Introduction
Clinical features of patients with ADPKD in Japan
Imaging modalities for the diagnosis of cyst infection in Japan
Identification of infected cysts in ADPKD
Cases (n = 88) | Controls (n = 147) | Sensitivity | Specificity | |
---|---|---|---|---|
High SI on DWI (%) | 86.4 | 66.7 | 86.4 | 33.3 |
Fluid-fluid level (%) | 50.0 | 12.9 | 50.0 | 87.1 |
Wall thickening (%) | 48.3 | 10.9 | 48.3 | 89.1 |
Fluid-fluid level or wall thickening (%) | 84.1 | 19.7 | 84.1 | 80.3 |
Gas (%) | 1.1 | 0 | 1.1 | 100 |
At least one of these four features (%) | 100 | 68.0 | 100 | 32.0 |
High SI on DWI with diameter > 5 cm (%) | 69.3 | 15.6 | 69.3 | 84.4 |
Fluid-fluid level or wall thickening with diameter > 5 cm (%) | 72.7 | 8.8 | 72.7 | 91.2 |
At least one of these four features with diameter > 5 cm (%) | 83.0 | 18.4 | 83.0 | 81.6 |
All episodes in cases (n = 88) | Cases with TKLV < 3000 cm3 (n =13) | Cases with TKLV 3000 to < 5500 cm3 (n = 39) | Cases with TKLV 5500 to 8500 cm3 (n = 17) | Cases with TKLV >8500 cm3 (n =17) | p value | |
---|---|---|---|---|---|---|
Number of episodes M/F) | 88 (39/49) | 13 (0/13) | 39 (16/23) | 17 (8/9) | 17 (14/3) | <0.0001 |
Age | 64.6 ± 10.7 | 63.4 ± 17.1 | 65.5 ± 11.0 | 66.6 ± 7.7 | 61.8 ± 5.8 | NS |
Renal function (Dialysis %) | 80.2 | 92.3 | 76.9 | 70.6 | 88.2 | NS |
High SI on DWI (%) | 86.4 | 92.3 | 82.5 | 82.4 | 94.4 | NS |
Fluid-fluid level (%) | 50.0 | 38.5 | 55.0 | 58.8 | 38.9 | NS |
Wall thickening (%) | 48.3 | 53.9 | 45.0 | 47.1 | 52.9 | NS |
Fluid-fluid level or wall thickening (%) | 84.1 | 84.6 | 85.0 | 82.4 | 83.3 | NS |
Gas (%) | 1.1 | 0 | 2.5 | 0 | 0 | NS |
At least one of these four features (%) | 100 | 100 | 100 | 100 | 100 | NS |
High SI on DWI with diameter > 5 cm (%) | 69.3 | 53.9 | 67.5 | 82.4 | 72.2 | NS |
Fluid-fluid level or wall thickening with diameter > 5 cm (%) | 72.7 | 53.9 | 75.0 | 82.4 | 72.2 | NS |
At least one of these four features with diameter > 5 cm (%) | 83.0 | 61.5 | 85.0 | 100.0 | 77.8 | NS |
All controls (n = 147) | Controls with TKLV < 3000 cm3 (n = 39) | Controls with TKLV 3000 to < 5500 cm3 (n = 35) | Controls with TKLV 5500 to <8500 cm3 (n = 35) | Controls with TKLV >8500 cm3 (n = 38) | p alue | |
---|---|---|---|---|---|---|
Number of patients M/F) | 147 (62/85) | 39 (14/25) | 35 (14/21) | 35 (19/16) | 38 (15/23) | NS |
Age (years) | 53.3 ± 11.0 | 50.3 ± 14.7 | 52.3 ± 8.8 | 55.4 ± 9.5 | 55.4 ± 9.1 | NS |
Renal function (Dialysis %) | 49.0 | 5.1 | 31.4 | 74.3 | 86.8 | < 0.0001 |
Without high SI on DWI (%) | 33.3 | 69.2 | 37.1 | 14.3 | 10.5 | < 0.0001 |
Without fluid-fluid level (%) | 87.1 | 100.0 | 82.9 | 82.9 | 81.6 | < 0.01 |
Without wall thickening (%) | 89.1 | 100.0 | 94.3 | 82.9 | 79.0 | < 0.005 |
Without fluid-fluid level or wall thickening (%) | 80.3 | 100.0 | 82.9 | 71.4 | 65.8 | < 0.0001 |
Without gas (%) | 100 | 100 | 100 | 100% | 100 | NS |
None of the four features (%) | 32.0 | 69.2 | 34.3 | 14.3 | 7.9 | < 0.0001 |
Without high SI on DWI (diameter > 5 cm) (%) | 84.4 | 100.0 | 94.3 | 77.1 | 65.8 | 0.0001 |
Without fluid-fluid level or wall thickening (diameter > 5 cm) (%) | 91.2 | 100.0 | 94.3 | 94.3 | 76.3 | < 0.005 |
Without at least one of the four features (diameter > 5 cm) (%) | 81.6 | 100.0 | 91.4 | 74.3 | 60.5 | 0.0001 |
