Battling EPN: Sparing Scalpels with Smart Drainage Strategies

Introduction: Emphysematous pyelonephritis (EPN) is a necrotizing, gas-forming infection of the renal parenchyma and perinephric tissues, predominantly affecting patients with uncontrolled diabetes mellitus. Historically associated with high mortality and managed with emergent nephrectomy, contemporary management has shifted toward renal preservation using percutaneous drainage (PCD) combined with culture-directed antimicrobial therapy. This study evaluates outcomes of a drainage-first strategy in patients with EPN and identifies predictors of successful renal salvage.  Methods: A prospective analysis was conducted of consecutive patients diagnosed with EPN at a tertiary referral centre between December 2024 and November 2025. Diagnosis and classification were based on contrast-enhanced computed tomography using the Huang and Tseng system. All patients received broad-spectrum intravenous antibiotics and hemodynamic resuscitation. Image-guided percutaneous catheter drainage was performed in patients with Class 2–4 disease or those with sepsis not responding to medical therapy. Primary outcomes included renal salvage rate and in- hospital mortality.  Results: A total of 18 patients were included. According to Huang–Tseng classification had Class 1, Class 2, Class 3A/3B, and Class 4 disease. Initial management with antibiotics plus PCD was undertaken while 1 required upfront nephrectomy due to refractory septic shock. Renal salvage was achieved in 17 patients managed with drainage-first strategy. No mortality in our study. Predictors of failure of conservative management includes diabetes altered sensorium, and extensive parenchymal destruction on imaging.  Conclusions: A structured drainage-first approach combined with aggressive resuscitation and tailored antibiotics enables high renal salvage rates in EPN, even in advanced radiological classes. Early risk stratification is critical to identify patients who may require prompt nephrectomy. Contemporary management should prioritise organ preservation where feasible, reserving surgery for refractory or non-responding cases.