Updated: 1/13/2019

Renal Papillary Necrosis

Topic
Review Topic
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Questions
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Evidence
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Snapshot
  • A 50-year-old man with a history of diabetes mellitus presents to the emergency room for gross amounts of blood in his urine. He denies any pain with urination and has never had hematuria before. He has no family history of cancer and does not smoke. Physical exam is unremarkable. His urinalysis reveals hematuria, proteinuria, and necrotic tissue.   
Introduction
  • Clinical definition
    • necrosis and sloughing of renal papillae
  • Epidemiology
    • demographics
      • middle-aged adults
      • uncommon in children, except in those with sickle cell disease or trait
    • risk factors
      • sickle cell disease or trait
      • acute severe pyelonephritis
      • analgesics such as NSAIDs  
        • one of the most common and preventable risk factors
        • phenacetin
      • diabetes mellitus
      • tubulointerstitial nephritis 
      • kidney stones causing obstruction
      • indinavir (anti-retroviral drug)
  • Pathogenesis
    • due to ischemia
    • in sickle cell trait or disease
      • sickling is promoted in the renal medulla
        • due to low oxygen tension, low pH, and high osmolality (pulling water out of red blood cell and increasing concentration of hemoglobin S)
        • increased blood viscosity leads to infarcts and causes papillary infarcts
    • in analgesic use
      • NSAIDs inhibit prostaglandin synthesis (remember that prostaglandins vasodilate)
      • this predisposes patients to renal hypoperfusion and ischemia, especially in those with pre-existing renal disease or any other risk factors for renal papillary necrosis
  • Prognosis
    • prognostic variable
      • negative
        • concomitant diabetes
        • older age
Presentation
  • Symptoms
    • primary symptoms
      • fever and chills
      • sudden onset flank or abdominal pain
    • may be asymptomatic
    • hematuria
    • pyelonephritis
  • Physical exam
    • tenderness to palpation in the flank or abdomen
Imaging
  • Radiographs
    • indications
      • if obstruction, such as kidney stones, is suspected
      • not diagnostic
    • recommend views
      • kidneys, ureters, and bladder (KUB)
    • findings
      • hydronephrosis from obstruction
      • may visualize kidney stones
  • CT
    • indications
      • typically performed if patients present with hematuria, even if renal papillary necrosis is suspected, as hematuria can indicate malignancy in the bladder
    • views
      • CT of abdomen and pelvis
    • findings
      • hydronephrosis
      • kidney stones
      • ring shadows in medullae
      • loss of papillae
  • Intravenous urography (IVU)  
    • indications
      • if CT scan is inconclusive and suspicious for renal papillary necrosis remains high
      • if there is no suspicion of obstruction but suspicion of renal papillary necrosis remains high
    • findings
      • ring shadow from desquamated papillae - “ring sign”
Studies
  • Labs
    • serum creatinine
      • if there is a sudden rise in creatinine, consider renal papillary necrosis in patient with diabetes or chronic urinary obstruction
  • Urinalysis
    • hematuria
    • pyuria
    • proteinuria
Differential
  • Nephrolithiasis  
    • kidney stone seen on imaging without evidence of renal papillary necrosis
  • Tubulointerstitial nephritis
    • often presents with rash, arthralgias, and eosinophilia in the urine
Treatment
  • Medical
    • supportive care with fluid resuscitation
      • indications
        • for all patients
Complications
  • Chronic pyelonephritis
  • Sepsis

References

 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M1.RL.35) A 45-year-old female presents to the emergency department with gross hematuria and acute, colicky flank pain. She denies any previous episodes of hematuria. She reports taking high doses of acetaminophen and aspirin over several weeks due to persistent upper back pain. The patient’s blood pressure and temperature are normal, but she is found to have proteinuria. Physical examination is negative for palpable flank masses. Which of the following is the most likely diagnosis: Review Topic

QID: 101253
1

Diffuse cortical necrosis

31%

(4/13)

2

Chronic pyelonephritis

0%

(0/13)

3

Autosomal dominant polycystic kidney disease

0%

(0/13)

4

Papillary necrosis

46%

(6/13)

5

Acute Nephrolithiasis

23%

(3/13)

M1

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