Updated: 1/13/2019

Renal Papillary Necrosis

Review Topic
  • 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 ring sign
      • 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
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(M1.RL.13.35) 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:

QID: 101253

Diffuse cortical necrosis



Chronic pyelonephritis



Autosomal dominant polycystic kidney disease



Papillary necrosis



Acute Nephrolithiasis



M 2 E

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