Renal Papillary Necrosis: Review and Comparison of Findings at Multi–Detector Row CT and Intravenous Urography

Published Online:https://doi.org/10.1148/rg.266065039

Renal papillary necrosis is not a pathologic entity but rather a descriptive term for a condition—necrosis of the renal papillae—that has various possible causes. The renal medulla and papillae are vulnerable to ischemic necrosis because of the peculiar arrangement of their blood supply and the hypertonic environment. The etiology of renal papillary necrosis includes diabetes, analgesic abuse or overuse, sickle cell disease, pyelonephritis, renal vein thrombosis, tuberculosis, and obstructive uropathy. Renal papillary necrosis has been diagnosed with the use of intravenous urography and ultrasonography, but contrast material–enhanced computed tomography (CT) may better depict a full range of typical features, including contrast material–filled clefts in the renal medulla, nonenhanced lesions surrounded by rings of excreted contrast material, and hyperattenuated medullary calcifications. In the presence of papillary sloughing, CT may depict hydronephrosis and filling defects in the renal pelvis or ureter, which also may contain calcifications. During healing, the epithelialized papillary tip appears blunted. Shrinkage of the kidney, a common sequela, also may be detected at CT. Multi–detector row CT depicts these and other features more clearly and directly than single–detector row CT, given the advantages of thinner sections and multiplanar reformation, and it may help identify the condition at an earlier stage, when effective treatment can reverse the ischemic process. Familiarity with the CT features of the condition therefore is useful for its successful diagnosis and management.

