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Renal Cortical Necrosis

Kidney Cortex Necrosis

Renal cortical necrosis, defined as the ischemia of the renal cortex with sparing of the medulla, is a rare, but very dangerous and life-threatening complication of the acute renal injury. Anuria, hematuria and a profoundly poor overall general condition are important clinical features. The diagnosis, made through laboratory and imaging studies, must be made early on, in order to increase the chances of survival.


Presentation

Renal cortical necrosis (RCN), responsible for approximately 2-7% of all acute kidney injuries (AKIs), can have a rapidly progressing clinical course that may result in death without early recognition [1]. Diminished perfusion of the renal cortex in both kidneys (as the underlying diseases are primarily of systemic etiology), occurs as a result of vascular spasm, coagulation, or microvascular injury, which may be seen in a myriad of disorders: hemolytic-uremic syndrome (HUS), placental abruption, sepsis, hemorrhagic shock (during pregnancy as well), eclampsia, extensive burn injury or severe dehydration resulting in hypovolemia, pancreatitis, snake bites and malaria [1] [2]. RCN may also be induced by several drugs, such as aminoglycosides, beta-lactam antibiotics, and non-steroidal anti-inflammatory drugs (NSAIDs), whereas post-nephrectomy of kidney donors may also result in RCN [1] [2]. Because of the nature of the condition, RCN is predominantly encountered in early infancy (HUS, sepsis, dehydration) and in women of childbearing age, when puerperal sepsis and placental abruption are responsible for the majority of cases [3]. Regardless of the underlying cause, an acute onset of absolute or relative anuria (defined as excretion of 0 or < 100 mL of urine per 24h, respectively) lasting for several days or even weeks is the typical clinical presentation [1]. Abdominal pain and fever, which may be severe in sepsis, can also appear. In addition, hematuria, both gross and/or microscopic, gastrointestinal hemorrhage, pulmonary edema and profound uremia lead to shock and multiorgan failure in many patients, and a fatal outcome is often seen without immediate initiation of dialysis [1] [2]. This condition usually results in acute kidney failure.

Nocturnal Leg Cramp
  • A 41-year-old woman was admitted for severe abdominal pain, melaena, fever and anuria two hours after quinine tablet intake for nocturnal leg cramps. Her medical history included angioneurotic edema caused by chloroquine for malaria prevention.[ncbi.nlm.nih.gov]
Toothache
  • Anaphylactoid shock, disseminated intravascular coagulation, and anuric renal failure requiring dialysis occurred in a patient receiving zomepirac sodium for toothache.[ncbi.nlm.nih.gov]
Protein S Deficiency
  • All together, these features suggested acquired protein S deficiency secondary to varicella.[ncbi.nlm.nih.gov]
Cotton Wool Spots
  • The patient's retinopathy included bilateral hemorrhages and cotton wool spots; visual fields and acuity remained normal. Funduscopic lesions disappeared by three months after the acute event.[ncbi.nlm.nih.gov]
Skin Lesion
  • An 18-year-old man developed skin lesions and anuria following exposure to sap of the marking-nut tree (Semecarpus anacardium). Renal biopsy showed diffuse cortical necrosis.[ncbi.nlm.nih.gov]
Eruptions
  • Ten days after the vesicle eruption appearance, he presented with ecchymosed heels, oligoanuric kidney failure, anemia [hemoglobin (Hb) 78 g/L], schizocytosis (2.5%), but normal platelet count.[ncbi.nlm.nih.gov]
Withdrawn
  • Dialytic support could be withdrawn as a result of improvement in renal function in 19 patients with patchy cortical necrosis. Dialysis-free survival of as long as 12 years has been recorded.[ncbi.nlm.nih.gov]
Oliguria
  • One patient spontaneously recovered renal function after prolonged oliguria. This case should be added to the small number of similar case reports in the literature.[ncbi.nlm.nih.gov]
  • Due to blast crisis the patient experienced sudden back pain, with oliguria and renal function deterioration followed by anaemia, in the context of haemolysis consistent with thrombotic microangiopathy, and as such, we were consulted.[ncbi.nlm.nih.gov]
  • Oliguria/anuria on admission and dialysis dependency are associated with RCN. PPH and history of operative intervention have significant association and are contributing factors to development of RCN.[ncbi.nlm.nih.gov]
  • The extent of the necrosis is a major determinant of the prognosis, which in turn is dependent on the duration of ischemia, duration of oliguria, and the severity of the precipitating conditions.[en.wikipedia.org]
  • He developed oliguria followed by anuria over two days. On examination, he was hemodynamically stable (BP - 120/80 mm of Hg) and had tenderness in the epigastrium and right hypochondriac areas.[doi.org]
Kidney Failure
  • It accounts for 2% of all cases of acute kidney failure in adults and more than 20% of cases of acute kidney failure during late pregnancy.[en.wikipedia.org]
  • This condition usually results in acute kidney failure.[symptoma.com]
  • Convert to ICD-10-CM : 583.6 converts approximately to: 2015/16 ICD-10-CM N17.1 Acute kidney failure with acute cortical necrosis Applies To Nephritis NOS with (renal) cortical necrosis Nephropathy NOS with (renal) cortical necrosis Renal cortical necrosis[icd9data.com]
  • Ten days after the vesicle eruption appearance, he presented with ecchymosed heels, oligoanuric kidney failure, anemia [hemoglobin (Hb) 78 g/L], schizocytosis (2.5%), but normal platelet count.[ncbi.nlm.nih.gov]
  • failure with tubular necrosis N171Acute kidney failure with acute cortical necrosis N172Acute kidney failure with medullary necrosis N178Other acute kidney failure N179Acute kidney failure, unspecified N181Chronic kidney disease, stage 1 N182Chronic[cms.gov]

