Risk Factors of Sepsis and Factors Influencing the Decision to Perform Emergency Drainage in Obstructive Acute Pyelonephritis Secondary to Urinary Calculi

Young Hwan Jung; Seung Chan Jeong; Minki Baek; Dong Soo Ryu

doi:10.14777/uti.2017.12.03.110

Journal List > Urogenit Tract Infect > v.12(3) > 1084215

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Jung, Jeong, Baek, and Ryu: Risk Factors of Sepsis and Factors Influencing the Decision to Perform Emergency Drainage in Obstructive Acute Pyelonephritis Secondary to Urinary Calculi

Original Article

Urogenit Tract Infect 2017;12(3):110-116.

Published online: 19 January 2017

DOI: https://doi.org/10.14777/uti.2017.12.03.110

Risk Factors of Sepsis and Factors Influencing the Decision to Perform Emergency Drainage in Obstructive Acute Pyelonephritis Secondary to Urinary Calculi

Young Hwan Jung, Seung Chan Jeong, Minki Baek¹, Dong Soo Ryu

Department of Urology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon

¹Department 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

Received 26 August 2017 Revised 12 October 2017 Accepted 13 October 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.

Abstract

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.

Keywords: Pyelonephritis, Sepsis, Urinary calculi, Nephrostomy, percutaneous, Ureteroscopy

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Table 1.

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.

Table 2.

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.

Table 3.

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.

Table 4.

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.

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