eMedicine Specialties > Urology > Infections and Related Inflammatory Conditions

Papillary Necrosis: Treatment

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

Treatment

Medical 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. 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. Basically, ameliorate the ischemia with hydration and alkalinization, treat the underlying cause of the renal papillary necrosis (eg, maintain normal glycemic state), and institute targeted antibiotic therapy.

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 immediate percutaneous nephrostomy to relieve the obstruction, ureteral stent placement, or endoscopic retrieval of the obstructing sloughed papillae. Endoscopic retrieval is not recommended unless the offending papillae are crowning or extruding from the ureteral orifice; even then, the procedure is challenging. Retrograde pyelography and ureteroscopy are useful diagnostic tools, but consider these only when the patient is afebrile and after intravenous administration of antibiotics. Otherwise, a ureteral stent would suffice, delaying retrograde instrumentation 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 is 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 a patient with hydronephrosis, high fever, leukocytosis, and overt sepsis, the preferred treatment is to percutaneously drain the kidney. Perform diagnostic cystoscopy and RPGs (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 renal 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 Lab Studies, limits the differential diagnoses of hematuria, excluding other possible causes. Attribute the hematuria to papillary necrosis only after performing the studies listed in Lab Studies and deeming the results negative.

Keep in mind that, if the patient's system is acutely obstructed with possible pyonephrosis, retrograde studies such as RPG 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 calculi, ureteropelvic junction obstruction, vesicoureteral reflux, ureteral strictures, and ureteroceles.

If transitional cell carcinoma of the collecting system is identified, thoroughly evaluate the patient for metastatic disease. If metastases are not found, the proper treatment for presumed invasive transitional cell carcinoma of the upper urinary tract is radical nephroureterectomy, removing the entire transmural ureter and a cuff of bladder mucosa. Recently, some physicians are resecting and staging tumors endoscopically and are treating selected patients more conservatively (ie, surveillance, if the tumor does not invade the muscle layer). Nevertheless, nephroureterectomy remains the criterion standard.

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.

Ensure that the patient has medical clearance to undergo a procedure that requires general anesthesia.

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 the complications listed above.

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

Follow-up

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.

For excellent patient education resources, visit eMedicine's Kidneys and Urinary System Center. Also, see eMedicine's patient education article Blood in the Urine.

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.

The development of transitional cell carcinoma of the renal pelvis or calyces is a serious complication, particularly in patients with papillary necrosis associated with analgesic abuse.

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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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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