Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Current management of emphysematous pyelonephritis

Nature Reviews Urology volume 6, pages 272–279 (2009)Cite this article

Abstract

Emphysematous pyelonephritis (EPN) is a severe, necrotizing renal parenchymal infection that is characterized by the production of intraparenchymal gas. EPN predominantly affects female diabetics, and can occur in insulin-dependent and non-insulin-dependent patients in the absence of ureteric obstruction. Nondiabetic patients can also develop EPN, but often have ureteric obstruction and do not seem to develop such extensive disease. One gaseous component—carbon dioxide—is generated by bacterial fermentation of glucose (present in excess in diabetics) and acids. Patients with EPN show relatively vague symptoms initially, but frequently undergo a sudden deterioration in their condition, necessitating urgent medical attention. Treatment of patients with EPN comprises resuscitation, correction of any electrolyte and glucose problems, and administration of antibiotics targeting Gram-negative bacteria. Ureteric obstruction, if present, is relieved by a percutaneous nephrostomy or stent. Definitive management is by percutaneous drainage, except when there is extensive diffuse gas with renal destruction; in this case, a nephrectomy is advised. The requirement for a nephrectomy could potentially be avoided by early diagnosis and treatment of diabetics with urinary infection. With the advent of CT, a staging system of the gas patterns generated in the kidneys of EPN patients has evolved. Risk factors have been defined to aid management.

Key Points

  • Diabetic patients with urinary tract infections should be adequately investigated

  • CT is the definitive modality for diagnosing EPN

  • Initial management of EPN involves resuscitation, antibiotic treatment and control of diabetes

  • Percutaneous drainage is the most appropriate management strategy for most patients

  • Emergency nephrectomy is advised for patients with extensive renal destruction

  • If ureteric obstruction is present, a percutaneous nephrostomy is required

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Figure 1: Histologic features of emphysematous pyelonephritis.
Figure 2: Kidney removed from a patient with emphysematous pyelonephritis.
Figure 3: CT can detect the presence, extent and position of gas in renal parenchyma.
Figure 4: Abdominal X-ray can diagnose emphysematous pyelonephritis in many patients.
Figure 5: Intravenous urography can be used to diagnose emphysematous pyelonephritis when CT facilities are not available.
Figure 6: Gas detected on ultrasonography shows up as a 'dirty shadow'.
Figure 7: Management algorithm for a typical patient presenting with symptoms of emphysematous pyelonephritis (EPN).

Similar content being viewed by others

References

  1. Schultz, E. H. Jr & Klorfein, E. H. Emphysematous pyelonephritis. J. Urol. 87, 762–766 (1962).

    Article  Google Scholar 

  2. Kelly, H. A. & MacCullem, W. G. Pneumaturia. JAMA 31, 375 (1898).

    Article  Google Scholar 

  3. Roy, C., Pfleger, D. D., Lang, H., Saussine, C. C. & Jacqmin, D. Emphysematous pyelitis: findings in five patients. Radiology 218, 647–650 (2001).

    Article  CAS  Google Scholar 

  4. Huang, J.-J. & Tseng, C.-C. Emphysematous pyelonephritis. Clinicoradiological classification, management, prognosis and pathogenesis. Arch. Intern. Med. 160, 797–805 (2000).

    Article  CAS  Google Scholar 

  5. Boltan, L. E., Randall, H. & Barri, Y. M. Iatrogenic emphysematous pyelonephritis in a renal transplant patient. Transpl. Infect. Dis. 10, 409–412 (2008).

    Article  CAS  Google Scholar 

  6. Ortiz, A. et al. Emphysematous pyelonephritis in dialysis patient after embolisation of failed allograft. Urology 70, 372.e17–e19 (2007).

    Article  Google Scholar 

  7. Baligei, K. V. et al. Successful medical treatment of emphysematous pyelonephritis in renal allograft recipient. Ren. Fail. 29, 755–758 (2007).

    Article  Google Scholar 

  8. Chuang, Y. W. et al. Severe emphysematous pyelonephritis in a renal allograft. Successful treatment with percutaneous drainage and antibiotics. Clin. Nephrol. 68, 42–46 (2007).

    Article  CAS  Google Scholar 

  9. Arai, S. et al. A case of emphysematous pyelonephritis in a renal allograft. Transplantation 81, 296–297 (2006).

    Article  Google Scholar 

  10. Schenkman, E. & Auriemma, P. Bilateral emphysematous pyelonephritis with autosomal dominant polycystic kidney disease. J. Urol. 159, 163–164 (1988).

    Google Scholar 

  11. Arun, N., Hussain, A., Kapoor, M. M. & Abul, F. Bilateral emphysematous pyelonephritis and emphysematous cystitis with autosomal dominant polycystic kidney disease. Is conservative management justified? Med. Princ. Pract. 16, 155–157 (2007).

    Article  Google Scholar 

  12. Guiard, D. U. Development spontané de gaz dans la vessie [French]. Ann. d Mol. Genitourin. (1883).

  13. Yang, W.-H. & Shen, N. C. Gas forming infection of the urinary tract. An investigation of fermentation as a mechanism. J. Urol. 143, 960–964 (1990).

