Sunil Pillai

Background: Emphysematous pyelonephritis (EPN) is a well-known clinical condition characterized by an aggressive, gas-forming infection of the kidney caused by uropathogenic bacteria. There is growing interest in identifying the effects of EPN on long-term renal function and the factors that can help predict its impact. Objectives: This study evaluated risk factors for the development of poorly functioning kidneys (PFK) in patients diagnosed with EPN. Design: A retrospective study was conducted at a university teaching hospital on patients with EPN from January 2019 to December 2024. Methods: Data were collected from the prospectively maintained patient records, and patient demographics, comorbidities, clinical presentation, laboratory investigations, imaging characteristics, and interventions were analyzed. PFKs were defined as those with less than 15% differential function on radionuclide renography performed at follow-up. Data were analyzed using SPSS version 23 (IBM Corp.). A p -value 200 mg/dL ( p < 0.0001), >50% parenchymal involvement on imaging ( p < 0.00001), Huang-Tseng Class 3b ( p < 0.00001), and persistence of gas in the renal parenchyma on follow-up imaging ( p < 0.0001) to be significantly associated with the development of PFK. Multivariate Analysis revealed that >50% parenchymal involvement on initial imaging was an independent and significant predictor of PFK. Conclusion: EPN is a fulminant renal infection with a high risk of renal functional deterioration. Renal parenchymal involvement of >50% on initial imaging emerged as the most significant and independent predictor of poor renal function. Additional contributory factors included RBS >200 mg/dL, Huang-Tseng Class 3b, and persistence of gas in the renal parenchyma on follow-up. Recognizing these clinical and radiological predictors can support early risk stratification, guide patient counseling, and inform individualized management strategies aimed at preserving renal function.

Aim: To explore the association between urinary stone cultures and infectious complications following PCNL. Materials and Methods: An observational case–control study was conducted in patients undergoing PCNL. The assessment included demographic parameters, medical history, urinalysis, and urine culture and blood testing. Pre-operatively, urinary stone samples were collected for cultures. Post-operatively, patients were observed for infectious complications such as fever and/or SIRS. Patients were divided into two groups based on the presence or absence of infected renal calculi. Patient characteristics, stone factors, and intra-operative and post-operative findings were studied in relation to stone culture. Descriptive statistics was used to present the data and the SPSS software was used for analysis. Results: From December 2023 to March 2025, a total of 126 patients were included in the study. A total of 16 patients (12.6%) had a positive stone culture. Statistical significance was found upon the comparison of stone culture with gender (p = 0.046), chronic kidney disease (p = 0.002), pre-operative urine culture (p = 0.001), pre-operative haemoglobin (g/dL) (p = 0.038), stone volume (mm³) (p = 0.012), CROES score (p = 0.023), SIRS (p = 0.001), and AKI (p = 0.021). Conclusions: Infected renal calculi identified by positive stone cultures were strongly associated with infective complications such as fever and SIRS following PCNL. E. Coli was the dominant bacteria present in both bladder urine and renal stone culture. The occurrence of infectious complications despite the administration of pre-operative antibiotics highlights the antibiotic resistance patterns noted among the cultured bacteria. The pre-operative factors identified to be associated with a positive stone culture could potentially be used for predicting infected stones, thereby improving outcomes.

