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Well, we know this, I hear you all say. It is standard practice that the obstructed kidney with associated infection requires prompt decompression, and this is drilled into all UK trainees. It is surprising therefore that although we frequently deal with this emergency situation there is scant quality evidence to support this practice: the American Urological Association (AUA) guidelines ascribe only a grade C level of evidence although the European Association of Urology (EAU) guidelines carry a strong recommendation for urgent decompression. It is theorised that pyelovenous backflow in the presence of obstruction increases translocation of bacteria into the bloodstream, and if not decompressed in patients with severe sepsis mortality may be as high as 19%. This current review of data from the US National Inpatient Sample from 2010 to 2015 adds new insights into the effect of time to decompression on outcomes. Overall, the mortality rates varied from 0.2% in the non-septic decompressed group to 13.6% in patients with septic shock, which is lower than previously reported. In the 154,600-patient cohort where data on time to decompression was available, those who underwent decompression were younger, less comorbid, had presented on a weekday rather than the weekend, were less likely to be from ethnic minorities, and more likely to live in wealthier areas, and more likely to have private insurance. Mean time to decompression was 0.42 days and 3.08 days. Delayed decompression increased the odds of death by 29%, or 7% increased odds per day or delay. The strength of this data is in its large sample size, six-year data and multivariate analysis that controlled for confounding factors such as co-morbidity and sepsis severity. Much has been written about the consequences of patients’ fear of attending hospital during an acute pandemic; this data lends support for greater expediency of delivering care for emergency situations.

Delayed decompression of obstructing stones with urinary tract infection is associated with increased odds of death.
Haas CR, Li G, Hyams ES, Shah O.
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Jay Khastgir

Princess of Wales Hospital, Bridgend & Swansea University School of Medicine.

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