Poor prognostic factors influencing cyst infection in ADPKD
Causative microorganisms for cyst infection and susceptibility to lipid-soluble antibiotics
Isolates | LVFX | CPFX | TS | |
---|---|---|---|---|
Cyst fluid culture in renal cyst infection | Escherichia coli (11 episodes in 11 patients) * | 54.5% (6/11) | 54.5% (6/11) | 63.6% (7/11) |
Klebsiella (2 episodes in 2 patients) | 100% (2/2) | 100% (2/2) | 100% (2/2) | |
Enterobacter (n = 0) | NA | NA | NA | |
Pseudomonas aeruginosa (n = 0) | NA | NA | NA | |
Cyst fluid culture in hepatic cyst infection | Escherichia coli (23 episodes in 20 patients) † | 21.7% (5/23) | 21.7% (5/23) | 65.2% (15/23) |
Klebsiella spp. (9 episodes in 9 patients) ‡ | 88.9% (8/9) | 88.9% (8/9) | 88.9% (8/9) | |
Enterobacter spp. (4 episodes in 4 patients) | 75.0% (3/4) | 75.0% (3/4) | 100% (4/4) | |
Pseudomonas aeruginosa (5 episodes in 3 patients) | 60.0% (3/5) | 60.0% (3/5) | NA | |
Blood culture in renal cyst infection | Escherichia coli (11 episodes in 10 patients) § | 63.6% (7/11) | 66.7% (6/9) | 63.6% (7/11) |
Klebsiella (8 episodes in 8 patients) | 100% (8/8) | 100% (8/8) | 100% (8/8) | |
Enterobacter (2 episodes in 2 patients) | 100% (2/2) | 100% (2/2) | 100% (2/2) | |
Pseudomonas aeruginosa (n=0) | NA | NA | NA | |
Blood culture in hepatic cyst infection | Escherichia coli (n = 20) ∥ | 30.0% (6/20) | 31.6% (6/19) | 65.0% (13/20) |
Klebsiella spp. (13 episodes in 13 patients) | 92.3% (12/13) | 92.3% (12/13) | 100% (13/13) | |
Enterobacter spp. (8 episodes in 7 patietns) | 87.5% (7/8) | 87.5% (7/8) | 100% (7/7) | |
Pseudomonas aeruginosa (5 episodes in 5 patients) | 60.0% (3/5) | 60.0% (3/5) | NA |
Origin of renal or hepatic cyst infection
Antibiotic therapy for cyst infection
Our antibiotics strategy for cyst infection at Toranomon Hospital
For mild cyst infection
Half-life in patients with a normal renal function (h) | Half-life in patients on hemodialysis (h) | |
---|---|---|
Sulbactam/Ampicillin (SBT/ABPC) | SBT 1.0/ ABPC 1.3* | SBT 13.4/ABPC 17.4a |
Tazobactam/Piperacillin (TAZ/PIPC) | TAZ 0.9/ PIPC 1.0* | TAZ 7.4/PIPC 2.1* |
Cefazolin (CEZ) | 2.5* | 26.4b |
Cefotiam (CTM) | 1.0c | 2.7c |
Cefmetazole (CMZ) | 1.0 –1.2* | 6.2–7.4* |
Ceftazidime (CAZ) | 1.7d | 13c |
Cefotaxime (CTX) | 1.0* | 2.4* |
Ceftriaxone (CTRX) | 7–9c | 12– 24c |
Cefepime (CFPM) | 2 d | 18d |
Flomoxef (FMOX) | 0.76* | α; 0.4, β; 17.4* |
Meropenem (MEPM) | 1.1c, e | 6–8c, e |
Imipenem (IPM) | 1.0e | 4.0c, e |
For severe cyst infection
Cyst drainage
Infection resistant to antibiotics therapy (a fever that persists for 1–2 weeks despite appropriate antimicrobial therapy) |
Large infected cyst exceeding 5 cm in diameter |
Severe cyst infection (sepsis, disseminated intravascular coagulation [DIC], etc.) |
Cyst infection with many repeat episodes |
Number of events | Percentage of all cyst drainage (%) | |
---|---|---|
Plueroperitoneal communication | 7 | 0.66 |
Bile fistula | 6 | 0.57 |
Peritonitis | 5 | 0.47 |
Pneumothorax | 4 | 0.38 |
Severe intracystic bleeding | 2 | 0.19 |
Bile duct hemorrhagic cholangitis | 1 | 0.09 |
Gastrointestinal perforation | 1 | 0.09 |
Sudden death | 3 | 0.28 |
All | 29 | 2.75 |