Conservative management of severe bilateral emphysematous pyelonephritis: Case series and review of literature

Emphysematous pyelonephritis (EPN) is a life-threatening condition most commonly observed in diabetes, with nephrectomy believed to be the treatment of choice. However, nephrectomy in EPN is associated with increased risk of complications secondary to associated hemodynamic instability and may result in lifelong hemodialysis in case of bilateral EPN. We present three patients of severe bilateral EPN and one patient of unilateral EPN with diabetic ketoacidosis (DKA) successfully managed conservatively. Patient 1 (severe bilateral EPN) and patient 4 (unilateral EPN with DKA) responded to aggressive broad spectrum antibiotics, whereas patients 2 and 3 (severe bilateral EPN) responded to broad spectrum antibiotics along with percutaneous catheter drainage (PCD). PCD resulted in initial drainage of 300 and 200 ml of pus, respectively. All patients had associated uncontrolled hyperglycemia, poor glycemic control (HbA1c >8.5%), prerenal and intrinsic renal failure, leukocytosis, and dyselectrolytemia which responded to aggressive supportive management and insulin. There are several reports of successful medical management of severe bilateral EPN. Nephrectomy might no longer be the preferred treatment of severe bilateral EPN and may be reserved for patients’ refractory to antibiotics and PCD. Urgent randomized controlled trials are warranted in EPN to optimize the treatment protocols.