Papillary Necrosis Treatment & Management

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

Approach Considerations

Patients with known or suspected renal papillary necrosis should limit or completely avoid the use of analgesics. Other nephrotoxic medications should also be avoided. The routine use of indwelling catheters should be discouraged except when clinically indicated. Clean intermittent catheterization, although more time-consuming, is equally effective for the purpose of monitoring output and is less likely to cause nosocomial urinary tract infection. 

In patients with obstructed collecting systems who are hemodynamically unstable, obtunded, and floridly septic, avoiding any retrograde evaluation of the ureter should be seriously considered. Unnecessary retrograde instrumentation is discouraged because of the risk of irrigating purulent or contaminated urinary inoculum from the lower urinary tract into the renal pelvis and pyelovenous system, exacerbating urosepsis. The exception is ureteral stent placement for urgent decompression of an obstructed kidney.

In general, in the clinically unstable patient, performing the quickest decompressive procedure, via either percutaneous nephrostomy tube or retrograde ureteral stent, is preferred. Take into account the patient's clinical picture. In patients with an uncorrectable coagulopathy, retrograde ureteral stent placement may be a safer approach. In patients with emphysematous pyelitis or severe obstruction, use of a percutaneous nephrostomy tube may be more appropriate. In the severely ill patient, perform the quickest and safest procedure to establish drainage of the hydronephrotic section. This means that carefully considered retrograde procedures are sometimes the preferred modalities.

Broad-spectrum intravenous antibiotics administered immediately prior to any retrograde study may have a protective effect.

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Medical Therapy

Basically, treatment for renal papillary necrosis consists of the following:

  • Ameliorate the ischemia with hydration and alkalinization
  • Treat the underlying cause of the renal papillary necrosis (eg, maintain normal glycemic state)
  • Institute targeted antibiotic therapy

Because ischemia is such a prominent underlying factor in the development of renal papillary necrosis, promptly resuscitate patients and treat their hypoxia, if present. In addition, patients with acute disease may require broad-spectrum intravenous antibiotics, hydration, glycemic control, and urinary alkalinization. Cessation of analgesic abuse stabilizes and may improve renal function.

In patients without acute ureteral obstruction, treat the infectious and metabolic complications of renal papillary necrosis by replacing insensible losses, maintaining hydration, alkalinizing the urine, and administering antibiotics directed toward the pathogen (as revealed by culture or Gram stain and by observing for the development of obstruction or sepsis).

Patients with hematuria significant enough to cause an acute drop in their hematocrit level may require blood transfusions. [27] Patients with sickle cell disease may require exchange transfusions, and patients with diabetes who have acute infectious complications and refractory hyperglycemia may require insulin therapy.

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Surgical Therapy

Patients with renal papillary necrosis may require diagnostic and therapeutic urologic intervention. The urologist is responsible for evaluating any obstruction, hematuria, overwhelming infection, and associated malignancies and for preventing recurrences of these sequelae.

Acute obstruction with concomitant urinary tract infection is a urologic emergency that requires urgent upper tract decompression to relieve the obstruction. Percutaneous nephrostomy tube placement and retrograde ureteral stent placement are options, dependeing on the patient's clinical picture. Endoscopic retrieval of an obstructing papillae is not recommended in the acute setting unless the offending papillae are crowning or extruding from the ureteral orifice; even then, the procedure is challenging and decompression should be the goal. Retrograde pyelography and ureteroscopy are useful diagnostic tools, but consider these only when the patient is afebrile and after intravenous administration of antibiotics. Otherwise, placement of a ureteral stent would suffice, with retrograde instrumentation postponed until the patient is afebrile.

The recommended treatment is to drain the dilated collecting system either endoscopically or percutaneously. In patients with severe disease who are febrile and have smoldering sepsis, percutaneous nephrostomy may be preferred because it does not require general anesthesia and carries a smaller risk of pyelovenous reflux and worsening sepsis. Cystoscopy and ureteral stent placement allow cystoscopic surveillance of the bladder, which is necessary if hematuria is the presenting symptom. However, in patients with an acute urinary tract infection, visualization within the bladder may be severely limited, and/or the bladder mucosa severely erythemic,  limiting proper evaluation for malignancy.  Perform diagnostic cystoscopy and retrograd pyelography (if necessary) later, when the patient's situation is not so dire.

Nephrectomy may be life-saving in patients with overwhelming infection (ie, emphysematous pyelonephritis). Consider that papillary necrosis is primarily a bilateral disease, and these patients must be informed that this may result in progressive kidney failure and possible dialysis dependency in the future.

In selected patients, ureteroscopic investigation of a ureteral filling defect may be warranted. A basket catheter can be introduced through the ureteroscope to extract the offending sloughed papilla. This is performed only in afebrile patients, after broad-spectrum intravenous antibiotics have been administered.

