Approaches to Emphysematous Pyelonephritis: Unresolved Questions and Management Predicaments

Emphysematous pyelonephritis (EPN) is a life-threatening infection of the kidney characterized by the presence of gas-forming bacteria in the renal parenchyma. It is most commonly seen in patients with diabetes mellitus, but can also occur in those with urinary tract obstruction, immunocompromised states, or renal stones. EPN carries a high mortality rate, particularly in patients presenting with advanced disease or sepsis. Mortality rates range from 15% to 30%, with higher rates seen in patients with bilateral involvement, delayed diagnosis, or severe renal failure. Prognosis largely depends on early identification, the extent of renal involvement, and the patient’s overall health, with diabetes being a significant risk factor for poor outcomes. The primary treatment for EPN involves a combination of broad-spectrum antibiotics and supportive care. Percutaneous drainage has become the preferred method for managing non-complicated cases, while nephrectomy remains critical in severe cases or when renal function is irreversibly compromised. Management of EPN presents several challenges, including the difficulty of early diagnosis due to its nonspecific symptoms and the potential for rapid disease progression. Additionally, selecting the appropriate surgical approach remains contentious, as nephrectomy is often associated with high morbidity, while conservative measures may fail in severe cases. This manuscript explores unresolved questions surrounding its classification, risk stratification, and therapeutic approaches. Emphasis is placed on the role of early diagnosis through imaging, tailored antibiotic therapy, and the balance between conservative management and surgical intervention. Improved understanding of these aspects is critical to optimizing patient outcomes and reducing mortality rates.