History

Renal papillary necrosis has a variable clinical course that ranges from a chronic, protracted, and relapsing form to an acute, rapidly progressive form. The acute progressive form is particularly rare, but the effects are devastating, resulting in death from septicemia and renal failure. Patients with the more common chronic form may remain asymptomatic until diagnosed incidentally through the appearance of a ring shadow on a radiographic image, by the passage of sloughed papillae in the urine, or during autopsy. The symptomatic form manifests as episodes of pyelonephritis and hydronephrosis, and it mimics nephrolithiasis.

The most common presenting symptoms in symptomatic patients include fever and chills, flank and/or abdominal pain, and hematuria. Acute kidney injury with oliguria or anuria is rare; when these symptoms develop, the disease may be fulminant, requiring dialysis and potentially resulting in death.

If kidney function deteriorates suddenly in a patient with confirmed diabetes or in a patient with a known history of chronic obstruction and/or pyelonephritis, consider the diagnosis of papillary necrosis, even if the patient is asymptomatic.^[19]

Acute ureteral obstruction from sloughed papillae manifests as flank pain and colic due to hydronephrosis or pyonephrosis; hematuria is invariably present. Pyonephrosis or secondary acute or relapsing pyelonephritis compounds the presentation with fever, chills, prostration, and sepsis.

Differential Diagnoses

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Media Gallery

In this figure, the multifactorial nature of renal papillary necrosis is represented by 5 of the disease's most frequently associated conditions: infection, obstruction, diabetes mellitus, analgesic abuse, and sickle cell disease. Each circle represents a condition. Note how the conditions overlap; the red areas show the coexistence of 2 conditions, and the black areas represent 3 coexistent conditions. Multiple conditions exhibit synergism and, therefore, worsen both the severity of the disease and the prognosis.
Cystoscopic photograph of sloughed papilla extruding from the ureteral orifice. The patient was a 51-year-old man with poorly controlled diabetes and a history of microhematuria and an acute onset of severe left flank pain. Findings of upper tract imaging with a renal ultrasonography and intravenous pyelography were remarkable only for mixed heterogeneity consistent with medical renal disease. Urine cytology results were negative, and culture showed no growth. In-office flexible cystoscopy revealed the mass extruding from the left ureteral orifice, which required sedation and rigid cystoscopy to extract. Gross examination yielded a tan, friable, irregular, wedge-shaped soft tissue mass 1.7 cm X 1.6 cm X 1.5 cm. Bilateral retrograde pyelography revealed a clubbed left upper pole calyx and no other filling defects. The pathology was necrotic epithelial tissue.

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Author

Robert H Blackwell, MD Assistant Professor, Division of Urology, Department of Surgery, Southern Illinois University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Bradley Fields Schwartz, DO, FACS Professor of Urology, Director, Center for Laparoscopy and Endourology, Department of Surgery, Southern Illinois University School of Medicine

Bradley Fields Schwartz, DO, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Association of Military Osteopathic Physicians and Surgeons, Endourological Society, Society of Laparoendoscopic Surgeons, Society of University Urologists

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Endourological Society Board of Directors; President Elect North Central Section of the American Urological Association<br/>Serve(d) as a speaker or a member of a speakers bureau for: Cook Medical.

Additional Contributors

Gamal Mostafa Ghoniem, MD, FACS Professor and Vice Chair of Urology, Chief, Division of Female Urology, Pelvic Reconstructive Surgery, and Voiding Dysfunction, Department of Urology, University of California, Irvine, School of Medicine

Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urogynecologic Society, American Urological Association, International Continence Society, International Urogynaecology Association, Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Astellas<br/>Received research grant from: Uroplasty/Cogentix, Astellas, Allergen.

Jack H Mydlo, MD Chief, Department of Urology, Woodhull Hospital; Chair and Professor, Department of Urology, Temple University School of Medicine

Jack H Mydlo, MD is a member of the following medical societies: American College of Surgeons, American Urological Association, International College of Surgeons US Section, Society of University Urologists

Disclosure: Nothing to disclose.

Jeffrey M Donohoe, MD, FAAP Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Children’s Medical Center, Medical College of Georgia

Jeffrey M Donohoe, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American Urological Association

Disclosure: Nothing to disclose.

Christopher Powell, MD Resident Physician, Department of Urology, University of Kansas Medical Center

Christopher Powell, MD is a member of the following medical societies: American Medical Association

Disclosure: Nothing to disclose.

Papillary Necrosis Clinical Presentation

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