Updated: 6/19/2018

Diffuse Cortical Necrosis

Topic
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Snapshot
  • A 35-year-old G1P1 woman recently delivered a boy via normal spontaneous vaginal delivery. As she holds her baby, she feels lightheaded and weak. An exam quickly reveals blood pooling below her vagina. Her uterus is immediately massaged and oxytocin is given. A few hours later, she reports having flank pain and seeing a significant amount of blood in her urine. Her creatinine is found to be elevated at 2 mg/dL.
Introduction
  • Clinical definition
    • diffuse necrosis of bilateral renal cortex
  • Epidemiology
    • incidence
      • rare in developed countries
      • 1-2% of all acute kidney injuries
  • Etiology
    • obstetric catastrophes
      • abruption placentae
      • amniotic fluid embolism
      • postpartum hemorrhage
    • septic shock
  • Pathogenesis
    • pathogenesis is likely a combination of diffuse intravascular coagulation and renal ischemia
      • hemorrhagic or septic shock causes endothelial damage and fibrin deposition, causing necrosis
        • mild to moderate endothelial damage induces release of nitric oxide to minimize thrombi formation
        • however, if the endothelia are severely damaged or frankly necrotic, nitric oxide release is impaired which leads to increased thrombi formation and ischemia
Presentation
  • Symptoms
    • sudden onset oliguria or anuria after an obstetric catastrophe
    • gross hematuria
    • flank pain
  • Physical exam
    • hypotension
Imaging
  • Ultrasound
    • findings
      • hyperechoic or hypodense areas in renal cortex
Studies
  • Urinalysis
    • gross hematuria
Differential
  • Acute kidney injury in the setting of other obstetric catastrophe
    • acute fatty liver of pregnancy
    • pregnancy-triggered, thrombotic thrombocytopenic purpura
Treatment
  • Conservative
    • supportive care
  • Medical
    • dialysis
Complications
  • Renal failure

References

 

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