Alkaline-encrusting pyelitis - A rare disastrous complication postPCNL leading to chronic renal failure.

Alkaline-encrusting pyelitis (AEP) is a severe form of infectious disease characterized by encrustation along the lining of the urinary tract leading to loss of renal function. Common predisposing factors are chronic infection, immunosuppression, and endourology procedures. Urea-producing organisms arefrequently associated, and urine alkalization leads to calcific deposition in the pelvicalyceal system. We present a 23-year male with AEP in a solitary kidney leading to chronic renal failure postpercutaneous nephrolithotomy for renal stones.

A 23-year-old male presented with left flank pain. On evaluation, plain X-ray showed multiple left radiopaque shadows at L2–L3 level [Figure 1a]. Intravenous urogram showed left solitary functioning kidney with hydronephrosis and the presence of multiple renal stones with hypoplastic right kidney [Figure 1b]. Routine workup including hemogram, renal function test, calcium, uric acid, and urine analysis was within the normal limits. Percutaneous nephrolithotomy (PCNL) was performed after written informed consent by standard technique using mid and inferior posterior calyx puncture, and complete stone clearance was achieved. The patient was discharged on day 4 after surgery. He presented 6 days later with urine leak from nephrostomy site for which double-J stent and urethral catheter were placed. The renal functions were normal, and urine culture was sterile. In view of persistent leak, contrast-enhanced computed tomography (CT) urography was done which revealed the site of leak from the inferior calyx [Figure 2a]. Percutaneous nephrostomy (PCN) was placed through the inferior calyx, and clear urine was drained. The leak subsided within a day, and the patient was discharged; however, he returned a month later with high-grade fever, vomiting, and oliguria. On evaluation, his serum creatinine was 9.4 mg/dl and total leukocyte count of 24000/mcL. The patient was started on IV antibiotics (third-generation cephalosporin) and given two sessions of hemodialysis after nephrology evaluation. Noncontrast CT abdomen revealed left kidney hydronephrosis with calcific encrustation of the entire renal pelvis and upper ureter with PCN in situ [Figure 2b]. Alkaline-encrusting pyelitis (AEP) was the working diagnosis, and metabolic workup showed urine pH of 9.2 and serum calcium, uric acid, and citrate all within the normal limits. Extended urine culture showed Corynebacterium growth with 50–60 pus cells and confirmed the diagnosis of AEP. The serum creatinine was 3.7 mg/dl and total leukocyte counts were 9800/mcL.

Figure 1

(a) X-ray kidney, ureter, and bladder showing left radiopaque dense shadows at L2–L3 level on the left side (white solid arrow). (b) Intravenous pyelogram showing left solitary functioning kidney with presence of multiple renal stones (white solid arrow)

Figure 2

(a) Computed tomography abdomen images (axial) showing renal parenchymal enhancement with site of urine leak and double-J stentin situ(white solid arrow). (b) Noncontrast computed tomography images (coronal) showing dense calcific encrustation along the whole lining of the pelvicalyceal system and ureter (white solid arrow)

AEP is characterized by encrustation along the whole lining of the urinary tract. Corynebacterium, a urea-splitting organism, is the most common causative agent. The high urine pH favors precipitation of calcific deposits along the lining of the urinary tract.[1] It is reported in renal transplant recipients.[2] Other predisposing factors are immunosuppression, endourological procedures, and chronic urinary infection.[3] Devine et al. recently reported a case of AEP in a renal allograft recipient with multiple risk factors.[4] Post-PCNL, the sequence of events leading to AEP has never been reported. AEP should be suspected if after intervention, imaging shows calcific deposit in the urothelium with alkaline urine and Corynebacterium growth on culture. The patient was started on antibiotic vancomycin, Vitamin C supplements, and Suby G solution irrigation through the PCN and kept on close follow-up. His creatinine reached nadir 2.1 mg/dl, and urine output from PCN was 2.4 l.

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