. 2013;37:228-232. 4. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med. 2008;36:296-327.
989
