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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 3  |  Issue : 1  |  Page : 12-17

A comparative study of acute nonemphysematous pyelonephritis in diabetics and nondiabetics from a tertiary care hospital in South India


Department of Nephrology, Ramaiah Medical College and Hospitals, Bengaluru, Karnataka, India

Date of Submission08-Jan-2018
Date of Acceptance12-Apr-2018
Date of Web Publication19-Jun-2018

Correspondence Address:
Dr. Mahesh Eswarappa
Department of Nephrology, Ramaiah Medical College and Hospitals, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/bjhs.bjhs_2_18

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  Abstract 


AIM: The aim of this study is to analyze the clinical, biochemical, and microbiological characteristics of patients with acute nonemphysematous pyelonephritis in diabetics and nondiabetics from Indian subcontinent.
MATERIALS AND METHODS: It is a retrospective study conducted at a tertiary care hospital from January 2012 to August 2016. The hospital medical records were searched electronically for clinical, biochemical, and microbiologic data.
RESULTS: A total of 177 patients were enrolled for the study. in the diabetic group (51.9 years) was slightly higher than the nondiabetic patients (45.7 years). Nondiabetic patients presented late when compared to diabetics (6.38 days against 4.7 days). About 11.5% in diabetics against 5.8% in nondiabetics had recurrent urinary tract infection. The urine culture in the diabetics and nondiabetics showed positive growth in 43.8% and 43.2% of cases, respectively, with Escherichia coli, extended-spectrum β-lactamase, and Klebsiella being commonly identified organisms. Blood culture specimens in both the groups had high negative results with 86.5% in diabetics and 98.8% in nondiabetics. Over 90% of patients in either group responded to treatment with either antibiotic alone or in combination with double-J stenting. Temporary hemodialysis was required in 8% in diabetic group and 6% in nondiabetic group. Maintenance hemodialysis was required in approximately 3% of diabetic patients.
CONCLUSION: In our study, the incidence of acute pyelonephritis was found to be higher in patients in their fifth decade of life. Diabetics had more severe infection at presentation and consequently had poorer outcomes in terms of residual renal function and need for dialysis.

Keywords: Diabetes mellitus, nonemphysematous pyelonephritis, renal failure


How to cite this article:
Eswarappa M, Suryadevara S, John MM, Chennabasappa G. A comparative study of acute nonemphysematous pyelonephritis in diabetics and nondiabetics from a tertiary care hospital in South India. BLDE Univ J Health Sci 2018;3:12-7

How to cite this URL:
Eswarappa M, Suryadevara S, John MM, Chennabasappa G. A comparative study of acute nonemphysematous pyelonephritis in diabetics and nondiabetics from a tertiary care hospital in South India. BLDE Univ J Health Sci [serial online] 2018 [cited 2018 Jul 23];3:12-7. Available from: http://www.bldeujournalhs.in/text.asp?2018/3/1/12/234640



Diabetes mellitus is putatively associated with an increased risk of these infections as a result of poorly controlled plasma glucose concentrations, which in turn may impair granulocyte function and cell-mediated immunity. Furthermore, the neurologic dysfunction associated with diabetic neuropathy may result in a neurogenic bladder with incomplete bladder emptying, urinary stasis, and retention. The increased likelihood of urethral instrumentation may predispose these patients to infection, as may diabetic microangiopathy, which can contribute to local ischemia and impaired host defenses.[1],[2] The new oral antidiabetic drug, sodium-glucose cotransporter-2 inhibitors, has a theoretical risk of increasing the urinary tract infection (UTI), but clinically, it has not been found to significantly increase the risk of symptomatic UTIs. Type 2 diabetes is not only a risk factor for community-acquired UTI but also for health-care-associated UTI,[3] catheter-associated UTI,[4] and postrenal transplant-recurrent UTI.[5]