Workup

Rapid detection of kidney failure is detrimental in order to save the life of the patient, which is why a detailed patient history and a thorough physical examination that will assess vital signs, history of urinary output, and note accompanying symptoms, are essential steps. A detailed laboratory workup comprising serum electrolyte levels (sodium, potassium, chloride, calcium, bicarbonate), arterial blood gas analyses (ABGs), kidney function tests (blood urea nitrogen and creatinine), a complete blood count (CBC) and urinalysis must be performed immediately, whereas imaging studies of the kidneys, either through ultrasonography or computed tomography (CT) should be subsequently employed. In fact, contrast-enhanced CT is considered as a very effective non-invasive method for early detection of RCN because it may identify a hypoattenuated subcapsular rim of the renal cortex [4], while magnetic resonance imaging (MRI) and contrast-enhanced ultrasonography may be used as well [1] [2] [4]. Although recommended in only a subset of patients due to its potential risks, renal biopsy is the gold standard for the diagnosis of RCN [5], which is classified into two types based on histopathological findings: diffuse, characterized by widespread cortical destruction; and patchy, where 30-50% of the cortical tissue is affected by ischemic necrosis [1] [3].

Treatment

  • Renal function improved partially after treatment with plasma exchange, steroids, and cyclophosphamide.[ncbi.nlm.nih.gov]
  • We began treatment with plasmapheresis and on the following day we performed haemodialysis (we carried out a total of 12 sessions of plasmapheresis until haemolysis disappeared).[ncbi.nlm.nih.gov]
  • Local infusion of anticoagulants or thrombolytic drugs into one renal artery offers the possibility of a controlled examination of the efficacy of this treatment in preventing cortical necrosis.[ncbi.nlm.nih.gov]
  • We report a case of bilateral renal cortical necrosis in a female after receiving 7 doses over 4 treatment days. The patient presented with worsening symptoms consisting of arthralgias, pruritus, and abdominal pain.[ncbi.nlm.nih.gov]
  • The length of exposure to tranexamic acid treatment was significantly more prolonged in women whose estimated glomerular filtration rate remained LIMITATIONS: Retrospective study; small sample size.[ncbi.nlm.nih.gov]

Prognosis

  • The renal prognosis improved as a result of the decreased mortality of patients.[ncbi.nlm.nih.gov]
  • Renal involvement has the worst prognosis. However, renal cortical necrosis is extremely unusual in SLE. In this case report, we describe the autopsy findings in a young female patient with SLE presenting with renal failure.[ncbi.nlm.nih.gov]
  • The disease had a fatal prognosis in 20 (87%) patients; mortality was due to uraemic complications and infections in the majority of patients.[ncbi.nlm.nih.gov]
  • The recognition of this entity and value of renal biopsy in cases of acute renal failure needs to be emphasized as this helps in establishing diagnosis, to assess prognosis and to aid in selection of a rational approach to therapy.[ncbi.nlm.nih.gov]
  • The presence of acute renal failure is generally associated with poor prognosis in case of bilateral renal cortical necrosis.[ncbi.nlm.nih.gov]

Etiology

  • RESULTS: The incidence of RCN was 3.12% of all cases of ARF of diverse etiology. RCN was observed in 57 patients; obstetric 32 (56.2%); non-obstetric 25 (43.8%).[ncbi.nlm.nih.gov]
  • The changing pattern in the incidence, etiology and outcome of RCN in patients with obstetric AKI was compared in the three study periods, namely 1982-1991, 1992-2002 and 2003-2014.[ncbi.nlm.nih.gov]
  • This review of BRCN, in conclusion, revealed the distinctive changes over the past 15 years in the etiology with a higher incidence of non-obstetric causes than obstetric ones, diagnostic procedures with less dependence on renal biopsy but new trials[ncbi.nlm.nih.gov]
  • Diminished perfusion of the renal cortex in both kidneys (as the underlying diseases are primarily of systemic etiology), occurs as a result of vascular spasm, coagulation, or microvascular injury, which may be seen in a myriad of disorders: hemolytic-uremic[symptoma.com]
  • Etiology severe hemodynamic shock traumatic blood loss postpartum hemorrhage septic shock venom toxin transfusion reaction severe dehydration microangiopathic hemolysis hemolytic uremic syndrome (HUS) renal transplantation CT Contrast-enhanced CT demonstrates[radiopaedia.org]