    Article  CAS  Google Scholar 

  14. Schainuck, L. I., Fouty, R. & Cutler, R. E. Emphysematous pyelonephritis: a new case and review of previous observations. Am. J. Med. 44, 134–139 (1968).

    Article  CAS  Google Scholar 

  15. Subramanyam, B. R., Lefleur, R. S. & Van Natta, F. C. Renal emphysema secondary to traumatic renal infarction. Urol. Radiol. 2, 53–54 (1980).

    Article  CAS  Google Scholar 

  16. Wang, Y. C., Shen, K. H., Yang, F. S. & Yang, S. How does retroperitoneal air shift to mediastinum in emphysematous pyelonephritis? Int. J. Urol. 13, 662–663 (2006).

    Article  Google Scholar 

  17. Strofilas, A. et al. Emphysematous pyelonephritis, a rare cause of pnenumoperitoneum, a case report and review of literature. Cases J. 1, 91 (2008).

    Article  Google Scholar 

  18. Modi, P., Goel, R. & Dodia, S. Scrotal extension of emphysematous pyelonephritis. Int. Urol. Nephrol. 39, 405–407 (2007).

    Article  Google Scholar 

  19. Chen, K. W. et al. Gas in hepatic veins. Rare and critical presentation of emphysematous pyelonephritis. J. Urol. 115, 125–126 (1994).

    Article  Google Scholar 

  20. Sarlesh, S., Randeva, H. S., Hillhouse, E. W. & Patel, V. Fatal emphysematous pyelonephritis with gas in spinal extradural space in a patient with diabetes. Diabetic Med. 18, 68–71 (2001).

    Article  Google Scholar 

  21. Michaeli, J., Mogle, P., Perlberg, S., Herman, S. & Caine, M. Emphysematous pyelonephritis. J. Urol. 131, 205–207 (1984).

    Article  Google Scholar 

  22. Langston, C. S. & Pfister, R. C. Renal emphysema. A case report and review of the literature. Am. J. Roentgen. Radium Ther. Nucl. Med. 110, 778–786 (1970).

    Article  CAS  Google Scholar 

  23. Wan, Y. L., Lo, S. K., Bullard, M., Chong, P. L. & Lee, T. Y. Predictors of outcome in emphysematous pyelonephritis. J. Urol. 159, 369–373 (1988).

    Article  Google Scholar 

  24. Chen, M. T. et al. Percutaneous drainage in the treatment of emphysematous pyelonephritis, 10 year experience. J. Urol. 157, 1569–1573 (1997).

    Article  CAS  Google Scholar 

  25. Shokeir, A. A., EL-Azab, M., Mohsen, T. & el Diosly, T. Emphysematous pyelonephritis. A 15 year experience with 20 cases. Urology 49, 343–346 (1997).

    Article  CAS  Google Scholar 

  26. Liao, H.-W. et al. Emphysematous pyelonephritis caused by Bacteroides fragilis. Nephrol. Dial. Transplant. 20, 2575–2577 (2005).

    Article  Google Scholar 

  27. Christensen, J. & Bistrup, C. Emphysematous pyelonephritis caused by Clostridium septicum and complicated by a mycotic aneurysm. Br. J. Radiol. 66, 842–843 (1993).

    Article  CAS  Google Scholar 

  28. Kamalian, M. D., Bhajan, M. A. & Dzarr, G. A. Emphysematous pyelonephritis caused by candida infection. Southeast Asian J. Trop. Med. Public Health 36, 725–727 (2005).

    Google Scholar 

  29. Hildebrand, T. S., Nibbe, L., Frei, U. & Schindler, R. Bilateral emphysematous pyelonephritis caused by candida infection. Am. J. Kidney Dis. 33, 1–10 (1999).

    Article  Google Scholar 

  30. Sultana, S. R., McNeille, S. A., Phillips, G. & Byrne, D. Candidal urinary tract infection as a course of pneumaturia. J. R. Coll. Surg. Edinb. 43, 198–199 (1998).

    CAS  PubMed  Google Scholar 

  31. Ahmad, M. & Dakshinamurty, K. V. Emphysematous renal tract disease due to Aspergillis fumigatis. J. Assoc. Physicians India 52, 495–497 (2004).

    CAS  PubMed  Google Scholar 

  32. Ahmad, M. Emphysematous pyelonephritis due to Aspergillis fumigatis. A case report. J. Nephrol. 17, 446–448 (2004).

    PubMed  Google Scholar 

  33. Pontin, A. R., Barnes, R. D., Joffe, J. & Kahn, D. Emphysematous pyelonephritis in diabetic patients. BJU 75, 71–74 (1995).

    Article  CAS  Google Scholar 

  34. Stapleton, A. Urinary tract infections in patients with diabetes. Am. J. Med. 113, 80–84 (2002).

    Article  Google Scholar 

  35. Falagas, M. E., Alexiou, V. G., Giannopoulou, K. P. & Siempos, I. I. Risk factors for mortality in patients with emphysematous pyelonephritis—a meta analysis. J. Urol. 178, 880–885 (2007).