© RSNA, 2006

References

  • 1 KimSH. Renal papillary necrosis. In: Kim SH, ed. Radiology illustrated: uroradiology. Philadelphia, Pa: Saunders, 2003; 273–310. Google Scholar
  • 2 FriedrichN. Ueber necrose der nierenpapillen bei hydronephrose. Arch Pathol Anat1877; 69: 308–312. CrossrefGoogle Scholar
  • 3 SimonHB, Bennett WA, Emmet JL. Renal papillary necrosis: a clinicopathologic study of 42 cases. J Urol1957; 77(4): 557–567. Crossref, MedlineGoogle Scholar
  • 4 SegasothyM, Abdul Samad S, Zulfiqar A, Shaariah W, Morad Z, Prasad Menon S. Computed tomography and ultrasonography: a comparative study in the diagnosis of analgesic nephropathy. Nephron1994; 66(1): 62–66. Crossref, MedlineGoogle Scholar
  • 5 SaifuddinA, Bark M. Case report: computed tomography demonstration of renal papillary necrosis. Clin Radiol1991; 44(4): 275–276. Crossref, MedlineGoogle Scholar
  • 6 AndrioleGL, Bahnson RR. Computed tomographic diagnosis of ureteral obstruction caused by a sloughed papilla. Urol Radiol1987; 9(1): 45–46. MedlineGoogle Scholar
  • 7 JoffeSA, Servaes S, Okon S, Horowitz M. Multi–detector row CT urography in the evaluation of hematuria. RadioGraphics2003; 23(6): 1441–1456. LinkGoogle Scholar
  • 8 KabalinJN. Anatomy of the retroperitoneum and kidney. In: Walsh PC, ed. Campbell’s urology. 6th ed. Philadelphia, Pa: Saunders, 1992;1:3–40. Google Scholar
  • 9 KimSH, Kim B. Renal parenchymal disease. In: Pollack HM, ed. Clinical urography. 2nd ed. Philadelphia, Pa: Saunders, 2000;3:2673–2676. Google Scholar
  • 10 GroopL, Laasonen L, Edgren J. Renal papillary necrosis in patients with IDDM. Diabetes Care1989; 12(3): 198–202. Crossref, MedlineGoogle Scholar
  • 11 RaoVM, Rao AK, Steiner RM, Burka ER, Grainger RG, Ballas SK. The effect of ionic and nonionic contrast media on the sickling phenomenon. Radiology1982; 144(2): 291–293. LinkGoogle Scholar
  • 12 SekineH, Mine M, Ohya K, Kojima S, Yokokawa M. Renal papillary necrosis caused by urinary calculus-induced obstruction alone. Urol Int1995; 54(2): 112–114. Crossref, MedlineGoogle Scholar
  • 13 BachPH, Gregg NJ. Experimentally induced renal papillary necrosis and upper urothelial carcinoma. Int Rev Exp Pathol1988; 30: 1–54. MedlineGoogle Scholar
  • 14 ChappleCR, Newman J, O’Brien JM, Considine J. Analgesic nephropathy complicated by transitional carcinoma of the renal pelvis. Br J Urol1987; 59(1): 89. Crossref, MedlineGoogle Scholar
  • 15 HareWS, Poynter JD. The radiology of renal papillary necrosis as seen in analgesic nephropathy. Clin Radiol1974; 25(4): 423–443. Crossref, MedlineGoogle Scholar
  • 16 KaudeJV, Stone M, Fuller TJ, Cade R, Tarrant DG, Juncos LI. Papillary necrosis in kidney transplant patients. Radiology1976; 120(1): 69–74. LinkGoogle Scholar
  • 17 EdmondsonHA, Reynolds TB, Jacobson HG. Renal papillary necrosis with special reference to chronic alcoholism: a report of 20 cases. Arch Intern Med1966; 118(3): 255–264. Crossref, MedlineGoogle Scholar
  • 18 ShapeeroLG, Vordermark JS. Papillary necrosis causing hydronephrosis in the renal allograft: sonographic findings. J Ultrasound Med1989; 8(10): 579–581. Crossref, MedlineGoogle Scholar
  • 19 LindvallN. Renal papillary necrosis: a roentgenographic study of 155 cases. Acta Radiol1960; 192(suppl): 1–153. Google Scholar
  • 20 LangEK, Macchia RJ, Thomas R, et al. Multiphasic helical CT diagnosis of early medullary and papillary necrosis. J Endourol2004; 18(1): 49–56. Crossref, MedlineGoogle Scholar
  • 21 LangEK, Macchia RJ, Thomas R, et al. Detection of medullary and papillary necrosis at an early stage by multiphasic helical computerized tomography. J Urol2003; 170(1): 94–98. Crossref, MedlineGoogle Scholar
  • 22 BittarEE, Misanik L. Renal necrotizing papillitis. Am J Med1963; 34: 82–87. Crossref, MedlineGoogle Scholar
  • 23 WeberM, Braun B, Kohler H. Ultrasonic findings in analgesic nephropathy. Nephron1985; 39(3): 216–222. Crossref, MedlineGoogle Scholar
  • 24 HartmanGW, Torres VE, Leago GF, Williamson B, Hattery RR. Analgesic-associated nephropathy. JAMA1984; 251: 1734–1738. Crossref, MedlineGoogle Scholar
  • 25 DyerRB, Chen MY, Zagoria RJ. Classic signs in uroradiology. RadioGraphics2004; 24(Spec Issue): S247–S280. LinkGoogle Scholar
  • 26 PoynterJD, Hare WS. Necrosis in situ: a form of renal papillary necrosis seen in analgesic nephropathy. Radiology1974; 111(1): 69–76. LinkGoogle Scholar
  • 27 HoffmanJC, Schnur MJ, Koenigsberg M. Demonstration of renal papillary necrosis by sonography. Radiology1982; 145(3): 785–787. LinkGoogle Scholar
  • 28 CheungH, Chan PS, Metreweli C. Case report: echogenic necrotic renal papillae simulating calculi. Clin Radiol1992; 46(1): 61–62. Crossref, MedlineGoogle Scholar
  • 29 VijayaraghavanSB, Kandasamy SV, Mylsamy A, Prabhakar M. Sonographic features of necrosed renal papillae causing hydronephrosis. J Ultrasound Med2003; 22(9): 951–956. Crossref, MedlineGoogle Scholar
  • 30 BradenGL, Kozinn DR, Hampf FE Jr, Parker TH, Germain MJ. Ultrasound diagnosis of early renal papillary necrosis. J Ultrasound Med1991; 10(7): 401–403. Crossref, MedlineGoogle Scholar

Article History

Published in print: Nov 2006