临床肾脏病学会杂志

ISSN:2576 - 9529

研究文章

气性肾盂肾炎——案例系列从一个中心在印度南部

Phanisri Alaparthi¹,Shobhana Nayak饶^{2 *}Pradeep谢诺伊米³

¹研究生一般医学K。对冲基金医学学院,Derlakatte,芒格洛尔575013年,印度
²美国肾脏学副教授,K。对冲基金医学学院,印度芒格洛尔
³肾脏学助理教授,K。对冲基金医学学院,印度芒格洛尔

*通信地址:Shobhana Nayak Rao副教授和头部,肾脏学,K。对冲基金医学学院,芒格洛尔、印度电话号码:+ 91-824-2204471-76;传真:0824 - 2204016;电子邮件:nayak_shobhana@rediffmail.com

日期:提交:2018年4月17日;批准:2018年5月02;发表:2018年5月03

本文引用:Alaparthi P,饶SN,谢诺议员。气性肾盂肾炎——案例系列从一个中心在印度南部。J临床Nephrol。2018;2:020 - 024。DOI:10.29328 / journal.jcn.1001014

版权许可:©2018 Alaparthi p . et al。这是一个开放的文章在知识金博宝app体育共享归属许可下发布的,它允许无限制的使用,分布,在任何介质,和繁殖提供了最初的工作是正确引用。

关键词:气性肾盂肾炎;死亡率肾切除术;经皮肾造口术

气性肾盂肾炎(杀虫剂)是一种罕见但有可能致命的坏死性感染肾实质特征是少的生产天然气。报道在西方国家流行仍低1 - 2例/年泌尿外科实践。然而印度次大陆的患病率可能更高可能由于较高的治疗糖尿病,一个明确的诱发危险因素。直到二十年前,杀虫剂的标准治疗是影响肾脏的肾切除术,因为努力保护肾脏的非手术治疗导致死亡60 - 80% [1]。情况已经过去二十年以来,然而显著改善随着计算机断层扫描(CT)的诊断和抗生素治疗的进步以及多学科重症脓毒症导致的整体死亡率下降20 - 25% [2]。我们提出我们的案例12系列杀虫剂治疗患者在我们在南印度西部高等护理中心。

我们回顾性分析了连续12的医疗记录病例的气性肾盂肾炎承认2014年1月- 2016年5月在KS。对冲基金医学学院、三级保健医院医学院在芒格洛尔。人口数据、临床和实验室资料和病人结果记录。糖尿病(DM)的存在和持续时间以及其他诱发因素,如发现有尿路梗阻。肾功能、血流动力学状态和意识水平在初始陈述相关的生化参数记录。最初的诊断是记录为急性肾盂肾炎(APN),尿脓毒病或多器官功能障碍(插件)。APN的三合会被诊断为发热、腰痛和排尿困难。尿脓毒病被定义为标记的脓尿脓毒症综合征和积极的尿/血培养。插件被定义为临床或生化标记两个或两个以上的器官系统功能障碍的脓毒症的存在。急性肾损伤是界定为肾小球滤过率(GFR)下降50%相比,血清肌酐水平的基线或海拔超过0.3 mg / dl相比以前记录报告或足够的液体复苏后第一个值。 Diagnosis of EPN was based on either initial ultrasound evidence of gas in renal parenchyma, confirmed by CT scan of abdomen in all patients. Cases were classified into four classes based on CT findings as described by Huang and Tseng [3]. We analyzed the difference in clinical features, management and outcome among the different clinic-radiological classes of EPN. All patients were treated by the multidisciplinary team comprising of the nephrology, urology and intensive care team if the patient was in the ICU. Standard treatment protocols for fluid resuscitation, insulin therapy as well as antibiotic therapy were followed. Empirical antibiotic treatment was with use of third generation cephalosporin and or piperacillin/tazobactum with adequate dosage modification for renal failure. Combination of antibiotics was used in all patients as first line therapy and then changed depending on the microbiological culture reports of blood/urine. The need for renal replacement therapy (RRT) was based on clinical and biochemical indication. Continuous variables are stated as mean±standard deviation comparison of means analyzed by student t-test and categorical variables by Fischer’s exact test. Predefined risk factors for mortality as well as renal failure namely: age (<60or > 60 ys), gender (male vs female), duration of diabetes mellitus (<10 yrs or >10 yrs), CT grading, serum creatinine at presentation, altered sensorium septic shock, thrombocytopenia and mode of treatment (medical therapy alone vs intervention). Two sided p value of <0.05 was considered significant. Statistical analysis was done using STATA version 14.0 (Stata Tex, USA).

