Stepwise treatment strategies and prognostic determinants in emphysematous pyelonephritis: A retrospective 10-year high-volume centre experience

Objective: To identify clinical, microbiological, and radiological factors associated with mortality in patients with emphysematous pyelonephritis (EPN) and to assess renal outcomes according to treatment strategy at a high-volume centre in Northern Mexico. Methods: We conducted an ambispective cross-sectional study including 125 patients diagnosed with EPN between 2014 and 2024. Clinical, laboratory, and imaging data were collected. Disease severity was classified using the Huang-Tseng system. Patients were managed with medical therapy alone, minimally invasive intervention (MMI), or nephrectomy. Univariate and multivariate logistic regression analyses were performed to identify independent predictors of mortality. Results: The mean age was 50.2 years, and 78.4% were women. Diabetes mellitus was present in 84.8% of cases. Escherichia coli was the most frequent pathogen (67.1%), and 34.2% of isolates were ESBL-producing. Overall mortality was 9.6%. On multivariate analysis, advanced age (OR = 1.08; 95% CI = 1.02–1.15; p = 0.008) and Huang-Tseng ⩾ 3b (OR = 5.68; 95% CI = 1.41–22.96; p = 0.015) were independent predictors of mortality. eGFR significantly improved after MMI (37.1→54.7 mL/min/1.73 m 2 ; p < 0.001) and nephrectomy (21.5→59.2 mL/min/1.73 m 2 ; p = 0.009), but not with medical therapy alone ( p = 0.82). Conclusions: Advanced radiological severity and older age were the strongest predictors of mortality in EPN. Minimally invasive management and timely nephrectomy improved renal function among survivors, highlighting the importance of early, individualised, and stepwise treatment guided by radiological staging and clinical stability. Level of evidence: III