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参考文献
１）TypeI，TypeII
Radiology. 1996 Feb;198(2):433-8.
Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome.
Wan YL, Lee TY, Bullard MJ, Tsai CC.
PURPOSE: To correlate imaging findings of types I and II emphysematous pyelonephritis (EPN) with clinical course and prognosis. MATERIALS AND METHODS: The imaging studies and clinical outcome in 38 patients with EPN were retrospectively studied. The imaging studies performed included radiography (n = 33), computed tomography (n = 31), and ultrasonography (n = 35). RESULTS: Two types of EPN were identified. Type I EPN was characterized by parenchymal destruction with either absence of fluid collection or presence of streaky or mottled gas. Type II EPN was characterized as either renal or perirenal fluid collections with bubbly or loculated gas or gas in the collecting system. The mortality rate for type I EPN (69%) was higher than that for type II (18%). Type I EPN tended to have a more fulminant course with a significantly shorter interval from clinical onset to death (P
２）Class１〜Class４，４ risk factors（thrombocytopenia, acute renal function impairment, disturbance of consciousness , shock）を考慮し治療方針を決定．
Arch Intern Med. 2000 Mar 27;160(6):797-805.
Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis.
Huang JJ, Tseng CC.
BACKGROUND: Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and its surrounding areas. The radiological classification and adequate therapeutic regimen are controversial and the prognostic factors and pathogenesis remain uncertain. OBJECTIVES: To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management (ie, antibiotic treatment alone, percutaneous catheter drainage combined with antibiotic treatment, or nephrectomy) and outcome among the various radiological classes of EPN; and to clarify the gas-forming mechanism and pathogenesis of EPN by gas analysis and pathological findings. PATIENTS AND METHODS: Forty-eight EPN cases from our institution were enrolled between August 1,1989, and November 30, 1997. According to the radiological findings on computed tomographic scan, they were classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN. The clinical manifestations, management, and outcome were compared. The gas contents of specimens from 6 patients were analyzed. The pathological findings from 8 patients who received nephrectomy were reviewed. The statistical methods consisted of the Fisher exact test (2 tailed) for categorical variables and Wilcoxon rank sum test for continuous variables to test the predictors of poor prognosis. RESULTS: Forty-six patients (96%) had diabetes mellitus, and 10 (22%) of the 46 also had urinary tract obstruction in the corresponding renoureteral unit. The other 2 nondiabetic patients (4%) had severe hydronephrosis. Twenty-one (72%) of the 29 patients with diabetes mellitus also had a glycosylated hemoglobin A(1c) level higher than 0.08. Escherichia coli (69%) and Klebsiella pneumoniae (29%) were the most common pathogens. The mortality rate in patients who received antibiotic treatment alone was 40% (2 of 5 patients). The success rate of management by percutaneous catheter drainage (PCD) combined with antibiotic treatment was 66% (27 of 41 patients). In classes 1 and 2 EPN, all the patients who were treated using a PCD or ureteral catheter combined with antibiotic treatment survived. In extensive EPN (classes 3 and 4), 17 (85%) of the 20 patients with fewer than 2 risk factors (ie, thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment; and the patients with 2 or more risk factors had a significantly higher failure rate than those with no or only 1 risk factors (92% vs 15%, P<.001 eight of the patients who had an unsuccessful treatment using a pcd underwent subsequent nephrectomy whom survived. only were managed by direct and overall success rate was total mortality five gas samples contained hydrogen all carbon dioxide pathological findings from revealed poor perfusion in most cases infarction vascular thrombosis arteriosclerosis glomerulosclerosis conclusion: acute renal infection with e coli or k pneumoniae diabetes mellitus urinary tract obstruction is cornerstone for development epn. mixed acid fermentation glucose enterobacteriaceae major pathway formation. localized epn combined antibiotic can provide good outcome. extensive more benign manifestation risks when saving kidney possible may be attempted due to high preserve kidney. however best management outcome should promptly fulminant course> |