UTIs are the third most common infections after lower respiratory tract infection and gastrointestinal infection. Acute pyelonephritis (APN)[6] is an infection of the renal pelvis and kidney that usually results from ascent of a bacterial pathogen up the ureters from the bladder to the kidneys. APN was defined as the presence of two of the following: (a) axillary temperature ≥ 38.3°C or chills; (b) flank pain or costovertebral angle tenderness or pain on bimanual palpation of the kidney; and (c) micturition syndrome (including two or more of the following; dysuria, frequency, suprapubic pain, or urgency), together with the presence of pyuria (a positive leukocyte esterase dipstick test result, subsequently confirmed by urinalysis with more than 10 leukocytes/mL in urine without centrifuging or more than 5 leukocytes per high-power field in centrifuged sediment) or a positive urine culture.[6] APN in the USA has an incidence as high as 250,000 cases per year and requires 100,000 hospitalizations annually.[7] Women are affected five times more frequently than men but have a lower mortality.[7] APN develops when uropathogens, mainly  Escherichia More Details coli, ascend to the kidneys from fecal flora; rarely, it is caused by seeding of the kidneys by bacteremia. Risk factors include frequency of sexual intercourse, genetic predisposition, old age, urinary instrumentation, diabetes, and UTIs in the previous months. Renal transplantation, chronic renal failure, neutropenia, immunosuppression, congenital and acquired obstruction, neurogenic bladder, renal cyst, renal calculus, and atrophic or malfunctioning kidney are other predisposing conditions. E. coli is responsible for ≥ 80% of cases of APN.[8],[9] Incidence was highest among young women, followed by infants and the elderly.[10]

There are relatively sparse data from the Indian subcontinent regarding the clinical and epidemiological characteristics of APN. Hence, we conducted this study to analyze the clinical, biochemical, and microbiological characteristics of patients with acute nonemphysematous pyelonephritis, and also, outcome data were analyzed and compared between diabetics and nondiabetics.


  Materials and Methods Top


It was a retrospective study conducted at a tertiary care teaching hospital from Bangalore. We initiated the search for patient records from January 1, 2012, to 31 August 2016. We initiated the search from medical records using the keywords, i.e. Urinary tract Infection and Acute Pyelonephritis as the final diagnosis at discharge. Patient files which satisfied the definition of APN were first segregated. The files were then subjected to inclusion–exclusion criteria, and patients who matched the criteria were selected for the final data entry and analysis. Data analysis was carried out using SPSS ver. 20. Institutional ethical clearance was obtained for the above study.

Definitions have been depicted in [Table 1].
Table 1: Definitions

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Inclusion and exclusion criteria are provided in [Table 2].
Table 2: Inclusion criteria and Exclusion criteria

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  Results Top


We identified a total of 209 patients with diagnosis of acute nonemphysematous pyelonephritis. The overall cohort was subclassified into two groups, i.e. diabetic and nondiabetic. After employing the inclusion–exclusion criteria, we were able to select a total of 177 patients for the study with 96 being diabetic and 81 being nondiabetic. We had to exclude 32 patients from this list for the following reasons; 23 were postrenal transplant patients, 2 were diagnosed as having chronic pyelonephritis, and 7 (1 in nondiabetic group and 6 in diabetic group) patients left the hospital with incomplete workup [Table 3].
Table 3: Baseline patient characteristics

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The mean age of patients in the diabetic group (51.9 years) was slightly higher than the nondiabetic patients (45.7 years). About 19.8% in diabetic group and 14.8% in the nondiabetic group were over 65 years. There was no sex preponderance noted in either group in our study (m: f = ~1). Fever with chills, nausea, vomiting, and constitutional symptoms such as generalized weakness and anorexia were reported with nearly equal frequency in both groups [Table 1]. However, nondiabetic patients had longer duration of fever with chills before presenting to the hospital (6.38 days' mean in nondiabetics against 4.7 days' mean in diabetics). Uremic symptoms, abdominal pain, hematuria, and oliguria were also noted with the same frequency in either group. Dysuria (78.9% vs. 70.4%, P = 0.19) and increased frequency of micturition (77.9% vs. 69.1%, P = 0.187) were observed with slightly higher frequency in diabetics but were not significant statistically. The diabetic patients presented more frequently with severe symptoms such as shock (12.5% vs. 2.4%, P = 0.068) and depressed level consciousness (7.4% vs. 1.2%, P = 0.052). The mean baseline serum creatinine estimated at the time of admission, the peak value attained during the hospital stay was only marginally higher in the diabetic group. Along with this, the diabetic cohort had a higher incidence of hypertension (n = 34 vs. 17) and recurrent UTI (11.5% vs. 5.8%) as comorbid conditions. Nearly 8.6% of the patients in the nondiabetic group were on immunosuppressive therapy with steroids due to primary glomerular disorders, which increased their risk for pyelonephritis [Table 4].
Table 4: Comorbidities

