Papillary Necrosis Clinical Presentation

Updated: Sep 02, 2021
  • Author: Robert H Blackwell, MD; Chief Editor: Bradley Fields Schwartz, DO, FACS  more...
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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.