Managing Emphysematous Pyelonephritis in Bilateral Disease or a Solitary Kidney

This protocol addresses two high-stakes presentations of emphysematous pyelonephritis (EPN): patients with bilateral EPN — who form a select, particularly vulnerable group — and patients with EPN involving a solitary (single) kidney, where the consequences of nephrectomy are especially severe.

In bilateral disease, a more conservative approach is appropriate; however, when a kidney is beyond salvage, nephrectomy should not be withheld. In a patient who has EPN in only a single kidney, conservative treatment is strongly preferred in order to avoid the patient becoming anephric and requiring lifetime dialysis or transplantation.

The preferred strategy is kidney-preserving, conservative management. A minimally invasive drainage procedure is considered the treatment of choice over open surgical approaches, combined with antibiotics and supportive care — though the full protocol specifies how clinical status and imaging findings guide each step.

Full regimen, sequencing, and monitoring criteria available in the complete protocol.

The primary endpoint is radiological resolution: a follow-up CT scan confirming disappearance of gas and resolution of inflammation — a process that may take up to 12 weeks.