Background: Delayed graft function (DGF) is a frequent early complication after deceased donor kidney transplantation (DDKT), leading to prolonged hospitalization, increased risk of acute rejection, and reduced graft survival. Reliable and easily measurable preoperative biomarkers for DGF prediction remain limited. This study aimed to evaluate the predictive value of pre-operative Absolute Eosinophil Count (AEC) and Albumin-to-Globulin Ratio (AGR) for DGF in DDKT recipients. Methods: A retrospective analysis was conducted on all DDKT procedures performed at our institution between January 2018 and December 2023. Patients were divided into two groups: Group 1 (DGF) and Group 2 (non-DGF). DGF was defined as the requirement for hemodialysis within the first seven postoperative days. Demographic, clinical, and laboratory data—including pre-operative AEC and AGR—were collected and compared between groups. Statistical analysis was performed using appropriate parametric and nonparametric tests. Receiver operating characteristic (ROC) curves were generated to assess the individual and combined predictive performance of AEC and AGR for DGF. Results: A total of 38 patients underwent DDKT, comprising 27 males (71.05%) and 11 females (28.95%), with a mean age of 43.3 ± 9.41 years. Fifteen patients (39.47%) developed DGF. The mean AEC and AGR were significantly lower in the DGF group compared to the non-DGF group (AEC: 0.20 ± 0.16 vs. 0.40 ± 0.35, p = 0.04; AGR: 1.43 ± 0.22 vs. 1.66 ± 0.39, p = 0.02). ROC analysis demonstrated that both AEC (p = 0.04) and AGR (p = 0.04) were significant predictors of DGF. Combining both parameters resulted in a higher area under the curve (AUC), improved sensitivity, and enhanced negative predictive value (NPV) compared to either marker alone. Conclusions: DGF occurred in nearly two-fifths of DDKT recipients in this cohort. Patients with lower preoperative AEC and AGR were more likely to develop DGF, suggesting that these easily available hematological and biochemical indices can serve as potential preoperative predictors of early graft dysfunction. Future multicentric prospective studies are warranted to validate these findings and explore their integration into DGF risk prediction models.

Objectives: To evaluate the occurrence, risk factors, and outcomes of post PCNL (Percutaneous Nephrolithotomy) Acute Kidney Injury (AKI), with a secondary goal of developing a nomogram for post-PCNL AKI prediction. Methods: A prospective observational study was conducted enrolling 333 patients who underwent PCNL between February 2022 and February 2023. Patient demographics, comorbidities, perioperative lab parameters, stone characteristics, intraoperative details, and postoperative AKI were assessed. Logistic regression analyses were employed to construct a nomogram for predicting post-PCNL AKI. Results: 40 patients (12.4%) experienced postoperative AKI, with recovery observed in all cases during the 3-month follow-up. Female gender ( p = 0.002), hypertension( p = 0.022), higher serum uric acid levels( p = 0.003), staghorn calculi( p = 0.001), higher Hounsfield Units( p = 0.013), bilateral PCNL( p < 0.001), larger tract size( p = 0.017), longer operative time( p < 0.001), greater stone volume( p = 0.025), higher baseline serum creatinine levels( p < 0.001), higher postoperative total leukocyte count( p = 0.005), and postoperative fever( p < 0.001) were significantly associated with the AKI group. Regression analysis identified female gender (OR = 0.26, p = 0.035), higher serum uric acid levels(OR = 1.62, p = 0.013), bilateral PCNL(OR = 12.55, p < 0.001), longer operation time(OR = 1.02, p = 0.047), and larger stone volume(OR = 1.12, p = 0.015) as independent risk factors for postoperative AKI. The internally validated nomogram( n = 70) for predicting AKI demonstrated excellent diagnostic performance, with an area under the ROC curve of 0.984(95% CI, p < 0.001). Conclusion: AKI occurs in approximately 12% of patients undergoing PCNL. We identified several significant predictors of post-PCNL AKI, including female gender, hypertension, hyperuricemia, higher Hounsfield units, larger stone volume, bilateral PCNL, larger access tract size, and longer operative time. Awareness of these factors is crucial for optimizing management and improving patient outcomes.

