eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Papillary Necrosis: Follow-up

Author: Jeffrey M Donohoe, MD, Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Medical College of Georgia
Coauthor(s): Jack H Mydlo, MD, Chief, Department of Urology, Woodhull Hospital; Chair and Professor, Department of Urology, Temple University School of Medicine
Contributor Information and Disclosures

Updated: Jan 9, 2008

Outcome and Prognosis

The prognosis of renal papillary necrosis depends on the etiology of the ischemic insult, the number of associated pathologic factors, the dispersal of the necrosis, the involvement of one or both kidneys, and the overall health of the patient. Elderly debilitated patients with multiple medical problems have a poor prognosis, as do patients with overwhelming sepsis and multiple comorbidities. The prognosis is generally worse in patients with diabetes, specifically those who are not compliant and who are prone to severe episodes of hyperglycemia because of the systemic nature of their disease. 

Considering the synergistic nature of its predisposing factors, papillary necrosis may be avoided by controlling chronic diseases such as sickle cell disease, diabetes, and cirrhosis. Patients with such conditions should be careful to avoid excessive use of analgesics that are known to be associated with papillary necrosis. Patients who use such analgesics should be screened for signs and symptoms of urinary tract infections and/or urinary obstruction and treated accordingly. When papillary necrosis arises unexpectedly (ie, in a patient with sepsis), the treatment focus should be to prevent urinary tract infections (eg, by avoiding unnecessary use of indwelling catheters), to maintain adequate hydration and homeostasis, to avoid analgesics and other nephrotoxic medications, and to maintain tight glycemic control in patients with diabetes.

Future and Controversies

Significant contributions aimed at improving the prevention, diagnosis, and treatment of renal papillary necrosis include preliminary studies by Falkenberg et al, who are investigating monoclonal antibodies that may provide direct diagnostic access to the renal papilla and may allow for early detection of papillary damage.11 Monoclonal antibodies specific for papillary antigens have been used to detect these antigens in urine following toxic insults to the kidney.

Studies by Garber et al have revealed that the angiotensin-converting enzyme (ACE) inhibitor enalapril has a protective and therapeutic effect in rats with bromoethylamine-induced renal papillary necrosis, which is characterized by marked interstitial fibrosis, impressive decreases in the glomerular filtration rate, and albuminuria.12 Histologic examination of rats treated with enalapril reveals a 67-88% decrease in renal papillary necrosis. These studies also demonstrate renoprotective effects of enalapril, including a significant improvement in the glomerular filtration rate and elimination of albuminuria.

A report from Abe et al described the treatment of renal papillary necrosis in a patient with diabetes.13 Prostaglandin E1 was infused intravenously at a dose of 40 mg/d for 14 days. This attempt at improving renal circulation increased both creatinine clearance and renal plasma flow, with a concomitant decrease in proteinuria. Vasodilatory agents such as prostaglandin E1 may improve renal circulation and hemodynamics and should be considered as possible therapy for renal papillary necrosis, particularly in patients with diabetes.

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 patients has risk factors for urinary stasis or frank obstruction, prophylactic antibiotics may prove useful.

 


More on Papillary Necrosis

Overview: Papillary Necrosis
Workup: Papillary Necrosis
Treatment: Papillary Necrosis
Follow-up: Papillary Necrosis
Multimedia: Papillary Necrosis
References
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References

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Further Reading

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Keywords

papillary necrosis, renal papillary necrosis, RPN, renal medullary necrosis, medullary necrosis, interstitial nephritis, sloughed papilla, urinary obstruction, ureteropelvic junction obstruction, UPJ obstruction, ureteral obstruction, ureterovesical junction obstruction, analgesic nephropathy, analgesic-induced nephropathy, analgesic abuse, pyelonephritis, tubulointerstitial nephritis, urinary tract infection, UTI, sickle cell hemoglobinopathy, sickle cell trait, sickle cell disease, tuberculosis, cirrhosis of the liver, cirrhosis, chronic alcoholism, renal transplant rejection, diabetes mellitus, diabetes complications, systemic vasculitis, phenacetin

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Contributor Information and Disclosures

Author

Jeffrey M Donohoe, MD, Assistant Professor of Pediatric Urology, Department of Surgery, Division of Urology, Medical College of Georgia
Jeffrey M Donohoe, MD is a member of the following medical societies: American Academy of Pediatrics and American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

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, and Society of University Urologists
Disclosure: Nothing to disclose.

Medical Editor

Gamal Mostafa Ghoniem, MD, FACS, Fellowship Program Director, Clinical Professor of Surgery, Head, Section of Voiding Dysfunction, Female Urology and Reconstruction, Cleveland Clinic Florida
Gamal Mostafa Ghoniem, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Society for Urology and Engineering, and Society of University Urologists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

CME Editor

J Stuart Wolf, Jr, MD, FACS, David A Bloom Professor of Urology, Director, Division of Minimally Invasive Urology, Department of Urology, University of Michigan Medical Center
J Stuart Wolf, Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, and Society of University Urologists
Disclosure: Terumo Corporation Consulting fee Consulting; Omeros Corporation Consulting fee Consulting

Chief Editor

Bradley Fields Schwartz, DO, FACS, Associate 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, and Society of University Urologists
Disclosure: Nothing to disclose.

 
 
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