如表1所示,共有12个杀虫剂确诊患者在研究期间(6 6雌性和雄性)。11/12(91.6%)的患者的糖尿病或被诊断出糖尿病患者在住院期间。5例(41.6%)患者除了有相关泌尿道阻塞输尿管的结石。我们组的平均年龄为59.92岁,女性的平均年龄是58.8和61岁男性,这是统计学上没有不同。血糖控制不佳的患者8例有糖化Hb 7 - 10% > 10%, 3例有水平反映非常控制不好的疾病。临床表现与比例导引的7例,尿脓毒病3例2和地图。10例(83.3%)患者在我们的研究中提出了肾脏功能障碍在入学所定义的血清肌酐> 1.5 mg / dl。血清肌酐的平均值为3.19 mg / dl, 8/12 (66.6%) > 2.5 mg / dl水平标志着中度到重度肾功能衰竭。肾脏替代治疗血液透析或缓慢的低效率的形式需要透析(雪橇)在我们组3例(25%)。33.3%的病人也面对改变的感觉器官,虽然没有一个病人昏迷入院的时候。 Septic shock requiring aggressive fluid resuscitation with/without ionotropic support was needed in 3 (25%) of patients. Thrombocytopenia was defined as platelets <1.5 lakh/cmm was noted in only 2 (16.6 %), hyponatremia (serum sodium<135meq/L) in 10 (83.3%) and hypoalbuminaemia (serum albumin<3.5g/dl) in 9 (75%) of patients.

大肠杆菌was the predominant organism isolated on blood and/or urinary culture in 10/12 (83.4%). One patient was culture negative while one patient had double culture positive with E.coli and Klebsiella species grown on culture. Patients were classified based on CT scan grading and Grade 1 with presence of gas in renal parenchyma was the predominant CT grade with 7 patients (58.7%%) presenting with this picture, grade 2 in 16.6% ( as shown in Fig 1) and grade 3 (bilateral involvement) in 25% of patients . All patients received broad spectrum antibiotics therapy with standard antibiotic regimen of piperacillin/tazobactum which was later modified to add ertapenem or meropenem based on culture sensitivity reports. 6 (50%) required DJ stenting and 3 (25%) patient required percutaneous drainage while the remaining patients improved with medical management alone. We did not have any mortality in our study, 10 patients recovered while 2 patients were discharged against medical advice and hence lost to follow-up. We did not perform prognostic risk factor analysis in our study since we had no mortality. We looked at risk factors between patients who required hemodialysis vs those who were conservatively treated. None of the conventional risk factors such as renal failure, thrombocytopenia and hypoalbuminaemia impacted patient outcome in our group. Duration of hospitalization however was longer in those (>2 weeks) with low serum albumin <3.5mg/dl (p=0.035).