Background: The overall survival rates are below 10% in patients with metastatic renal cell carcinoma (RCC) posing a significant health challenge. There is a pressing need for novel and simple predictors of metastasis in patients with RCC to aid in early detection, thereby having prognostic and therapeutic implications. Objectives: To assess the efficacy of various inflammatory markers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), Systemic Inflammatory Response Index (SIRI), and Systemic Immune-Inflammatory Index (SII), in predicting metastasis amongst individuals diagnosed with RCC. Methods: A retrospective study was undertaken at a tertiary hospital, focusing on individuals diagnosed with RCC. Patients were divided into two groups: Those with and without metastases. Patient demographics and clinical, pathological, and laboratory data were collected. The researchers evaluated the predictive capabilities of NLR, PLR, SIRI, and SII using ROC curves, with cut-off points determined via the Youden Index. Results: Of the 91 patients, 25 (27.5%) had metastatic RCC. Significant differences in NLR (P = 0.047), PLR (P = 0.004), SIRI (P = 0.006), and SII (P = 0.005) were noted between metastatic and non-metastatic groups. The ROC analysis showed that SIRI and SII had the highest predictive capacity with areas under the curve (AUCs) of 0.687 and 0.693, respectively. Logistic regression demonstrated NLR, PLR, SII, and SIRI as independent predictors of metastasis in RCC, with a combined predictive accuracy of 83.5%. Conclusions: Neutrophil-lymphocyte ratio, PLR, SIRI, and SII are reliable predictors of metastasis in RCC, with their combined use enhancing predictive accuracy. These hematological parameters can be easily derived from routine blood tests, could help in the early diagnosis of metastases, and tailor the management of RCC, improving patient outcomes. Further multicentric studies are recommended to validate these findings and help integrate them into clinical practice.

Background: The study assesses the decisional regret following Shared Decision-making (SDM) in patients selecting either early ureteroscopic lithotripsy (URSL) or medical expulsive therapy (MET) for ureteric stones ≤ 1 cm, with the aim to evaluate their decisional Conflict, satisfaction, and regret regarding their opted treatment choices. Methods: Adults aged more than 18 years with one stone up to 1 cm in either ureter were included. After SDM, the patients were allocated into their opted group viz. URSL or MET. Patients in each group were reassessed at “treatment completion”. Cambridge Ureteric Stone PROM (CUSP) questionnaire for HRQoL, Decision Regret Scale and the OPTION scale (SDM) were filled at treatment completion. Findings: 111 patients opted for MET, while 396 patients opted for early URSL. Mean stone size was larger in URSL group (7.16 ± 1.63 mm vs. 5.50 ± 1.89; p < 0.001). Decisional conflict was higher in patients opting for URSL (77.3% vs. 57.7%; p < 0.001). Stone-free rate at four weeks was higher in URSL group (87.1%vs68.5%, p < 0.001). Decisional regret was higher in patients opting for MET (33.24 ± 30.89 vs. 17.26 ± 12.92; p = 0.002). Anxiety, was higher in patients opting for MET (6.94 ± 1.89 vs. 5.85 ± 1.54; p < 0.001). Urinary symptoms and interference in patients’ travel plans and work-related activities were more in URSL group (6.21 ± 1.57 vs. 5.59 ± 1.46; p < 0.001 and 6.56 ± 1.59 vs. 6.05 ± 1.72; p < 0.001 respectively). Interpretation: After SDM, decisional regret is higher in patients opting for MET mainly due protracted treatment duration with increased pain and anxiety during the treatment course and the need for additional procedure for attaining stone clearance and the. Despite higher decisional conflict, a larger proportion of patients opt for early URSL with the aim of avoiding anxiety and achieving early stone clearance.

Background: The management of ureteric obstruction secondary to pelvic malignancies (UOPM) presents a significant challenge. Objectives: Our study aimed to assess the factors affecting the feasibility of interventions for patients with UOPM - including retrograde and antegrade double J (DJ) stenting, and percutaneous nephrostomy (PCN) insertion. Methods: We conducted a retrospective analysis of patients who underwent intervention for UOPM over two years, from January 2022 to December 2023. Patients were categorized into groups based on intervention type: Group 1: Retrograde DJ stenting, group 2: Antegrade DJ stenting, and group 3: PCN insertion. Demographic, clinical, radiological, cystoscopic, and laboratory data were compared between the three groups. Analysis of Variance (ANOVA), logistic regression, and marginal mean plots were utilized for statistical analysis. Results: Fifty–nine patients were included in the study, consisting of 14 males and 45 females, and the mean age of the study population was 60.1 ± 10.8 years. Retrograde DJ stenting was successfully achieved in 59.3% of patients, with 10.2% undergoing antegrade DJ stenting and 30.5% needing PCN insertion. Serum albumin (P = 0.04), serum creatinine (P = 0.02), albumin creatinine ratio (P < 0.001), and severity of hydroureteronephrosis (HDUN) (P = 0.02) were significantly associated with intervention outcomes. There was an increased likelihood of PCN insertion in higher serum creatinine and lower serum albumin levels. Multinomial logistic regression with univariate and multivariate analysis revealed significance among the above-mentioned variables. Conclusions: Even though DJ stenting remains common, a significant proportion of patients require PCN insertion. Serum albumin, serum creatinine, albumin creatinine ratio, and HDUN severity are significant predictors of intervention success. Further research is warranted to validate these findings and enhance management strategies for UOPM.

