Fulminant emphysematous pyelonephritis in a transplant kidney (clinical observation and literature review)

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma and its surrounding areas that causes gas accumulation around the renal parenchyma, collecting system and surrounding tissues in the process of vital activity of several microorganisms. EPN occurs nearly exclusively in people with diabetes. Treatment strategies for EPN have evolved over the past 20 years, with minimally invasive procedures replacing nephrectomy, which has resulted in lower mortality rates (12.5–13%). EPN is rare in kidney transplant (KT) recipients and is characterized by a severe, often fulminant course with a high rate of adverse outcomes, which is determined primarily by background immunosuppressive therapy. There is no universally accepted consensus on the radiographic classification of EPN in KT recipients and its management. We present the first description of EPN in transplanted kidney in a 45-year-old woman with post-transplant diabetes, obesity and recurrent urinary tract infections. Massive antibiotic therapy (ABT), percutaneous nephrostomy, transplantectomy, renal replacement therapy, selective cytokine adsorption, and ventilatory support were all administered on the patient after she was admitted to the hospital with increasing clinical symptoms of sepsis and multiple organ failure. Death occurred on the fourth day after disease onset. The article examines 38 clinical cases from the English-language segment of the medical literature from the late 1970s to the present. EPN in KT recipients is characterized by the predominance of male gender, including among the deceased, rapid development of sepsis and acute kidney injury. There was no statistically significant difference in the frequency of emergency transplantectomies among surviving and deceased patients. Mortality was 28%. The issue of EPN in transplanted kidney requires more research and the development of optimal therapeutic plans, including surgical strategies.

1. Wu SY, Yang SS, Chang SJ, Hsu CK. Emphysematous pyelonephritis: classification, management, and prognosis. Tzu Chi Med J. 2022; 34(3): 297–302. doi: 10.4103/tcmj.tcmj_257_21. PMID: 35912050; PMCID: PMC9333110.

2. Novinsky AA, Zinukhov AF. Emphysematous pyelonephritis: epidemiology, modern approaches to diagnosis and treatment. Experimentaland Clinical Urology 2020; 13(5): 100–105. [In Russ, English abstract] doi:10.29188/2222-8543-2020-13-5-100-105.

3. Desai R, Batura D. A systematic review and meta-analysis of risk factors and treatment choices in emphysematous pyelonephritis. Int Urol Nephrol. 2022; 54(4): 717–736. doi: 10.1007/s11255-022-03131-6. PMID: 35103928.

4. Ngo XT, Nguyen TT, Dobbs RW, Thai MS, Vu DH, Dinh LQV, et al. Prevalence and Risk Factors of Mortality in Emphysematous Pyelonephritis Patients: A Meta-Analysis. World J Surg. 2022; 46(10): 2377–2388. doi:10.1007/s00268-022-06647-1.

5. Kelly HA, MacCallum WG. Pneumaturia. JAMA. 1898 (178); 375–381.

6. SCHULTZ EH Jr, KLORFEIN EH. Emphysematous pyelonephritis. J Urol. 1962; 87: 762–766. doi: 10.1016/S0022-5347(17)65043-2. PMID: 13909504.

7. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. J Urol. 1984; 131(2): 203–208. doi:10.1016/s0022-5347(17)50309-2.

8. Palagin IS, Sukhorukova MV, Dekhnich AV, Edelstein MV, Perepanova TS, Kozlov RS, et al. Antimicrobial resistance of pathogens causing community-acquired urinary tract infections in Russia: results of the multicenter study “DARMIS-2018.”. Clinical Microbiology and Antimicrobial Chemotherapy. 2019; 21(2): 134–146. [In Russ, English abstract] doi: 10.36488/cmac.2019.2.134-146.

9. Kuzmenkov AYu, Vinogradova AG, Trushin IV, Edelstein MV, Avramenko AA, Dekhnich AV, Kozlov RS, et al. AMRmap - antibiotic resistance surveillance system in Russia. Clinical Microbiology and Antimicrobial Chemotherapy. 2021; 23(2):198–204 [In Russ, English abstract]. doi: 10.36488/cmac.2021.2.198-204.

10. Tseng CC, Wu JJ, Wang MC, Hor LI, Ko YH, Huang JJ. Host and bacterial virulence factors predisposing to emphysematous pyelonephritis. Am J Kidney Dis. 2005; 46(3): 432–439. doi: 10.1053/j.ajkd.2005.05.019. PMID: 16129204.

11. Norinder BS, Lüthje P, Yadav M, Kadas L, Fang H, Nord CE, Brauner A. Cellulose and PapG are important for Escherichia coli causing recurrent urinary tract infection in women. Infection. 2011; 39(6): 571–74. doi: 10.1007/s15010-011-0199-0. PMID: 22002732.

12. Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000; 160(6): 797–805. doi: 10.1001/archinte.160.6.797. PMID: 10737279.

13. Darsan SL, Pillai BS, Krishnamoorthy H. A rare neurological presentation of emphysematous pyelonephritis. Indian J Urol. 2022; 38(4): 315–316. doi: 10.4103/iju.iju_145_22. PMID: 36568452.

14. Razazi K, Luciani A, de Prost N, Mekontso Dessap A. Multiple gas emboli complicating an emphysematous pyelonephritis. IDCases. 2018; 12: 64–65. doi: 10.1016/j.idcr.2018.03.005. PMID: 29942752.

15. Gillies CL, Flocks R. Spontaneous renal and perirenal emphysema. Report of a case in a diabetic from Escherichia coli infection. Amer. J Roentgen. 1941; 46 (2): 173–174.

16. Arrambide-Herrera JG, Robles-Torres JI, Ocaña-Munguía MA, Romero-Mata R, Gutiérrez-González A, Gómez-Guerra LS. Predictive factors for mortality and intensive care unit admission in patients with emphysematous pyelonephritis: 5-year experience in a tertiary care hospital. Actas Urol Esp (Engl Ed). 2022; 46(2): 98–105. English, Spanish. doi: 10.1016/j.acuroe.2021.01.010. PMID: 35120854.

17. Lu YC, Chiang BJ, Pong YH, Huang KH, Hsueh PR, Huang CY, et al. Predictors of failure of conservative treatment among patients with emphysematous pyelonephritis. BMC Infect Dis. 2014; 14: 418. doi: 10.1186/1471-2334-14-418. PMID: 25074590.

18. Balsara VJ, Raval B, Maklad NF. Emphysematous pyelonephritis in a renal transplant: sonographic and computed tomographic features. J Ultrasound Med. 1985; 4(2): 97–99. doi: 10.7863/jum.1985.4.2.97. PMID: 3882994.

19. Harris PNA, Tambyah PA, Lye DC, Mo Y, Lee TH, Yilmaz M, et al. MERINO Trial Investigators and the Australasian Society for Infectious Disease Clinical Research Network (ASID-CRN). Effect of Piperacillin-Tazobactam vs Meropenem on 30-Day Mortality for Patients With E coli or Klebsiella pneumoniae Bloodstream Infection and Ceftriaxone Resistance: A Randomized Clinical Trial. JAMA. 2018; 320(10): 984–994. doi: 10.1001/jama.2018.12163. doi: 10.1001/jama.2019.6706. PMID: 30208454.

20. Lu YC, Hong JH, Chiang BJ, Pong YH, Hsueh PR, Huang CY, et al. Recommended Initial Antimicrobial Therapy for Emphysematous Pyelonephritis: 51 Cases and 14-Year-Experience of a Tertiary Referral Center. Medicine (Baltimore). 2016; 95(21): e3573. doi: 10.1097/MD.0000000000003573. PMID: 27227920.

21. Hsueh PR, Lau YJ, Ko WC, Liu CY, Huang CT, Yen MY, et al. Consensus statement on the role of fluoroquinolones in the management of urinary tract infections. J Microbiol Immunol Infect. 2011; 44(2): 79–82. doi: 10.1016/j.jmii.2011.01.015. PMID: 21439507.

22. Parameswaran R, Feest T. Gas nephrogram: an unusual complication of renal transplantation. Br J Radiol. 1977; 50(594): 438–440. doi: 10.1259/0007-1285-50-594-438. PMID: 326327.

23. Brenbridge AN, Buschi AJ, Cochrane JA, Lees RF. Renal emphysema of the tranplanted kidney: sonographic appearance. AJR Am J Roentgenol. 1979; 132(4): 656–658. doi: 10.2214/ajr.132.4.656. PMID: 106703.

24. Potter JL, Sullivan BM, Flournoy JG, Gerza C. Emphysema in the renal allograft. Radiology. 1985; 155(1): 51–52. doi: 10.1148/radiology.155.1.3883423. PMID: 3883423.

25. O'Donnell D, Rumbak M, Anderson J. Emphysematous pyelonephritis in a transplanted kidney. Clin Nephrol. 1986; 25(1): 52–53. PMID: 3514013.

26. Glen D, Bayliss AP, Robertson EM. Percutaneous drainage in emphysematous pyelonephritis. Clin Radiol. 1989; 40(4): 434. doi: 10.1016/s0009-9260(89)80155-2. PMID: 2667850.

27. Kalra OP, Malik N, Minz M, Gupta KL, Sakhuja V, Chugh KS. Emphysematous pyelonephritis and cystitis in a renal transplant recipient--computed tomographic appearance. Int J Artif Organs. 1993; 16(1): 41–44. PMID: 8458671.

