eMedicine Specialties > Pediatrics: General Medicine > Nephrology

Renal Cortical Necrosis

Author: Elif Erkan, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Nephrology, University of Rochester School of Medicine
Coauthor(s): Prasad Devarajan, MD, Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of Clinical Nephrology Laboratories, Chief Executive Officer of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine
Contributor Information and Disclosures

Updated: Jan 28, 2010

Introduction

Background

Renal cortical necrosis (RCN) is a rare cause of acute renal failure secondary to ischemic necrosis of the renal cortex. The lesions are usually caused by significantly diminished renal arterial perfusion secondary to vascular spasm, microvascular injury, or intravascular coagulation. Renal cortical necrosis is usually extensive, although focal and localized forms occur. In most cases, the medulla, juxtamedullary cortex, and a thin rim of subcapsular cortex are spared.

Pathophysiology

Cases are usually bilateral. Although the pathogenesis remains unclear, the presumed initiating factor is intense vasospasm of the small vessels. If this vasospasm is brief and vascular flow is reestablished, acute tubular necrosis results. More prolonged vasospasm can cause necrosis and thrombosis of the distal arterioles and glomeruli, and renal cortical necrosis ensues. In hemolytic-uremic syndrome (HUS) and septic abortion, an additional mechanism involves endotoxin-mediated endothelial damage that leads to vascular thrombosis. Renal cortical necrosis in placental abruption may be due to a combination of a hypercoagulable state, endothelial injury, and intravascular thrombosis.

Frequency

United States

Renal cortical necrosis accounts for 2% of all cases of acute renal failure in adults and more than 20% of acute renal failure during the third trimester of pregnancy. Renal cortical necrosis was detected by postmortem examination in 5% of infants aged 3 months or younger at death.

International

Renal cortical necrosis incidence is higher in developing countries, ranging from 6-7% of all cases of acute renal failure. The incidence of acute cortical necrosis has been decreasing in the developing countries over the past years. The incidence of renal cortical necrosis was reported to be 3.12% of all cases of acute renal failure based on a study from India.1 Acute cortical necrosis due to obstetric causes was observed in 56.2% of patients whereas nonobstetric causes accounted for acute renal failure in 43.8% of the patients.

Mortality/Morbidity

In untreated patients, the mortality rate exceeds 50%. Early initiation of dialysis significantly diminishes this rate.

Race

Renal cortical necrosis has no racial predilection.

Sex

In childhood, renal cortical necrosis equally affects both sexes. In adults, renal cortical necrosis occurs more frequently in women because the most common cause is placental abruption (50% of all cases).

Age

The first peak of renal cortical necrosis occurrence is in early infancy and is associated with severe perinatal events or conditions. Renal cortical necrosis in childhood is usually secondary to HUS or severe volume depletion. Occurrence also peaks in women of childbearing age because of obstetric causes.

Clinical

History

The following may be noted in the history of patients with renal cortical necrosis (RCN):

  • Renal failure
  • Neonatal conditions
    • Perinatal asphyxia
    • Bleeding
    • Cyanotic heart disease
  • Childhood conditions
    • Diarrhea
    • Vomiting
    • Blood in stools
    • Hemolytic-uremic syndrome (HUS)
  • Pregnancy
    • Bleeding
    • Abortion
    • Symptoms of eclampsia
  • Other
    • Severe trauma
    • Snakebite (eg, sea snake, cobra, green pit viper, Russell viper)

Physical

  • Kidney
    • Abdominal or bilateral costovertebral tenderness
    • Palpable, tender kidneys
  • Shock
    • Hypotension
    • Tachycardia
    • Delayed capillary refill
  • Pregnancy
    • Lower abdominal tenderness
    • Contracted uterus
    • Vaginal bleeding

Causes

  • Neonatal conditions
    • Congenital heart disease
    • Fetal-maternal transfusion
    • Dehydration
    • Perinatal asphyxia
    • Anemia
    • Placental hemorrhage
    • Severe hemolytic disease
    • Sepsis
  • Childhood conditions
    • HUS
    • Acute gastroenteritis with dehydration
  • Pregnancy-related conditions (more than 50% of cases)
    • Placental abruption
    • Infected abortion
    • Prolonged intrauterine fetal death
    • Severe eclampsia
  • Miscellaneous
    • Sepsis
    • Shock
    • Trauma
    • Snakebite
    • Hyperacute kidney transplant rejection
    • Poisons
    • Drugs (eg, nonsteroidal anti-inflammatory drugs)
    • Contrast media

More on Renal Cortical Necrosis

Overview: Renal Cortical Necrosis
Differential Diagnoses & Workup: Renal Cortical Necrosis
Treatment & Medication: Renal Cortical Necrosis
Follow-up: Renal Cortical Necrosis
References
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References

  1. Prakash J, Vohra R, Wani IA, et al. Decreasing incidence of renal cortical necrosis in patients with acute renal failure in developing countries: a single-centre experience of 22 years from Eastern India. Nephrol Dial Transplant. Apr 2007;22(4):1213-7. [Medline].