Purpose: To assess the safety and efficacy of super-mini PCNL (SMP, 14 Fr) when compared to standard PCNL (sPCNL, 24–30 Fr) in the management of renal calculi of size ranging from 1.5 to 3 cm. Methods: From February 2021 to January 2022, a total of 100 patients were randomized to either SMP group or sPCNL group in a 1:1 ratio (50 in each group) using computer-generated simple randomization. Demographic data, stone characteristics, operative times, perioperative complications, blood transfusions, postoperative drop in haemoglobin, postoperative pain, duration of hospital stay and stone-free rates were compared between the two groups. Results: Mean stone volume (2.41 cm² vs 2.61 cm²) and stone-free rates (98% vs 94%, p = 0.14) were similar in both the SMP and sPCNL groups, respectively. The SMP group had significantly longer mean operative times (51.62 ± 10.17 min vs 35.6 ± 6.8 min, p = 0.03). Intraoperative calyceal injury (1/50 vs 7/50, p = 0.42) and mean postoperative drop in haemoglobin (0.8 ± 0.7 g/dl vs 1.2 ± 0.81, p = 0.21) were lower in the SMP group, but not statistically significant. SMP group showed significantly lower mean postoperative pain VAS scores (5.4 ± 0.7 vs 5.9 ± 0.9, p = 0.03) and mean duration of hospital stay (28.38 ± 3.6 h vs 39.84 ± 3.7 h, p = 0.0001). Complications up to Clavien grade 2 were comparable, with grade ≥ 3 complications higher in the standard group, but not statistically significant. Conclusion: Super-mini PCNL is equally effective as standard PCNL in treating renal calculi up to 3 cm, with significantly reduced postoperative pain and duration of hospital stay and lower risk of Clavien grade ≥ 3 complications, although with higher operative times.

Introduction: Emphysematous pyelonephritis (EPN), an acute necrotizing infection of the kidney and surrounding tissues, is associated with considerable mortality. We evaluated how existing critical care scoring systems could predict the need for intensive care unit (ICU) management for these patients. We also analyzed if CT-imaging further enhances these predictive systems. Patients and Methods: A retrospective analysis of 90 consecutive patients diagnosed clinico-radiologically with EPN from January 2011 to September 2020. Five scoring systems were evaluated for their predictive ability for the need for ICU management and mortality risk: National Early Warning Score (NEWS), Modified Early Warning Score (MEWS), ‘quick’ Sequential Organ Failure Assessment score (qSOFA), Systemic Inflammatory Response Syndrome score (SIRS), and Sequential Organ Failure Assessment score (SOFA). CT images were classified as per Huang & Tseng and evaluated as stand-alone or added to the different predictive models. Receiver operating characteristic (ROC) curves were plotted for each critical care score and CT-Class using logistic regression, to obtain the area under curve (AUC) value for comparison of ICU admission predictability. Patients were analyzed up till discharge. Results: Ninety patients were diagnosed with EPN. Twenty-six patients required ICU management and nine patients died. The best scoring system to predict the need of early ICU management is NEWS (AUC 0.884). CT Class had no independent predictive power, nor did it add significantly to improvement in most of the early warning scoring systems, but rather guided us to the need for radiological, endourological or surgical intervention. Conclusion: In patients with EPN, the NEWS scoring system predicts best the requirement of ICU care. It aids in triage of patients with EPN to appropriate early management and reduce mortality risk.