    Article  Google Scholar 

  36. Soo Park, B. et al. Outcome of nephrectomy and kidney preserving procedures for the treatment of emphysematous pyelonephritis. Scand. J. Urol. Nephrol. 40, 332–338 (2006).

    Article  Google Scholar 

  37. Stein, J. P. et al. Bilateral emphysematous pyelonephritis: a case report and review of the literature. Urology 47, 129–134 (1996).

    Article  CAS  Google Scholar 

  38. Jain, H., Greenblatt, J. M. & Albornoz, M. A. Emphysematous pyelonephritis, a rare cause of pneumaturia. Lancet 357, 194 (2001).

    Article  CAS  Google Scholar 

  39. Wan, Y. L., Lee, T. U., Bullard, M. J. & Tsai, C.-C. Acute gas producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology 198, 433–438 (1996).

    Article  CAS  Google Scholar 

  40. Liu, K.-L., Lee, W.-J., Huang, K.-H. & Chen, S.-J. Right perirenal air: emphysematous pyelonephritis or duodenal perforation? Kidney Int. 72, 773–774 (2007).

    Article  Google Scholar 

  41. Fujita, S. et al. Case of emphysematous pyelonephritis in a renal allograft. Clin. Transplant. 19, 559–562 (2005).

    Article  Google Scholar 

  42. Paivansalo, M., Hellstrom, P., Sinihroto, T. & Leinonen, A. Emphysematous pyelonephritis. Radiologic and clinical findings in six cases. Acta Radiol. 30, 311–315 (1989).

    Article  CAS  Google Scholar 

  43. Ahlering, T. E. et al. Emphysematous pyelonephritis. A 5 year experience with 13 patients. J. Urol. 134, 1086–1088 (1985).

    Article  CAS  Google Scholar 

  44. Chan, P.-H. et al. Treatment of emphysematous pyelonephritis with broad spectrum antibiotics and percutaneous drainage. An analysis of 10 patients. J. Chin. Med. Assoc. 68, 29–32 (2005).

    Article  Google Scholar 

  45. Hudson, M., Weyman, P. J., van der Vliet, A. H. & Catalona, W. J. Emphysematous pyelonephritis: successful management by percutaneous drainage. J. Urol. 136, 884–886 (1986).

    Article  CAS  Google Scholar 

  46. Akpek, S., Turgut, T., Ozdemir, H., Ilgit, E. T. & Isik, S. Emphysematous pyelonephritis: fatal outcome during percutaneous drainage. Eur. J. Radiol. 26, 287–289 (1998).

    Article  CAS  Google Scholar 

  47. Bauman, N., Sabbagh, R., Hanmiah, R. & Kapoor, A. Laparoscopic nephrectomy for emphysematous pyelonephritis. Can. J. Urol. 12, 2764–2768 (2005).

    PubMed  Google Scholar 

  48. Flores, G., Nellen, H., Magana, F. & Calleja, J. Acute bilateral emphysematous pyelonephritis successfully managed by medical therapy alone: a case report and review of the literature. BMC Nephrol. 3, 4 (2002).

    Article  Google Scholar 

  49. Lin, C. S. et al. Bilateral emphysematous pyelonephritis with perirenal abscess cured by conservative therapy. J. Nephrol. 13, 155–158 (2000).

    Google Scholar 

  50. Tahir, H. et al. Successful medical treatment of acute bilateral emphysematous pyelonephritis. Am. J. Kidney Dis. 36, 1267–1270 (2000).

    Article  CAS  Google Scholar 

  51. Darabi, M. & Keshvari, M. Bilateral emphysematous pyelonephritis: a case report. Urol. J. 2, 118–119 (2005).

    PubMed  Google Scholar 

  52. Lim, C. S. et al. Bilateral emphysematous pyelonephritis with perirenal abscess cured by conservative therapy. J. Nephrol. 13, 155–158 (2000).

    CAS  PubMed  Google Scholar 

  53. De Pauw, P. & Ross, G. Emphysematous pyelonephritis in a solitary kidney. J. Urol. 125, 734–736 (1981).

    Article  CAS  Google Scholar 

  54. Schenkman, E. & Auriemma, P. Bilateral emphysematous pyelonephritis with autosomal polycystic kidney disease. J. Urol. 159, 1633–1634 (1998).

    Article  CAS  Google Scholar 

Download references

Acknowledgements

Charles P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

Author information

Authors and Affiliations

  1. Division of Urology, Groote Schuur Hospital, Cape Town, South Africa

    Alan R. Pontin & Richard D. Barnes

Authors
  1. Alan R. Pontin
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Richard D. Barnes
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Alan R. Pontin.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Pontin, A., Barnes, R. Current management of emphysematous pyelonephritis. Nat Rev Urol 6, 272–279 (2009). https://doi.org/10.1038/nrurol.2009.51

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1038/nrurol.2009.51

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing