Abstract
We read with interest the article entitled, “Septic Shock Following Surgical Decompression of Obstructing Ureteral Stones: A Prospective Analysis,” by Srougi and colleagues that was published in Journal of Endourology. 1 We are pleased to submit the following letter in response to this article. 1
In this study, the authors analyzed prognostic factors for both sepsis and septic shock caused by obstructing ureteral stones. Unlike other types of shock events, septic shock caused by obstructive pyelonephritis can be very rapid and those patients with acute pyelonephritis caused by urinary tract stones can often progress to septic shock. Seventeen of 85 patients with acute pyelonephritis caused by ureteral stones who visited our institution developed septic shock. 2 If septic shock occurs, it is urgent enough to require pressor support and intensive care management, resulting in an increase in medical costs. Therefore, anticipating septic shock events is very important to reducing both overall morbidity and the resultant costs.
The authors revealed two important points. The first is that incorrect antibiotic selection increases the risk of septic shock caused by widespread quinolone resistance. The other is that high white blood cell counts at the time of admission can be predictive of septic shock.
We propose adding two additional prognostic markers. The first is serum albumin level. 3 –5 Hypoalbuminemia is an important risk marker for septic shock and is closely related to the mortality rate of patients with sepsis. Also, hypoalbuminemia is closely related to the presence of malnutrition and cirrhosis. In general, serum albumin plays an important role in the maintenance of homeostasis and temporary hypoalbuminemia appears in various environments where this is disrupted, including undergoing major surgery as well as in urosepsis. The reason for this decrease in serum albumin is thought to be a combination of decreased liver synthesis, increased leakage into the interstitial space, and accelerated catabolism. In addition, the inflammation caused by sepsis further increases the leakage of extravasating albumin. Also, endothelial cell damage increases capillary loss up to 13 times higher than normal, with a significant decrease in serum albumin. 6
The second additional factor to examine is thrombocytopenia. 3 –5 Thrombocytopenia is known to occur because of several causes. Sepsis can adversely affect the bone marrow and cause the loss of platelets in the peripheral blood vessels. Also, in the case of disseminated intravascular coagulation, platelet consumption can lead to further decreased platelet numbers and thrombocytopenia. 7