Epidemiology

  • […] following: Sepsis [5] Shock Trauma Snakebite [6] [7] Hyperacute kidney transplant rejection Poisons Drugs (eg, nonsteroidal anti-inflammatory drugs [NSAIDs]) Contrast media Malaria [8] Antiphospholipid syndrome [9] [10] Smoking synthetic cannabinoids [11] Epidemiology[emedicine.medscape.com]
  • Epidemiologic studies, clinical description, and comparison of P. vivax with P. falciparum are needed to understand the dynamics and its interaction with the immune system.[indianjnephrol.org]
  • Synthetic cannabinoids: epidemiology, pharmacodynamics, and clinical implications. Drug Alcohol Depend . 2014; 144 :12-41. [ PubMed ] [ DOI ] 5. Kunos G , Járai Z, Bátkai S, Goparaju SK, Ishac EJ, Liu J, Wang L, Wagner JA.[wjgnet.com]
  • In this study, we report epidemiological, clinical and Para clinical patterns of five obstetrical cortical renal necrosis in Aristide Le Dantec Hospital of Dakar.[omicsonline.org]
  • Epidemiology Microscopic nephrocalcinosis is a common incidental finding at post-mortem but macroscopic nephrocalcinosis is uncommon.[patient.info]
Sex distribution
Age distribution

Pathophysiology

  • The pathophysiology of this condition is complex, but ultimately leads to the destruction of the renal cortex with sparing of the renal medulla. A definitive diagnosis is based on renal histology.[ncbi.nlm.nih.gov]
  • Brenner/Rector remains the go-to resource for practicing and training nephrologists and internists who wish to master basic science, pathophysiology, and clinical best practices.[books.google.com]
  • Furthermore, the protective effect of various pharmacologic agents against 2 and 3 h of normothermic ischemia is investigated and the pathophysiology of renal ischemic damage is pointed out. 1976 S.[karger.com]
  • The pathophysiology of vivax malaria. Trends Parasitol 2009;25:220-7. 10. Andrade BB, Reis-Filho A, Souza-Neto SM, Clarêncio J, Camargo LM, Barral A, et al. Severe Plasmodium vivax malaria exhibits marked inflammatory imbalance.[indianjnephrol.org]
  • Rifampicin-associated acute renal failure: pathophysiologic, immunologic, and clinical features. Am J Kidney Dis 1998;31:108-15. [PubMed] 1 1. Lomaestro BM. Fluoroquinolone-induced renal failure. Drug Saf 2000;2: 479-85. [PubMed] 12.[antimicrobe.org]

Prevention

  • Local infusion of anticoagulants or thrombolytic drugs into one renal artery offers the possibility of a controlled examination of the efficacy of this treatment in preventing cortical necrosis.[ncbi.nlm.nih.gov]
  • Undelayed diagnosis and treatment did not avoid kidney insufficiency but prevented life-threatening complications.[ncbi.nlm.nih.gov]
  • Her medical history included angioneurotic edema caused by chloroquine for malaria prevention. Physical examination was normal. Laboratory data showed acute renal failure, hemolytic anemia without schistocytes and Dic.[ncbi.nlm.nih.gov]
  • Education and coaching of envenomed patients and exotic snake owners is mandatory to prevent dramatic accidents.[ncbi.nlm.nih.gov]
  • Treat your inpatient and ambulatory patients more effectively with the absolute latest on new topics such as quality improvement and patient care safety *school violence and bullying * preventive measures * vitamin deficiencies * adolescent rape * effect[books.google.com]

References

Article

  1. Prakash J, Singh VP. Changing picture of renal cortical necrosis in acute kidney injury in developing country. World Journal of Nephrology. 2015;4(5):480-486.
  2. Prakash J, Srivastava A, Singh S, Ghosh B. Renal cortical necrosis in a live kidney donor. Indian J Nephrol. 2012;22(1):48-51.
  3. Prakash J, Vohra R, Wani IA, Murthy AS, Srivastva PK, Tripathi K, 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. 2007;22(4):1213-1217.
  4. François M, Tostivint I, Mercadal L, Bellin MF, Izzedine H, Deray G. MR imaging features of acute bilateral renal cortical necrosis. Am J Kidney Dis. 2000;35(4):745-748.
  5. Aksoy S, Hocaoglu E, Karahasanoglu A, Igus B, Acay MB, Inci E. Bisphosphonate-induced bilateral acute renal cortical necrosis. Radiology Case Rep. 2015;10(2):992.

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Last updated: 2019-06-28 10:31