Acute cortical and papillary necrosis: urological considerations

Overview

Renal cortical and papillary necrosis are rare but potentially severe conditions.

For the physician managing urological emergencies, the priorities are to:

• recognize the clinical context;
• rule out obstruction and other reversible causes of AKI;
• arrange joint management with a nephrologist.

Cortical necrosis

• Associated with severe impairment of renal blood flow and microcirculation.
• Causes: sepsis, severe obstetric complications, disseminated intravascular coagulation (DIC).
• Presents as severe AKI with oliguria or anuria.
• Diagnosis requires specialized imaging of vascular and parenchymal perfusion.

Papillary necrosis

• Associated with diabetes mellitus, infection, obstruction, and certain drug exposures.
• Possible features include renal colic, hematuria, and passage of sloughed necrotic papillae causing secondary ureteral obstruction.

Emergency diagnostic assessment

• Pain, hematuria, or AKI → rule out a stone, clot, papillary fragment, and infected obstruction.
• Ultrasonography is the first investigation.
• CT according to the clinical question.
• In systemic disease, assess coagulation, hemodynamics, electrolytes, and signs of sepsis.

Treatment

• Treatment targets the cause and complications: control infection, correct hemodynamic and metabolic disturbances, and restore drainage if obstruction is present.
• Endoscopic intervention for migrated necrotic material and persistent obstruction.
• Renal replacement therapy according to standard indications.

Algorithm