Objective. The mortality rate among patients with emphysematous pyelonephritis (EPN) is high and the best therapy has long been debated. Material and methods. Between January 1993 and December 2004, 26 patients diagnosed with EPN were treated at our hospital. Historical, demographic and laboratory data were obtained from medical records for analysis. Results. The mean age of the patients was 58.7±12.7 years. All patients had diabetes, and women outnumbered men (23:3). The clinical findings were non-specific. A plain abdominal X-ray was diagnostic in only 9/26 patients (36%), ultrasonography was accurate in 13 (50%) and CT was diagnostic in all cases. Eighteen patients survived, including all five treated with open drainage and three out of four treated with percutaneous drainage (although one of these later required nephrectomy), and eight died. Diabetic ketoacidosis or non-ketotic hyperosmolar syndrome, obesity and smoking were significant predictors of death. Conclusions. Early diagnosis by means of CT and CT-guided percutaneous drainage (which is better than ultrasonography-guided drainage) or open drainage, along with antibiotic treatment, may be a reasonable alternative to nephrectomy for this high morbidity condition.