28. Akalin E, Hyde C, Schmitt G, Kaufman J, Hamburger RJ. Emphysematous cystitis and pyelitis in a diabetic renal transplant recipient. Transplantation. 1996; 62(7): 1024–1026. doi: 10.1097/00007890-199610150-00023. PMID: 8878399.

29. Cheng YT, Wang HP, Hsieh HH. Emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and nephrostomy. Clin Transplant. 2001; 15(5): 364–367. doi: 10.1034/j.1399-0012.2001.150511.x. PMID: 11678965.

30. Iqubal M, John GT, Gopalakrishnan G, Jacob CK. Abdominal gas is not always bowel associated: lessons from an allograft recipient. Nephrol Dial Transplant. 2004; 19(2): 503–504. doi: 10.1093/ndt/gfg465. PMID: 14736985.

31. Ishigami K, Olsen KM, Hammet BK, Katz DA, Wu YM. Intravascular gas in the transplanted kidney: a sign of extensive graft necrosis. Emerg Radiol. 2004; 10(5): 279–281. doi: 10.1007/s10140-004-0334-7. PMID: 15290479.

32. Al-Makadma AS, Al-Akash SI. An unusual case of pyelonephritis in a pediatric renal transplant recipient. Pediatr Transplant. 2005; 9(2): 258–560. doi: 10.1111/j.1399-3046.2004.00276.x. PMID: 15787804.

33. Fujita S, Watanabe J, Reed AI, Hemming AW, Solis D, Netzel TC, et al. Case of emphysematous pyelonephritis in a renal allograft. Clin Transplant. 2005; 19(4): 559–562. doi: 10.1111/j.1399-0012.2005.00264.x.

34. Arai S, Makino T, Okugi H, Hasumi M, Shibata Y, Hatori M, et al. A case of emphysematous pyelonephritis in a renal allograft. Transplantation. 2006; 81(2): 296–297. doi: 10.1097/01.tp.0000191623.83885.ee. PMID: 16436977.

35. Ortiz A, Petkov V, Urbano J, Contreras J, Alexandru S, Garcia-Pérez A, et al. Emphysematous pyelonephritis in dialysis patient after embolization of failed allograft. Urology. 2007; 70(2): 372.e17-9. doi: 10.1016/j.urology.2007.04.044. PMID: 17826516.

36. Chuang YW, Chen CH, Cheng CH, Hung SW, Yu TM, Wu MJ, et al. Severe emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and antibiotics. Clin Nephrol. 2007; 68(1): 42–46. doi: 10.5414/cnp68042. PMID: 17703835.

37. Baliga KV, Narula AS, Sharma A, Khanduja R, Manrai M, Debnath J, et al. Successful medical treatment of emphysematous pyelonephritis in a renal allograft recipient. Ren Fail. 2007; 29(6): 755–658. doi: 10.1080/08860220701460434. PMID: 17763174.

38. Boltan LE, Randall H, Barri YM. Iatrogenic emphysematous pyelonephritis in a renal transplant patient. Transpl Infect Dis. 2008; 10(6): 409–412. doi: 10.1111/j.1399-3062.2008.00319.x. PMID: 18507751.

39. Debnath J, Baliga KV, George RA, Satija L, Khanduja R, Vaidya A, et al. Temporal evolution of emphysematous pyelonephritis in a renal allograft: imaging findings. Emerg Radiol. 2009; 16(3): 231–233. doi: 10.1007/s10140-008-0728-z. PMID: 18473150.

40. Schmidt S, Foert E, Zidek W, van der Giet M, Westhoff TH. Emphysematous pyelonephritis in a kidney allograft. Am J Kidney Dis. 2009; 53(5): 895–897. doi: 10.1053/j.ajkd.2008.12.032. PMID: 19344987.

41. Salehipour M, Roozbeh J, Rasekhi AR, Afrasiabi MA, Rezaee H, Izadpanah K, et al. Emphysematous pyelonephritis in a transplant kidney. Int J Organ Transplant Med. 2010;1(1):49–51. PMID: 25013564.

42. Al-Geizawi SM, Farney AC, Rogers J, Assimos D, Requarth JA, Doares W, et al. Renal allograft failure due to emphysematous pyelonephritis: successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis. 2010; 12(6): 543–250. doi: 10.1111/j.1399-3062.2010.00538.x. PMID: 20825591

43. Alexander S, Varughese S, David VG, Kodgire SV, Mukha RP, Kekre NS, et al. Extensive emphysematous pyelonephritis in a renal allograft treated conservatively: case report and review of the literature. Transpl Infect Dis. 2012; 14(6): E150-5. doi: 10.1111/tid.12016. PMID: 23025565.

