Ninety-eight patients required emergency drainage by percutaneous nephrostomy or ureteral stenting for the treatment of APN with upper urinary tract calculi on a total of 101 occasions. All 98 patients were hospitalized. Emergency drainage was performed a total of 1, 2, and 3 times in 96 patients, 1 patient, and 1 patient, respectively. All cases had hydronephrosis. Table lists the characteristics of the patients and their calculi, as well as intervention and hospitalization data. The median age was 67 years (range: 29-90 years). Sixty-nine (68.3%) events occurred in females and 32 (31.7%) occurred in males. For 22 events (21.8%), calculi were located in the kidney, while calculi were in the ureter for 74 events (73.3%) and the location was unclear for 5 (5.0%). The median size of the stones was 9 mm (range: 1-78 mm). A case of stone in 1 mm diameter had a ureteral stenosis. Of the 101 events, 69 (68.3%) were associated with a positive urine culture and 36 (35.6%) with bacteremia.
The characteristics of patient, calculi, intervention and hospitalization
Of the 101 events, 90 (89.1%) were managed by ureteral stenting and 11 (10.9%) were managed by percutaneous nephrostomy. Thirteen patients (12.9%) required endotracheal intubation because their respiratory status deteriorated. The median time from onset of symptoms to drainage was 3 days (range: 0-38 days) and the median hospital stay was 11 days (range: 1-171 days). Two patients died despite receiving emergency drainage.
Table lists the laboratory data. The median white blood cell count was 12.9 × 1,000/μL (range: 0.7-38.3), the platelet count was 14.6 × 10,000/μL (range: 0.3-77.0), serum creatinine was 1.6 mg/dl (range: 0.5-11.6), CRP was 16.1 mg/dl (range: 0.1-48.2), and serum albumin was 3.2 mg/dl (range: 1.5-4.9). Of the 101 events, 79 (78.2%) had elevated serum creatinine levels above the normal range.
Laboratory data when patients were at the consultation
Table displays the complications and past history of the patients. Of the 101 events, 25 (24.8%) were associated with diabetes mellitus, 41 (40.6%) with hypertension, 20 (19.8%) with psychosis, and 11 (10.9%) with paralysis. Forty-two (41.6%) events were associated with a history of urolithiasis, 18 (17.8%) with cerebral infarction (or hemorrhage or aneurysm), and 12 (11.9%) with cardiovascular disease. The daily median estimated glomerular filtration rate (eGFR) was 63.0 ml/min (range: 6.7-178.0). The performance status was ≥ 2 in 27 (26.7%) events. In 64 (63.4%) of the 101 events, the criteria for sepsis were fulfilled and 21 (20.8%) met the criteria for septic shock.
The characteristics of complications, past history of disease and others
Comparison between the patients with and without septic shock showed that those with septic shock were significantly older (median: 74 years; range: 34-90 years) than those without septic shock (median: 64 years; range: 29-78 years) (p < 0.001) (Table ). Patients with septic shock were significantly more likely to have bacteremia than those without septic shock (71.0% vs. 26.0%) (p < 0.001). In patients with septic shock, there was a significantly shorter period from the onset of symptoms to drainage (median: 2 days; range: 0-16 days) than in those without septic shock (median: 3 days; range: 0-38 days) (p < 0.001). Furthermore, patients with septic shock had a significantly longer hospital stay (median: 14 days; range: 1-95 days) than those without septic shock (median: 10 days; range: 1-171 days) (p = 0.008). Moreover, the median white blood cell count and CRP level of patients with septic shock were significantly higher than those of patients without septic shock (21.3 × 1,000/μL and 23.2 mg/dl with septic shock vs. 11.9 × 1,000/μL and 14.7 mg/dl without septic shock) (p = 0.009 and 0.005, respectively), while the median platelet count and serum albumin level of patients with septic shock were significantly lower (8.6 × 10,000/μL and 2.7 mg/dl with septic shock vs. 17.0 × 10,000/μL and 3.2 mg/dl without septic shock) (p < 0.001 and p = 0.017, respectively) (Table ). Significantly more patients with septic shock had paralysis than among those without septic shock (33.3% vs. 5.0%, p = 0.001). Significantly more patients with septic shock also had a history of cardiovascular disease (28.6% vs. 7.5%, p = 0.016) and an ECOG performance status 2 (52.4% vs. 20.0%, p = 0.005) (Table ). However, diabetes mellitus was not a risk factor. Multivariate analysis revealed that old age (OR: 1.07, p = 0.007) and the presence of paralysis (OR: 10.78, p = 0.004) were independent risk factors for septic shock.