Dongmei Liu et al., 2024: The association between renal pelvis urine density and the risk of severe infectious complications in patient with symptom-free hydronephrosis after shock wave lithotripsy: a multi-center prospective study
Dongmei Liu # 1 , Junlong Liu # 1 , Zheming Li # 1 , Chengshan Ge 2 , Hongqiang Guo 2 , Shiyu Song 3 , Zhenhua Li 4 , Song Bai 5
1Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
2The Fifth Hospital of Liaoyang City, Liaoyang, China.
3Luhe Hospital of Yingkou City, Yingkou, China.
4Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
5Department of Urology, Shengjing Hospital of China Medical University, 36 Sanhao Street, Shenyang, Liaoning, 110004, People's Republic of China.
#Contributed equally.
Abstract
Finding reliable and easy-to-obtain predictors of severe infectious complications after shock wave lithotripsy (SWL) is a major clinical need, particular in symptom-free hydronephrosis. Therefore, we aim to prospectively investigate the predictive value of Hounsfield units (HU) in renal pelvis urine for the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL. This multi-center prospective study was conducted from June 2020 to December 2023. The HU of renal pelvis urine was measured by non-enhanced computed tomography. The severe infectious complications included systemic inflammatory response syndrome, sepsis, and septic shock. Binary logistic regression models assessed the odds ratios (ORs) and 95% confidence intervals (CIs). Finally, 1,436 patients with ureteral stones were enrolled in this study. 8.9% (128/1,436) of patients experienced severe infectious complications after SWL treatment. After adjusting confounding variables, compared with the patients in the lowest renal pelvis urine density quartile, the OR (95% CI) for the highest quartile was 32.36 (13.32, 78.60). There was a positive linear association between the HU value of renal pelvis urine and the risk of severe infectious complications after SWL (P for trend < 0.001). Furthermore, this association was also observed stratified by age, gender, BMI, stone size, stone location and hydronephrosis grade (all P for interaction > 0.05). Additionally, the nonlinear association employed by restricted cubic splines is not statistically significant (nonlinear P = 0.256). The AUROC and 95%CI of renal pelvis urine density were 0.895 (0.862 to 0.927, P value < 0.001). The cut-off value was 12.0 HU with 78.59% sensitivity and 85.94% specificity. This multi-center prospective study demonstrated a positive linear association between HU in renal pelvis urine and the risk of severe infectious complications in patients with ureteral stones and symptom-free hydronephrosis after SWL, regardless of age, gender, BMI, stone size, stone location, and hydronephrosis grade. These findings might be helpful in the SWL treatment decision-making process.
Urolithiasis. 2024 Apr 29;52(1):72. doi: 10.1007/s00240-024-01572-5. PMID: 38683224
Comments 1
Stone removal with SWL is one of the greatest inventions in the care of patients with urinary tract stones. Although the outcome varies because of lithotripter capacity, treatment method and necessary precautions, the choice of this non-invasive approach usually is superior for avoiding potential serious complications. The two most feared side effects are renal hematomas and infection leading to septicemia. Infection complications can be counteracted by a careful medical history and examination with bacterial tests and/or cultures. Appropriate treatment with antibiotics usually is sufficient.
However, as shown in this article, infected urine might be present in patients with asymptomatic hydronephrosis, in which patients’ urine cultures might be negative. The conclusion from a study in 1436 patients disclosed that there was a positive association between the HU-value of pelvic urine and severe infection complications following SWL. The severe infections were SIRS, septicemia and septic shock. All such patients need appropriate attention before SWL or any other surgical intervention.
Interestingly a cut-off value for HU of pelvic urine was 12.0.
The important bottom-line of this article is that despite negative urine cultures a high HU of pelvic urine should be observed and urine diversion together with antibiotic treatment carried out before proceeding with SWL.
This is an important note that might be of great help to counteract unexpected serious infection complications following SWL.
Hans-Göran Tiselius