Department of Urology, The Heart of England NHS Foundation Trust, Birmingham, UK.
BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14.
Emphysematous pyelonephritis (EPN) is a severe necrotizing infection of the renal parenchyma. The clinical course of EPN can be severe and life-threatening if not recognized and treated promptly. Most of the information has been from case reports, a few large series have also been reported. Using an evidence-based approach, this review describes the pathogenesis, classification, complications, and management of EPN. Emphysematous pyelonephritis (EPN) is an acute severe necrotizing infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue. The cause for mortality in EPN is primarily due to septic complications. Up to 95% of the cases with EPN have underlying uncontrolled diabetes mellitus. The risk of developing EPN secondary to a urinary tract obstruction is about 25-40%. There are three classifications of EPN based on radiological findings. Acute renal failure, microscopic or macroscopic haematuria, severe proteinuria are other positive findings in EPN. Escherichia coli is the most common causative pathogen with the organism isolated on urine or pus cultures in nearly 70% of the reported cases. A plain radiograph shows an abnormal gas shadow in the renal bed raising the suspicion whereas an ultrasound scan or computed tomography (CT) will confirm the presence of intra-renal gas thus supporting the diagnosis of EPN. Gas may extend beyond the site of inflammation to the sub capsular, perinephric and pararenal spaces. In some cases, gas was found to be extending into the scrotal sac and spermatic cord. Subsequent case studies have shown patients being successfully treated with PCD when used in addition to medical management, with significant reduction in the morality rates. PCD should be performed on patients who have localized areas of gas and functioning renal tissue is present. The treatment strategies include MM alone, PCD plus MM, MM plus emergency nephrectomy, and PCD plus MM plus emergency nephrectomy. In small proportion of patients managed with MM and PCD, subsequent nephrectomy will be required and in these patients the reported mortality is 6.6% Nephrectomy in patients with EPN can be simple, radical or laparoscopic.
气肿性肾盂肾炎（EPN）是一种严重的肾实质坏死性感染。如果不能及时发现和治疗，EPN 的临床病程可能很严重，危及生命。大多数信息都来自病例报告，也有少数大系列报告。本文采用循证方法，描述了 EPN 的发病机制、分类、并发症和治疗方法。气肿性肾盂肾炎（EPN）是一种肾实质及其周围组织的急性严重坏死性感染，导致肾实质、集合系统或肾周组织中存在气体。EPN 患者死亡的主要原因是感染性并发症。高达 95%的 EPN 患者合并未控制的糖尿病。继发于尿路梗阻的 EPN 风险约为 25-40%。EPN 基于影像学表现可分为三种类型。急性肾衰竭、镜下或肉眼血尿、严重蛋白尿也是 EPN 的阳性发现。大肠杆菌是最常见的病原体，近 70%的报告病例的尿液或脓液培养可分离出该病原体。腹部平片显示肾区异常气影，提示可疑；超声或 CT 扫描可证实肾内气体存在，从而支持 EPN 的诊断。气体可延伸至炎症部位以外的肾被膜下、肾周和肾旁间隙。在一些病例中，气体被发现延伸至阴囊和精索。随后的病例研究表明，在附加药物治疗的基础上使用经皮肾镜碎石术（PCD）治疗可获得成功，死亡率显著降低。PCD 应在存在局限性气体和功能肾组织的患者中进行。治疗策略包括单独使用 MM、PCD 加 MM、MM 加紧急肾切除术，以及 PCD 加 MM 加紧急肾切除术。在接受 MM 和 PCD 治疗的小部分患者中，随后可能需要肾切除术，这些患者的死亡率为 6.6%。EPN 患者的肾切除术可以是单纯性、根治性或腹腔镜性。