Patients who present with hematuria, even if all the diagnostic interventions indicate papillary necrosis, require a full urologic workup for their hematuria. A thorough evaluation of the urinary tract, as outlined in Workup/Approach Considerations, limits the differential diagnoses of hematuria, excluding other possible causes. Attribute the hematuria to papillary necrosis only after performing the studies listed in Workup/Approach Considerations and deeming the results negative.

Keep in mind that if the patient's system is acutely obstructed with possible pyonephrosis, retrograde studies such as retrograde pyelography and ureteroscopy are contraindicated because they are likely to cause or exacerbate sepsis from pyelovenous reflux of purulent material from the lower urinary tract. If this clinical scenario occurs, decompress the system with either a double-J ureteral stent or, preferably, a nephrostomy tube. Send any urine or pus obtained from these procedures for microscopic analysis, Gram stain, and culture. After proper decompression, administer systemic antibiotics with empiric coverage until the Gram stain and culture results are received. Once the patient responds systemically, with stable hemodynamics, no fever, no acidosis, and no leukocytosis, the urologist can proceed with the diagnostic workup.

If the infection rages and the patient does not improve despite supportive measures and proper antibiotic coverage, a nephrectomy may be life-saving. However, remember that the disease is usually bilateral.

Surgery may be indicated for associated anatomic anomalies that predispose patients to urinary stasis and recurrent urinary tract infections. Treatable conditions include the following:

  • Calculi
  • Ureteropelvic junction obstruction
  • Vesicoureteral reflux
  • Ureteral strictures
  • Ureteroceles

If urothelial cell carcinoma of the collecting system is identified, thoroughly evaluate the patient for metastatic disease. Staging for upper urinary tract malignancies typically is performed ureteroscopically to confirm the tumor and obtain pathologic confirmation. Depending on tumor size, location, and histologic grade, treatment can be determined. In brief, small and low grade tumors may be treated endoscopically, while high grade tumors or large tumors may require formal resection.

In general, the gold standard for treatment of high grade urothelial cell carcinoma of the renal pelvis or ureter is nephroureterectomy (removal of the kidney, ureter, and a cuff of bladder around the affected ureteral orifice). For select ureteral tumors, segmental ureterectomy with ureteroureterostomy or distal ureterectomy with ureteroneocystostomy can be considered.

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Preoperative Details

Give the patient intravenous hydration and withhold food for 8 hours. Obtain informed consent; the patient must be aware that ureteroscopy and ureteral stent placement are possibilities.

Patients should be aware that when a ureteral stent is placed, it is not meant to be a permanent implant, and that a subsequent procedure may be required to remove or exchange the stent in the future to prevent serious complications.

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Postoperative Details

Common complications after any instrumentation of the ureter include infection, extravasation and urinoma formation, bleeding, ureteral stricture, and urosepsis due to pyelovenous backflow. Persistent postoperative fever or failure to thrive may be harbingers of those complications.

Ensure that patients clearly understand that, if they require an indwelling ureteral stent, these devices are associated with a host of unique complications.

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Complications

Necrotic papillae represent a fertile environment for the deposition of both infectious organisms and lithogenic sediment. This necrotic deposition can lead to the development of florid pyelonephritis, perirenal abscesses, and sepsis. Calculous formation compounds the necrosis because certain bacteria thrive within the calculi. Calculi can also propagate, which may lead to further obstruction, increased pyelovenous pressure, and worsened ischemia.

Always consider sloughed papillae as a cause of ureteral obstruction in the differential diagnoses of flank pain, colic, and hematuria, especially when no calculi are visible and particularly in patients with diabetes.

 

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Prevention

Finally, although they are a reasonable course of preventive treatment, prophylactic antibiotics are by no means standard treatment in patients with renal papillary necrosis. The utility of antibiotics requires further study. More importantly, prevention of nosocomial urinary tract infection should take precedence. If indwelling catheters are necessary or if the patient has risk factors for urinary stasis or frank obstruction, prophylactic antibiotics may prove useful.

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Long-Term Monitoring

Proper follow-up includes a visit with a general practitioner to prevent further exacerbations and to manage any associated conditions. Follow-up may include a referral to specialists, as deemed necessary by the primary care doctor.

Stopping analgesic intake and controlling blood pressure help to preserve renal function, and preventing symptomatic urinary infections with long-term, low-dose medical therapy reduces the morbidity associated with renal papillary necrosis. If analgesic use is indispensable to certain patients, instruct them to hydrate accordingly. Reports indicate that adequate hydration may help prevent lesions in persons who must take analgesics long-term.

Physicians may find prophylactic antibiotics useful for treating patients with obstructed urinary tracts who are not surgical candidates. Patients who receive urinary tract intervention require follow-up evaluations with a urologist, particularly if they require further treatment. In any case, hematuria in these patients requires a complete evaluation by the urologist.

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