Introduction
Von Friedrick described renal papillary necrosis in the year 1877. It is one of the complications of diabetes mellitus, where there is acute destruction of the renal papilla and an absence of suppuration in the affected area. It is a worrisome complication but is rare. Renal papillary necrosis can occur as a sequel of obstructive uropathy (a condition when urine cannot drain through the urinary tracts) in nondiabetic cases.
What Is Renal Papillary Necrosis?
Renal papillary necrosis is a disorder of the kidney in which one or all renal papillae are destroyed. The renal pyramid has an apex called the renal papilla, where the openings of the collecting ducts enter the kidney, and the urine flows into the ureters.
What Are the Synonyms of Renal Papillary Necrosis?
The synonyms involve:
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Necrotizing pyelonephritis.
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Papillitis renis necroticans.
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Gunther's disease (also called congenital erythropoietic porphyria affects skin, teeth, bones, hematopoietic system, and bones).
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Diphtheria of the papilla.
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Papillitis necroticans.
Pathogenesis of Renal Papillary Necrosis:
In the absence of urinary tract obstruction, the lesions of renal papillary necrosis are rarely seen in cases of nondiabetic patients. The most accepted concept is ischemia of the medullary portion of the medulla, which is an ischemic infarct. The characteristics of the lesion are similar to that of an infarct (a condition in which there is the death of a tissue due to obstruction of blood supply caused by a blood clot or narrowing of a blood vessel). The demerit of this theory is that there is no evidence of obstructed blood flow to the papilla. In studies, conducted authors have suggested that it may be due to the coalescence of abscesses at the base of the medulla, and some say it is due to arteriosclerosis of the blood vessels supplying the medulla. Increased hydrostatic pressure, which leads to extrinsic pressure in the tubules caused after obstruction, may also be one of the reasons.
What Are the Symptoms?
The symptoms include:
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Flank Pain: The pains present on one side of the body between the upper abdomen and the back.
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Presence of blood (hematuria) or dark and cloudy urine.
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Presence of tissue pieces in the urine.
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The patient may sometimes have chills along with fever.
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Dysuria: Pain while passing urine.
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Urgency: Strong irresistible urge to pass urine, patient is often not able to hold the urine.
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Increased frequency of passing urine.
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Urinary Hesitancy: Difficulty in maintaining a continuous urine stream.
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Urinary Incontinence: Leaky urine caused due to loss of bladder control.
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Passing urine in large volumes.
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Increased frequency of passing urine at night.
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Azotemia: Increased levels of urea and nitrogen compounds in the blood.
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Albuminuria: The presence of high levels of albumin in the urine.
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Individuals have elevated white blood cell count.
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Stupor: A state of unconsciousness.
What Are the Diagnostic Tests Done in Renal Papillary Necrosis?
On examination, the affected flank area may be tender, and the patient may have a history of frequent urinary tract infections. The patient may also show signs of kidney failure or blocked urine flow.
The doctor may advise the following tests:
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Ultrasound.
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Computed tomography (CT).
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Blood test.
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Urine test.
Structural changes cause an increase in the size of the minor calyces, which are cavities in the kidney where the urine gets collected. There may be sloughing of the papilla, which produces negative shadows in the large calyces or pelvis. A retrograde urogram can detect all these findings. The program may fail to detect initial cases in which no sloughing has occurred and may appear normal.
What Are the Causes?
Causes involve:
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Analgesic Nephropathy: This condition involves damage to the internal structures of the kidney caused due to long-term usage of pain medications (analgesics). They involve counter drugs (such as phenacetin and acetaminophen) and NSAIDs (such as Ibuprofen and Aspirin).
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Sickle Cell Nephropathy: Sickling of red blood cells in the small blood vessels leading to kidney complications.
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Diabetes mellitus accompanied urinary tract infections.
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Prolonged usage of NSAID (Nonsteroidal anti-inflammatory drugs).
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Pyelonephritis: Infection in the kidneys.
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Kidney transplant rejection.
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Urinary tract blockage.
What Are the Complications of Renal Papillary Necrosis?
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Infection of the kidney (pyelonephritis).
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Renal calculi: Formation of kidney stones.
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Cancer of the kidneys.
When to Seek Help?
Contact a health care professional immediately if there is blood in urine and other symptoms that have been mentioned above in this article.
Prognosis:
Prognosis solely depends on the condition causing the disease. If symptomatic relief is provided and the cause is eliminated, then the person with renal papillary necrosis can recover. But not all cases see complete recovery and may lead to kidney failure, which will require a kidney transplant or dialysis.
What Is the Possible Treatment for Renal Papillary Necrosis?
The treatment for renal papillary necrosis is more of a symptomatic approach, where the doctor will try to ease the symptoms and try to eliminate the cause.
Analgesic Neuropathy:
In cases of analgesic nephropathy, which is caused due to over the counter pain medications, the doctor will advise the patient to stop those medications.
Sickle Cell Neuropathy:
In cases of sickle cell nephropathy, proteinuria managed by a low protein diet should be avoided. Medications that help manage sickle cell nephropathy involve angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) to help reduce proteinuria. Hydroxyurea is an analgesic that helps decrease the complications caused by sickle cell nephropathy. It helps reduce lactate dehydrogenase and reticulocytes. Erythropoietin stimulating agents are given to treat anemia and hypoxia.
Conclusion
Renal papillary necrosis is a disorder of the kidney in which one or all renal papillae are destroyed. The renal pyramid has an apex called the renal papilla, where the openings of the collecting ducts enter the kidney, and the urine flows into the ureters. Von Friedrick described this disease in the year 1877. Renal papillary necrosis is caused by analgesic nephropathy, sickle cell neuropathy, diabetes mellitus, pyelonephritis, and urinary tract blockage. The treatment modalities for renal papillary necrosis are more of a symptomatic approach, where the doctor tries to ease the symptoms and eliminate the cause.
