uti Urogenital Tract Infection Urogenit Tract Infect 2465-8243 2465-8510 Korean Association of Urogenital Tract Infection and Inflammation 10.14777/uti.2017.12.03.110 uti-12-110 Original Article Risk Factors of Sepsis and Factors Influencing the Decision to Perform Emergency Drainage in Obstructive Acute Pyelonephritis Secondary to Urinary Calculi JungYoung Hwan JeongSeung Chan BaekMinki 1 RyuDong Soo Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon Department of Urology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Correspondence to: Dong Soo Ryu http://orcid.org/0000-0002-7557-0820 Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 158 Paryong-ro, Masanhoewon-gu, Changwon 51353, Korea Tel: +82-55-290-6551, Fax: +82-55-290-1224 E-mail: dsryumd@skku.edu 012017 19012017 123110 116 26082017 12102017 13102017 Copyright © 2017 Korean Association of Urogenital Tract Infection and Inflammation 2017 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Purpose:

To investigate the risk factors for sepsis and analyze the criteria for emergency drainage in patients with obstructive acute pyelonephritis (APN) secondary to urinary calculi.

 Materials and Methods:

We included 64 patients with obstructive APN secondary to urinary calculi. Patients were divided into two groups: the sepsis and non-sepsis groups. Independent risk factors for sepsis were also identified. Forty-three patients in the sepsis group were further divided into two subgroups: those who underwent emergency drainage and those who did not. A retrospective analysis was performed.

 Results:

Of the 64 patients, 43 showed signs of sepsis. There was a lower lymphocyte count and lymphocyte percentage, as well as a higher C-reactive protein level and neutrophil-to-lymphocyte ratio (NLR) in the sepsis group compared with the non-sepsis group. Increased sepsis showed a statistically significant association with increased Charlson comorbidity index (CCI). Four out of 21 patients in the non-sepsis group underwent emergency drainage compared with 26 out of 43 patients in the sepsis group. Independent variables for sepsis in a multivariate logistic regression analysis showed positive blood culture, high NLR, and increased CCI score. Among sepsis patients, the likelihood of performing emergency drainage increased with higher creatinine, positive urine culture, and higher CCI score.

 Conclusions:

In patients with obstructive APN secondary to urinary calculi, a high CCI score were associated with a higher probability of progression to sepsis. In patients with higher creatinine and higher CCI scores, proactive treatment is usually necessary.

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Univariable analysis of variables for sepsis between non-sepsis group and sepsis group

Variable Non-sepsis group (n=21) Sepsis group (n=43) p-value
Age (y) 65.43±16.20 61.74±14.67 0.37
Gender     0.51
  Male 5 7  
  Female 16 36  
Performance status     0.98
  0-1 17 36  
  2-4 4 1  
Hospital stay (d) 9.71±8.40 12.53±9.82 0.26
Diabetes mellitus     0.59
  No 12 28  
  Yes 9 15  
HTN/CVD/neurologic disease     0.87
  No 10 25  
  Yes 13 30  
WBC count (×10³/μl) 12.78±7.02 15.05±6.33 0.2
Lymphocyte (%) 11.20±9.44 6.70±4.42 0.011
Lymphocyte count (×10³/μl) 1.18±0.68 0.84±0.40 0.013
Neutrophil (%) 81.43±11.33 88.17±5.38 0.002
Neutrophil count (×10³/μl) 10.69±6.43 13.44±6.01 0.098
PLT count (×10³/μl) 177.19±80.03 184.65±96.16 0.76
PT-INR 1.08±0.20 1.15±0.21 0.16
CRP (mg/L) 106.69±76 207.06±111.66 0.001
Albumin (g/dl) 3.11±0.73 3.00±0.61 0.51
Creatinine (mg/dl) 1.63±1.33 1.96±1.28 0.35
Total bilirubin (mg/dl) 0.87±0.59 1.04±0.38 0.18
Urine culture     0.6
  Negative 11 19  
  Positive 10 24  
Blood culture     0.003
  Negative 18 20  
  Positive 3 23  
Hydronephrosis     0.25
  Grade 1 12 19  
  Grade 2 8 18  
  Grade 3 1 6  
Laterality     0.14
  Right 7 26  
  Left 11 16  
  Bilateral 3 1  
Stone position     0.76
  Upper 14 29  
  Middle 1 5  
  Lower 6 9  
Stone size (mm) 7.52±4.72 8.19±3.85 0.55
  NLR 10.90±8.68 18.67±12.68 0.014
  PLR 199.10±139.26 307.47±345.81 0.17
CCI     0.02
  1-2 15 6  
  3-4 4 11  
  ≥5 2 26  
Observation (n=34) 17 (50.0) 17 (50.0) 0.003
Intervention (n=30) 4 (13.3) 26 (86.7) 0.96
  URS (n=5) 0 (0) 5 (100.0)  
  PCN (n=25) 4 (16.0) 21 (84.0)  

Values are presented as mean±standard deviation, number only, or number (%).

