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Kidney Week

Abstract: PO0285

A Case of Renal Papillary Necrosis in the Setting of Acute Pyelonephritis and Chronic NSAID Use

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials


  • Kalaria, Arjun Lalit, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Heslin, Michael, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Nalesnik, Michael A., University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
  • Abramovitz, Blaise William, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States

Renal papillary necrosis is an ischemic process that affects the renal papillae and inner medulla leading to acute kidney injury. Most common causes include diabetes mellitus often with urinary tract infection, sickle cell anemia, and analgesic use. It is histologically delineated by coagulative necrosis of the renal papilla and medullary pyramids, and potentially acute liquefactive necrosis in the presence of infection. We report a case of renal papillary necrosis in the setting of acute pyelonephritis and chronic NSAID use.

Case Description

A 59-year-old Caucasian male with a history of hypertension, irritable bowel syndrome, hyperlipidemia who presented with 4 days of vomiting, diarrhea, decreased urinary output, and generalized weakness. He endorsed twice daily use of naproxen for the past couple months. Physical examination only notable for dry mucous membranes.

Initial work-up demonstrated serum creatinine of 12.7 mg/dL (baseline 1.0 mg/dL), serum sodium level of 123 mmol/L, serum potassium level of 7.4 mmol/L, blood urea nitrogen 147 mg/dL, WBC count 30.5 x10^9/L, and urinalysis with pyuria, microscopic hematuria, and proteinuria. Further work-up showed urine culture with pan-sensitive Escherichia coli, sub-nephrotic proteinuria, and complete serologic work-up only positive for serum protein electrophoresis. CT abdomen/pelvis without contrast did not demonstrate any hydronephrosis. A native kidney biopsy was performed and revealed diffuse tubulointerstitial inflammation with prominent intratubular white cell casts and areas of confluent parenchymal necrosis consistent with acute pyelonephritis leading to renal papillary necrosis. He completed a 7-day course of ceftriaxone for E. coli urinary tract infection and eventually required hemodialysis with no signs of kidney recovery upon discharge.


Renal papillary necrosis is a rare disease entity and is underdiagnosed due to its variable clinical presentation. Unfortunately, it could have potentially fatal outcomes if undiagnosed, which is evident upon reviewing the current literature. By presenting this case, we highlight this unique presentation of renal papillary necrosis in a non-diabetic individual and urge clinicians to have a high index of suspicion and subsequently a low threshold for kidney biopsy to establish a diagnosis and improve patient outcomes.