  2. Kamioka I, Nozu K, Fujita T, et al. Prognosis and pathological characteristics of five children with non-Shiga toxin-mediated hemolytic uremic syndrome. Pediatr Int. Apr 2007;49(2):196-201. [Medline].

  3. [Guideline] Papnicolaou N, Francis IR, Casalino DD, Arellano RS, Baumgarten DA, Curry NS, Dighe M, Israel GM, Jafri SZ, Kawashima A, Leyendecker JR, Prasad S, Ramchandani P, Remer EM, Sheth S, Fulgham P, Expert Panel on Urologic Imaging. ACR Appropriateness Criteria renal failure. [online publication]. Reston (VA): American College of Radiology (ACR); 2008.

  4. Ali BH, Al-Qarawi AA, Mahmoud OM, Hashad M. Influence of spironolactone treatment on gentamicin-induced nephrotoxicity in rats. Basic Clin Pharmacol Toxicol. Jul 2004;95(1):20-3. [Medline].

  5. Ali SS, Rizvi SZ, Muzaffar S, et al. Renal cortical necrosis: a case series of nine patients & review of literature. J Ayub Med Coll Abbottabad. Apr-Jun 2003;15(2):41-4. [Medline].

  6. Chugh KS, Jha V, Sakhuja V, Joshi K. Acute renal cortical necrosis--a study of 113 patients. Ren Fail. 1994;16(1):37-47. [Medline].

  7. Hashimoto S, Shiroshita K, Sakurai T, et al. Unilateral renal cortical necrosis with contralateral hydronephrosis after surgery for uterus carcinoma. Clin Exp Nephrol. Mar 2003;7(1):72-6. [Medline].

  8. Lerner GR, Kurnetz R, Bernstein J, et al. Renal cortical and renal medullary necrosis in the first 3 months of life. Pediatr Nephrol. Nov 1992;6(6):516-8. [Medline].

  9. Mertens PR, Duque-Reina D, Ittel TH, et al. Contrast-enhanced computed tomography for demonstration of bilateral renal cortical necrosis. Clin Investig. Jul 1994;72(7):499-501. [Medline].

  10. Racusen LC, Solez K. Renal infarction, cortical necrosis, and atheroembolic disease. In: Tisher CC, Brenner BM, eds. Renal Pathology. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 1994:810-31.

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Further Reading

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Keywords

renal cortical necrosis, RCN, acute renal failure, acute renal failure in pregnancy, kidney failure, dehydration, placental abruption, ischemic necrosis of the renal cortex, renal arterial perfusion, acute tubular necrosis, hemolytic uremic syndrome, HUS, septic abortion, acute renal failure, oliguria, hematuria, perinatal asphyxia, cyanotic heart disease, eclampsia, hypotension, congenital heart disease, anemia, hemolytic disease, gastroenteritis

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Contributor Information and Disclosures

Author

Elif Erkan, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Nephrology, University of Rochester School of Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Prasad Devarajan, MD, Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of Clinical Nephrology Laboratories, Chief Executive Officer of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine
Prasad Devarajan, MD is a member of the following medical societies: American Heart Association, American Society of Nephrology, American Society of Pediatric Nephrology, National Kidney Foundation, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Laurence Finberg, MD, Clinical Professor, Department of Pediatrics, University of California at San Francisco and Stanford University
Laurence Finberg, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Luther Travis, MD, William W Glauser Professor of Pediatrics and Pediatric Nephrology, Department of Pediatrics, Divisions of Nephrology and Diabetes, University of Texas Medical Branch and Children's Hospital
Luther Travis, MD is a member of the following medical societies: Alpha Omega Alpha, American Federation for Medical Research, International Society of Nephrology, and Texas Pediatric Society
Disclosure: Nothing to disclose.

CME Editor

Howard Trachtman, MD, Program Director, Pediatrics Research, Schneider Children's Hospital, Department of Pediatrics, Division of Nephrology, Professor, Albert Einstein College of Medicine
Howard Trachtman, MD is a member of the following medical societies: American Society of Hypertension, American Society of Nephrology, American Society of Pediatric Nephrology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Chief Editor

Craig B Langman, MD, The Isaac A Abt, MD, Professor of Kidney Diseases, Feinberg School of Medicine, Northwestern University; Division Head of Kidney Diseases, Children's Memorial Hospital, Chicago
Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, and International Society of Nephrology
Disclosure: Amgen Grant/research funds None; Genzyme Grant/research funds None; Merck Grant/research funds None; NIH Grant/research funds None; Raptor Pharmaceuticals, Inc Grant/research funds None; Alexion Pharmaceuticals, Inc. Grant/research funds None

 
 
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