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Pathology for Urologists

Renal Papillary Necrosis


Image A
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Image B
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  • Defined as necrosis of papillae and inner portions of renal medulla (which receives 10% of renal blood flow).
  • Clinical:
  • When bilateral and diffuse, it may be associated with ARF, fever, chills, flank pain, and hematuria.
  • When insidious in onset, may manifest as a concentrating defect or as progressive renal failure.
  • Typically affects adults (>60 years).
  • Bilateral in 70% of cases.
  • May be associated with any number of disease entities, but most common is diabetes mellitus; also: analgesic abuse, sickle cell disease.
  • Pathogenesis is ischemic, related to marginal blood supply of medulla (which explains prevalence in patients with underlying vascular disorders such as diabetics); also vasoconstriction due to prostaglandin inhibition by NSAID.
  • Gross: necrosis of renal papillae/medullary portion (image A).
  • Histology:
    • Coagulative necrosis rimmed by acute inflammation (image B).
    • Minimal inflammation at necrotic area.
    • Necrosis usually does not involve the entire medulla.
    • From a vascular standpoint, the papillary tip is the most vulnerable, so it is the first to go.
    • Because the necrosis is induced by ischemia, it typically has a coagulative appearance (ghost cells).
    • Microcalcifications may be present.
    • Renal changes of cause: diabetes nephropathy (diffuse nodular mesangial sclerosis), analgesic nephropathy (interstitial fibrosis, tubular atrophy, capillary sclerosis), and sickle cells (sickling in blood vessels) can be seen.
  • Prognosis depends on the causative factor and extent of damage and varies (diabetes worst).

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