Papillary necrosis causing hydronephrosis in renal allograft treated by percutaneous retrieval of sloughed papilla

Renal Papillary Necrosis (RPN) in an African Population: Disease Patterns, Relevant Pathways, and Management

Renal papillary necrosis (RPN) is characterized by coagulative necrosis of the renal medullary pyramids and papillae. Multiple conditions and toxins are associated with RPN. Several RPN risk factors, or POSTCARDS, have been identified, with most patients presenting with RPN having at least two contributing risk factors. Currently, there is no specific test to diagnose and confirm RPN; however, several imaging tools can be used to diagnose the condition. RPN is currently underdiagnosed in African populations, often with fatal outcomes. In African clinical settings, there is a lack of consensus on how to define and describe RPN in terms of kidney anatomy, pathology, endourology, epidemiology, the identification of African-specific risk factors, the contribution of oxidative stress, and lastly an algorithm for managing the condition. Several risk factors are unique to African populations including population-specific genetic factors, iatrogenic factors, viral infections, antimicrobial therapy, schistosomiasis, substance abuse, and hypertension (GIVASSH). Oxidative stress is central to both GIVASSH and POSTCARDS-associated risk factors. In this review, we present information specific to African populations that can be used to establish an updated consensual definition and practical grading system for radiologists, urologists, nephrologists, nuclear physicians, and pathologists in African clinical settings.

Impact of ureteral length on urological complications and patient survival after kidney transplantation

BACKGROUND

Urologic complications are of the most important complications after kidney transplantation which increases mortality and morbidity significantly.

OBJECTIVES

We designed this study to evaluate the association between ureteral length and postoperative complications.

PATIENTS AND METHODS

We recorded the length of the transplanted ureter during the operation. Ureter-to-bladder anastomosis was performed using modified Lich-Gregoir method on the ureteral stent. Complications like urine leakage and increased creatinine were evaluated. We used both univariate and multivariate analyses and survival analysis according lengths of ureter. It means that the main variable is ureteral length and other variables are studied based on it.

RESULT

A total of 395 patients with the mean age of 37 years (range, 18 to 68 years) were enrolled in the study, twenty six graft lost during the follow-up period. The Mean age of recipients was 37 ± 13 years. Urinary stenosis was seen in 6 patients (1.5%) and urinary leakage in 4 (1%) patients. The complication rate was not significantly different between these groups (P = 0.67). We found that there were no significant difference among complication (P = 0.25), hospitalization (P = 0.31) and survival (P = 0.84) at 5.5 cm length cut off.

CONCLUSIONS

The length of transplanted ureter does not affect the postoperative urologic complications (including urinary fistula and ureter-to-bladder anastomosis stricture), and it seems that decreased rate of complication frequency during the recent years is due to technical improvement, surgeon's skillfulness and development in use of immunosuppressant's postoperatively.

Papillary necrosis with invasive fungal infections: a case series of 29 patients

BACKGROUND

Renal papillary necrosis (RPN) is associated with a number of comorbid conditions. However, it has been rarely reported in patients with fungal infections of the kidney.

METHODS

We analyzed medical records of our hospital for the last two decades and identified 29 patients with fungal infections and RPN.

RESULTS

Among the 29 patients, there were 24 men and 5 women. The median (range) age at presentation was 31.2 years (2 days-73 years). Three patients (10%) were kidney transplant recipients. The remaining had varied co-existing medical conditions that included diabetes mellitus in 16 (55%) and septicemia in 4 (14%). Clinical features at presentation were fever and oliguric kidney failure in 17 patients and loin pain accompanied by passage of fleshy material per urethra in 11 (38%). Diagnosis was made ante-mortem in 17 (59%) patients. Twenty patients (69%) had infection limited to the kidneys, while in the rest, it was disseminated. Kidney involvement was bilateral in 17 patients (59%). Urinalysis showed pyuria in 23 (79%) and microhematuria in 8 (28%) patients. Fungal infections included candidiasis (69%), aspergillosis (21%) and zygomycosis (10%). Of the 17 patients in whom the diagnoses was made ante-mortem, 12 survived and 5 died. Overall mortality was observed in 48% of cases.

CONCLUSIONS

We herein report a series of patients with RPN associated with fungal infections of the kidney. Presentation varies from asymptomatic urinary tract infection to severe kidney failure with poor outcome. High index of suspicion is necessary to reduce the associated high mortality in these patients.

Acute Renal Papillary Necrosis with Complete Bilateral Ureteral Obstruction in a Child

A 9-year-old girl presented with apparent meningococcal septicemia and developed acute renal failure after 48 hours of treatment with antibiotics and analgesics. Early ultrasound scanning demonstrated mild bilateral hydronephrosis and hydroureter. Intravenous urography showed slow contrast uptake with delay nephrogram and no contrast entering the bladder. Repeat ultrasonography revealed bilateral papillary irregularity and echogenic debris in the distal ureters. Bilateral double-J stents were inserted cystoscopically, resulting in prompt polyuria and a return of normal renal function. Although rare, recognition of sloughed papilla in papillary necrosis causing ureteral obstruction can lead to early management with no long-term sequelae.