Updated: 12/14/2019

Renal Papillary Necrosis

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Snapshot
  • ring signA 60-year-old woman presents to the emergency room with fever, chills, sudden flank pain, and gross hematuria. She has a history of recurrent urinary tract infections. Urinalysis reveals pyuria, hematuria, proteinuria, and dead tissue. An intravenous urography is obtained, revealing a ring sign. She is immediately given hydration and appropriate antibiotics.
Introduction
  • Clinical definition
    • necrosis and sloughing of renal papillae
  • Epidemiology
    • incidence
      • 30-40% in those with sickle cell disease or trait
    • 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)
      • congenital urinary tract obstructions such as posterior urethral valves
      • shock
  • Pathogenesis
    • in sickle cell disease or trait
      • increased blood viscocity in the renal medulla causes renal papillary infarcts
        • the renal medulla has a low oxygen tension resulting in red blood cell sickling
    • in analgesic use
      • NSAIDs inhibits prostaglandin synthesis
        • prostaglandins promote vasodilation
  • Prognosis
    • prognostic variable
      • negative
        • concomitant diabetes
        • older age
Presentation
  • History
    • may be chronic and asymptomatic or acute
    • gross blood in urine
    • may have history of recent infection or autoimmune flare
    • pyelonephritis
  • Symptoms
    • primary symptoms
      • fever and chills
      • sudden onset flank or abdominal pain
    • may be asymptomatic
  • Physical exam
    • tenderness to palpation in the flank or abdomen
Imaging
  • This clinical image of angiogram shows the string-of-beads appearance of fibromuscular dysplasia.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 patient presents with hematuria, even if renal papillary necrosis is suspected, as hematuria can indicate malignancy in the bladder
      • if renal obstruction is suspected
      • most accurate test
    • views
      • CT of abdomen and pelvis
    • findings
      • hydronephrosis
      • kidney stones
      • ring shadows in medullae
      • loss of papillae
  • Intravenous urography
    • 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
      • shrinkage of renal papillae
      • ring shadow from desquamated papillae - “ring sign”
      • filling defect in renal pelvis
      • contrast-containing tiny cavities in papillae
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
    • best initial test and results may show
      • hematuria
      • pyuria
      • proteinuria
      • sloughed papillae
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
  • Conservative
    • avoid analgesics or any other nephrotoxic medications
  • Medical
    • supportive care with fluid resuscitation
      • indications
        • for all patients
    • antibiotics
      • indications
        • if pyelonephritis is suspected
Complications
  • Chronic pyelonephritis
  • Sepsis
 

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Questions (1)
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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(M2.RL.15.40) A 43-year-old Caucasian female with a long history of uncontrolled migraines presents to general medical clinic with painless hematuria. She is quite concerned because she has never had symptoms like this before. Vital signs are stable, and her physical examination is benign. She denies any groin pain, flank pain, or costovertebral angle tenderness. She denies any recent urinary tract infections or dysuria. Urinary analysis confirms hematuria and a serum creatinine returns at 3.0. A renal biopsy reveals papillary necrosis and a tubulointerstitial infiltrate. What is the most likely diagnosis? Review Topic | Tested Concept

QID: 104487
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Analgesic nephropathy

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(19/25)

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Kidney stone

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Bladder cancer

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Kidney cancer

4%

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Sickle cell disease

16%

(4/25)

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