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All the patients in our study were subjected to blood and urine cultures. Urine culture was positive in only 43.8% in diabetics and 43.2% in nondiabetics. The microbial profile was also similar between the groups with E. coli, extended-spectrum β-lactamase, and Klebsiella being the commonly identified organisms [Figure 1]. Majority of the blood cultures were sterile. Among the positive results, it was found that bacteremia was more frequent in diabetics when compared to nondiabetics (13.5% vs. 1.2%) [Table 5].
Figure 1: Microbiological profile

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Table 5: Urine and blood culture in diabetic and nondiabetic group

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Over 90% of patients in either group responded to treatment with either antibiotic alone or in combination with double-J (DJ) stenting [Table 4]. Temporary hemodialysis was required only in 8% of patients with diabetes and 6% in nondiabetic group. While most of these patients recovered in nondiabetic group, maintenance hemodialysis was required in approximately 3% of patients with diabetes (n = 3). The residual renal function at the time of discharge declined significantly in the diabetic group, and they also had lower serum sodium levels when compared to the nondiabetics [Table 6].
Table 6: Treatment

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  Discussion Top


APN is a form of complicated UTI and its incidence is higher in elderly population, female sex, and diabetics. In the present study, we aimed to analyze the clinical, biochemical, and microbiological characteristics of patients with acute nonemphysematous pyelonephritis in diabetics and compare it with nondiabetic patients from Indian subcontinent. In the demographic data, we found that diabetic patients presented with acute nonemphysematous pyelonephritis at a later age (51.9 years) when compared to nondiabetics (45.7 years). This finding was similar to Kim et al.,[12] where the diabetic group showed a higher median age at presentation than the nondiabetic group in community-acquired pyelonephritis. It is believed by conviction and data supporting to suggest that diabetics are at more risk of developing pyelonephritis owing to a state of immunodeficiency caused by diabetes mellitus and also the fact that glucose is a good medium for the growth of organisms. The possible explanation for this finding would be that the nondiabetic group might have had some other predisposing condition, which made them more vulnerable to this condition. This finding was contradictory to the findings of Kumar et al.[13] and Akbar,[14] where pyelonephritis was more common in females compared with male sex.

In analyzing the symptoms, we found that fever was the most common presenting symptom in both the groups. There was no significant difference in the symptomatology and their frequency between the two groups. Interestingly, it was noted that diabetic patients were presenting to the hospital earlier when compared to their nondiabetic counterparts. Average duration of the fever before coming to hospital was 6.3 days in nondiabetics when compared to 4.7 days in diabetic patients. Recurrent UTI was also more common in diabetics when compared to nondiabetic population. In spite of diabetes mellitus being a partial immunosuppressive state, patients are able to mount an inflammatory response, and the presence of fever should prompt a clinician to a serious underlying infection in diabetics. In the absence of a focus of infection, urinary tract should be evaluated for a possible source of infection.

Diabetic patients with pyelonephritis are more likely to have leukocytosis and azotemia when compared to the nondiabetic counterparts. This can partly be explained by some degree of preexisting renal dysfunction in diabetics, which itself is a risk factor for worsening renal function. This finding was highlighted in studies by Kim et al.[11] and Kumar et al.[13] The finding in our study was no different, and diabetic patients were more likely to have azotemia than nondiabetic patients.

Gil-Ruiz et al.[15] in their study on electrolyte disturbances in APN in infants showed that hyperkalemia was a consistent finding which was unresponsive to treatment. The explanation given was aldosterone resistance which might be secondary to inflammation of interstitium. In our study, there were significant electrolyte disturbances (hyponatremia [P = 0.001] and hyperkalemia [P = 0.065]) in diabetic group compared to nondiabetic group which might be due to the hyporenin state of diabetes mellitus. In our study, the presence of fever, azotemia, hyponatremia, and hyperkalemia was consistent with the diagnosis of APN.

In our study, positive urine cultures were observed in 43.8% in diabetic group and 43.2% in nondiabetic group. In a study by Foxman et al.,[16] culture confirmation was available for only 2408 (59%) of 4059 individuals who received a diagnosis of pyelonephritis. In our study, E. coli was the most common organism isolated from both the groups followed by Klebsiella, Enterococcus, Staphylococcus, and Candida. This finding was similar to all previously published data.