HTN: hypertension, CVD: cardiovascular disease, WBC: white blood cell, PLT: platelet, PT-INR: prothrombin time (seconds)–international normalized ratio, CRP: C-reactive protein, NLR: neutrophil-to-lymphocyte ratio, PLR: platelet-to-lymphocyte ratio, CCI: Charlson comorbidity index, URS: ureterorenoscopy, PCN: percutaneous nephrostomy.

Multivariate analysis of independent variables for sepsis (all patients)

Variable OR 95% CI p-value
Blood culture 8.415 1.660-242.665 0.01
NLR 1.092 1.006-1.142 0.03
CCI score     0.04
  1-2 1 1  
  3-4 1.52 0.678-3.46  
  ≥5 3.70 0.45-30.37  

OR: odds ratio, 95% CI: 95% confidence interval, NLR: neutrophil-to-lymphocyte ratio, CCI: Charlson comorbidity index.

Univariate analysis of variables between the non-emergency drainage group and emergency drainage group within the sepsis group

Variable Non-emergency drainage group (n=17) Emergency drainage group (n=26) p-value
Age (y) 58.00±16.13 64.20±13.39 0.18
Gender     0.9
  Male 3 4  
  Female 14 22  
Performance status     0.69
  0-1 15 21  
  2-4 2 5  
Hospital stay 9.24±10.10 14.70±9.20 0.05
Diabetes mellitus     0.21
  No 13 15  
  Yes 4 11  
HTN/CVD/neurologic disease     0.66
  No 8 0  
  Yes 9 12  
WBC count (×103/l) 15.41±4.63 14.82±7.32 0.77
Lymphocyte (%) 6.41±2.67 6.88±5.28 0.74
Lymphocyte count (×103/l) 0.92±0.31 0.79±0.44 0.29
Neutrophil (%) 87.86±3.62 88.37±6.33 0.77
Neutrophil count (×103/l) 13.58±4.26 13.34±7.01 0.9
PLT count (×103/l) 216.29±100.20 163.96±89.34 0.05
PT-INR 1.13±0.24 1.17±0.18 0.54
CRP (mg/L) 210.26±115.04 204.97±111.64 0.88
Albumin (g/dL) 3.09±0.67 2.93±0.57 0.42
Creatinine (mg/dL) 1.43±0.72 2.30±1.45 0.02
Total bilirubin (mg/dL) 1.01±0.37 1.06±0.39 0.67
Urine culture     0.03
  Negative 11 8  
  Positive 6 18  
Blood culture     0.01
  Negative 12 8  
  Positive 5 18  
Hydronephrosis     0.15
  Grade 1 10 9  
  Grade 2 4 14  
  Grade 3 3 3  
Laterality     0.41
  Right 9 17  
  Left 7 9  
  Bilateral 1 0  
Stone position     0.99
  Upper 12 17  
  Middle 2 3  
  Lower 3 6  
Stone size (mm) 8.76±5.43 7.81±2.38 0.43
  NLR 16.24±8.65 20.27±14.70 0.31
  PLR 278.59±223.01 326.35±410.04 0.66
Septic shock     0.45
  No 15 20  
  Yes 12 6  
CCI     ＜0.001
  1-2 5 0  
  3-4 9 6  
  ≥5 3 20  

Values are presented as mean±standard deviation or number only.

HTN: hypertension, CVD: cardiovascular disease, WBC: white blood cell, PLT: platelet, PT-INR: prothrombin time (seconds)–international normalized ratio, CRP: C-reactive protein, NLR: neutrophil-to-lymphocyte ratio, PLR: platelet-to-lymphocyte ratio, CCI: Charlson comorbidity index.

Multivariabl group patients le analysis o f independent variabl les in sepsis

Variable OR 95% CI p-value
Creatinine (mg/dl) 5.03 0.82-31.02 0.04
Urine culture 1.092 1.78-350.02 0.01
CCI score     0.05
  1-2 1 1  
  3-4 1.52 1.75-5.609  
  ≥5 3.7 0.169-17.568  

OR: odds ratio, 95% CI: 95% confidence interval, CCI: Charlson comorbidity index.