杀虫剂被定义为坏死性感染肾实质及其周边地区导致气体的存在肾实质,收集系统或肾周的组织。这个词首次使用杀虫剂由舒尔茨和花里胡哨[4],虽然它在1898年首次报告为气尿。杀虫剂是报道与各种研究报告更常见于女性比例从3:1到43:3 (5、6)。这是归因于这样一个事实:无症状菌尿是在女性中更为常见。在我们的研究中,50%的女性患者。杀虫剂也常见的糖尿病患者和高达90%的糖尿病控制不佳[5]。所有病人在我们的例子中系列是糖尿病患者和所有与糖化血红蛋白控制不好> 7%。使人患糖尿病易患杀虫剂的因素可能包括不受控制的糖尿病,高水平的糖化血红蛋白和宿主免疫机制受损。酒精发酵的葡萄糖与二氧化碳生产organsims已被确认为源气体的组织。杀虫剂的气体含量分析表明氮气(60%)、氢(15%)、二氧化碳(5%)和氧(8%)[7]。 Unilateral or bilateral urinary tract obstruction is also a documented risk factor, however the disease has been reported to be less extensive in them. 6 (50%) of our patients had hydronephrosis secondary to ureteric calculi necessitating DJ stent placement. This incidence has been higher than previously reported studies and is worth noting. Most patients also presented with less extensive disease (CT grading) thereby accounting for good clinical outcomes in our group. Even in patients with no obstruction, placement of a urinary stent has been previously used to facilitate drainage of purulent material and hasten recovery. Placement of a urinary drainage may facilitate recovery by drainage of pus and necrotic papillary material. The association of two documented risk factors namely diabetes mellitus and urinary tract obstruction has also been rarely reported in previous studies so far. Since we had only no mortality in our group we did not analyse the prognostic risk factors predicting bad outcome proposed by Huang and Tseng [3], including thrombocytopenia, renal failure and shock. Previously reported Indian series of patients with EPN have also reported a female preponderance with mortality rates of 13-14% [8-12]. Certain factors have been associated with poor outcomes in EPN, these bad prognostic factors include thrombocytopenia, azotemia, hematuria, altered sensorium, shock (systolic BP<90mm of Hg) at initial presentation, need for emergency hemodialysis, severe hypoalbuminemia (serum albumin<3.0mg/dl), extension into the perinephric space and polymicrobial infection [10,11].

杀虫剂已经改变了患者的临床方法。由于先进的医学影像、介入放射学更新更有效的抗生素和更好支持重症监护,包括透析患者杀虫剂有更好的结果。管理杀虫剂更保守也因此成为标准的护理[13]。系统回顾气性肾盂肾炎患者的回顾性研究包括210对干预措施的时机和性质指出,死亡率与医疗管理+经皮引流明显低于医疗管理+紧急切除(13.5% vs 25%) [14]。最近的一个荟萃分析还与患者死亡率增加相关的肾切除术,并再次强调保守的相关性和微创程序[15]。

早期干预的位置intraureteric支架有或没有经皮肾造口术引流可以解释较低的死亡率在我们的研究中。175年七回顾性队列研究的荟萃分析气性肾盂肾炎患者[2],看着23个风险因素的总体死亡率25%。四个主要风险因素显著增加死亡率的风险是:第4类杀虫剂,肾实质坏死和气体/液体内容,保守治疗定义为液体复苏和抗菌素没有PCD和血小板减少。

我们的研究是有限的回顾性设计、小型这限制了统计推断。然而杀虫剂仍然是一个相对罕见的疾病在医学实践肾脏学或泌尿实践。大多数的研究也报道很少或类似的病人数字(9 - 11、13)。在我们的研究中,早期和积极的液体治疗,血糖控制和抗生素治疗以及明智地使用支架植入手术患者是有助于成功的管理我们的杀虫剂。尽管多个风险因素被发现在45%的患者中,提示干预加上抗生素治疗和良好的支持性护理改善患者的结果。因此微创方法是成功的。

杀虫剂的临床情况已经改变随着时间的推移,反映在我们的研究。杀虫剂在过去十年与病人的生存。然而随着意识,提高可用性和降低阈值成像方法的CT扫描患者严重的尿路感染和败血症,更多的患者数量现在诊断为杀虫剂导致更好的病人在早期阶段的结果。也有一个明显的趋势管理杀虫剂以最少的干预更为保守,这已成为标准治疗。与我们研究设计和小样本大小的限制,我们可以得出这样的结论:CT分级患者病变(2)可以成功地与一个保守的管理计划。肾功能衰竭的表现不应阻碍经皮干预和康复可以预期在这个组。