Over 90% of patients in either group responded to treatment with either antibiotic alone or in combination with DJ stenting. Temporary hemodialysis was required in 8% of patients in the diabetic group and 6% in the nondiabetic group. Maintenance hemodialysis was required in approximately 3% of diabetic patients and none in the nondiabetic group. This again establishes the fact that preexisting renal dysfunction is a risk factor for permanent renal dysfunction following acute kidney injury.


  Conclusion Top


In our study, the incidence of APN was found to be higher in patients in their fifth decade of life. Interestingly, hyperglycemia and gender were not significant confounding factors in the incidence of APN although diabetics had more severe infection at presentation and consequently had poorer outcomes in terms of residual renal function and need for dialysis.


  Strength of the Study Top


This is a largest South Indian study comparing diabetics and nondiabetics with APN.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rayfield EJ, Ault MJ, Keusch GT, Brothers MJ, Nechemias C, Smith H, et al. Infection and diabetes: The case for glucose control. Am J Med 1982;72:439-50.  Back to cited text no. 1
    
2.
Wheat LJ. Infections in Diabetes. Diabetes Care 1980;3:187-97.  Back to cited text no. 2
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3.
Datta P, Rani H, Chauhan R, Gombar S, Chander J. Health-care-associated infections: Risk factors and epidemiology from an Intensive Care Unit in Northern India. Indian J Anaesth 2014;58:30-5.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Lee JH, Kim SW, Yoon BI, Ha US, Sohn DW, Cho YH, et al. Factors that affect nosocomial catheter-associated urinary tract infection in Intensive Care Units: 2-year experience at a single center. Korean J Urol 2013;54:59-65.  Back to cited text no. 4
    
5.
Lim JH, Cho JH, Lee JH, Park YJ, Jin S, Park GY, et al. Risk factors for recurrent urinary tract infection in kidney transplant recipients. Transplant Proc 2013;45:1584-9.  Back to cited text no. 5
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Colgan R, Williams M, Johnson JR. Diagnosis and treatment of acute pyelonephritis in women. Am Fam Physician 2011;84:519-26.  Back to cited text no. 6
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Ramakrishnan K, Scheid DC. Diagnosis and management of acute pyelonephritis in adults. Am Fam Physician 2005;71:933-42.  Back to cited text no. 7
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8.
Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE, et al. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med 2005;142:20-7.  Back to cited text no. 8
    
9.
Talan DA, Stamm WE, Hooton TM, Moran GJ, Burke T, Iravani A, et al. Comparison of ciprofloxacin (7 days) and trimethoprim-sulfamethoxazole (14 days) for acute uncomplicated pyelonephritis pyelonephritis in women: A randomized trial. JAMA 2000;283:1583-90.  Back to cited text no. 9
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10.
Czaja CA, Scholes D, Hooton TM, Stamm WE. Population-based epidemiologic analysis of acute pyelonephritis. Clin Infect Dis 2007;45:273-80.  Back to cited text no. 10
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Stamm WE. Measurement of pyuria and its relation to bacteriuria. Am J Med 1983;75:53-8.  Back to cited text no. 11
    
12.
Kim Y, Wie SH, Chang UI, Kim J, Ki M, Cho YK, et al. Comparison of the clinical characteristics of diabetic and non-diabetic women with community-acquired acute pyelonephritis: A multicenter study. J Infect 2014;69:244-51.  Back to cited text no. 12
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13.
Kumar S, Ramachandran R, Mete U, Mittal T, Dutta P, Kumar V, et al. Acute pyelonephritis in diabetes mellitus: Single center experience. Indian J Nephrol 2014;24:367-71.  Back to cited text no. 13
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14.
Akbar DH. Urinary tract infection. Diabetics and non-diabetic patients. Saudi Med J 2001;22:326-9.  Back to cited text no. 14
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15.
Gil-Ruiz MA, Alcaraz AJ, Marañón RJ, Navarro N, Huidobro B, Luque A, et al. Electrolyte disturbances in acute pyelonephritis. Pediatr Nephrol 2012;27:429-33.  Back to cited text no. 15
    
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Foxman B, Ki M, Brown P. Antibiotic resistance and pyelonephritis. Clin Infect Dis 2007;45:281-3.  Back to cited text no. 16
[PUBMED]    


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