44. Tsai YF, Wu CC, Lin AC. Emphysematous pyelonephritis in a renal allograft. J Emerg Med. 2012; 43(6): e485-6. doi: 10.1016/j.jemermed.2011.06.048. PMID: 22070875.

45. Agreda Castañeda F, Lorente D, Trilla Herrera E, Gasanz Serrano C, Servian Vives P, Iztueta Saavedra I, et al. Extensive emphysematous pyelonephritis in a renal allograft: case report and review of literature. Transpl Infect Dis. 2014; 16(4): 642–647. doi: 10.1111/tid.12246. PMID: 24984587.

46. Tienza A, Hevia M, Merino I, Velis JM, Algarra R, Pascual JI, et al. Case of emphysematous pyelonephritis in kidney allograft: Conservative treatment. Can Urol Assoc J. 2014; 8(3-4): E256–259. doi: 10.5489/cuaj.1555. PMID: 24839494.

47. Althaf MM, Abdelsalam MS, Rashwan M, Nadri Q. Emphysematous pyelonephritis and cystitis in a renal transplant recipient. BMJ Case Rep. 2014; 2014: bcr2014205589. doi: 10.1136/bcr-2014-205589. PMID: 25320257.

48. Narcisse D, Agarwal M, Hancock M, Wells D, Sands C. A rare case of emphysematous pyelonephritis in a renal transplant patient. Ther Adv Infect Dis. 2016; 3(6): 141–144. doi: 10.1177/2049936116678122. PMID: 28386406.

49. Alhajjaj FS, Pasha F. Emphysematous Pyelonephritis in Renal Allograft - a case report. Int J Health Sci (Qassim). 2016; 10(2): 311–313. PMID: 27103911.

50. Oliveira CC, Garcia PD, Viero RM. Emphysematous pyelonephritis in a transplanted kidney. Autops Case Rep. 2016; 6(4): 41–47. doi: 10.4322/acr.2016.051. PMID: 28210573;

51. Bansal RK, Lambe S, Kapoor A. Emphysematous pyelonephritis in failed renal allograft: Case report and review of literature. Urol Ann. 2016; 8(1): 111–113. doi: 10.4103/0974-7796.171500. PMID: 26834417.

52. Crouter AJ, Abraham MK, Wilkerson RG. Emphysematous pyelonephritis in a renal allograft. Am J Emerg Med. 2017; 35(3): 520.e1-520.e2. doi: 10.1016/j.ajem.2016.09.043. PMID: 27717721.

53. Rajaian S, Pragatheeswarane M, Krishnamurthy K, Murugasen L. Bilateral graft emphysematous pyelonephritis. BMJ Case Rep. 2019; 12(6): e231051. doi: 10.1136/bcr-2019-231051. PMID: 31227572.

54. Ambinder D, Saji A, Bassily D, Wong V, John D, Wong NC. Evolving case of emphysematous pyelonephritis in a second renal allograft. Urol Case Rep. 2021; 38: 101663. doi: 10.1016/j.eucr.2021.101663. PMID: 33981584.

55. Cases-Corona C, Shabaka A, Gonzalez-Lopez A, Martin-Segarra O, Moreno de la Higuera MA, Lucena R, et al. Fulminant Emphysematous Pyelonephritis by Candida glabrata in a Kidney Allograft. Nephron. 2020; 144(6): 304–309. doi: 10.1159/000507259. PMID: 32344404.

56. Abu Jawdeh BG, Nguyen MC, Ryan MS, Vikram HR. Case report: Emphysematous pyelonephritis associated with kidney allograft abscess formation. Front Med (Lausanne). 2022; 9:1066512. doi: 10.3389/fmed.2022.1066512. PMID: 36619614.

57. Hassanein M, Aleter O, Stephany BR, Eltemamy M, Augustine JJ. Emphysematous pyelonephritis in a kidney transplant recipient. Transpl Infect Dis. 2022; 24(2):e13807. doi: 10.1111/tid.13807. PMID: 35148025.

58. Chippa V, Chenna S, Gujarathi R. Emphysematous Pyelonephritis Involving Native Kidneys and a Transplanted Kidney. Cureus. 2022; 14(9): e29024. doi: 10.7759/cureus.29024. PMID: 36237790.

59. Belavina NI, Trushkin RN, Artyukhina LYu, Ivanova ES, Stolyarevich ES, Manchenko OV, et al. Ultrasound examination of failed renal transplant in patients with graft intolerance syndrome. Case series. Nephrology and Dialysis. 2023; 25(3): 401–412. [In Russ, English abstract] doi: 10.28996/2618-9801-2023-3-401-412.