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Renal Cortical Necrosis

By

Zhiwei Zhang

, MD, Loma Linda University School of Medicine

Reviewed/Revised Mar 2023
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Topic Resources

Renal cortical necrosis is destruction of cortical tissue resulting from renal arteriolar injury and leading to acute kidney injury. This rare disorder typically occurs in neonates and in pregnant or postpartum women when sepsis or pregnancy complications occur. Symptoms and signs include gross hematuria, flank pain, decreased urine output, fever, and symptoms of uremia. Symptoms of the underlying disorder may predominate. Diagnosis is by ultrasonography, CT, or renal biopsy. Mortality rate at 1 year is > 20%. Treatment is directed at the underlying disorder and at preserving renal function.

In renal cortical necrosis, which may be patchy or diffuse, bilateral renal arteriolar injury results in destruction of cortical tissues and acute kidney injury Acute Kidney Injury (AKI) Acute kidney injury is a rapid decrease in renal function over days to weeks, causing an accumulation of nitrogenous products in the blood (azotemia) with or without reduction in amount of urine... read more . Renal cortical tissues eventually calcify. The juxtamedullary cortex, medulla, and the area just under the capsule are spared.

Etiology of Renal Cortical Necrosis

Injury usually results from reduced renal artery perfusion secondary to vascular spasm, microvascular injury, or intravascular coagulation.

Table

Symptoms and Signs of Renal Cortical Necrosis

Gross hematuria, flank pain, and sometimes decreased urine output or abrupt anuria occur. Fever is common, and chronic kidney disease with hypertension develops. However, these symptoms are often overshadowed by symptoms of the underlying disorder.

Diagnosis of Renal Cortical Necrosis

  • Imaging study or renal biopsy

Diagnosis is suspected when typical symptoms occur in patients with a potential cause.

Urinalysis, complete blood count (CBC), serum electrolytes, liver tests, and renal function tests are done routinely. These tests often confirm renal dysfunction (eg, indicated by elevated creatinine and blood urea nitrogen and by hyperkalemia) and may suggest a cause. Severe electrolyte abnormalities may be present depending on the cause (eg, hyperkalemia Hyperkalemia Hyperkalemia is a serum potassium concentration > 5.5 mEq/L (> 5.5 mmol/L), usually resulting from decreased renal potassium excretion or abnormal movement of potassium out of cells. There... read more , hyperphosphatemia Hyperphosphatemia Hyperphosphatemia is a serum phosphate concentration > 4.5 mg/dL (> 1.46 mmol/L). Causes include chronic kidney disease, hypoparathyroidism, and metabolic or respiratory acidosis. Clinical... read more , hypocalcemia Hypocalcemia Hypocalcemia is a total serum calcium concentration < 8.8 mg/dL (< 2.20 mmol/L) in the presence of normal plasma protein concentrations or a serum ionized calcium concentration < 4... read more ). CBC often detects leukocytosis (even when sepsis is not the cause) and may detect anemia and thrombocytopenia if hemolysis Overview of Hemolytic Anemia At the end of their normal life span (about 120 days), red blood cells (RBCs) are removed from the circulation. Hemolysis is defined as premature destruction and hence a shortened RBC life span... read more Overview of Hemolytic Anemia , disseminated intravascular coagulation Disseminated Intravascular Coagulation (DIC) Disseminated intravascular coagulation (DIC) involves abnormal, excessive generation of thrombin and fibrin in the circulating blood. During the process, increased platelet aggregation and coagulation... read more (DIC), or sepsis Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more is the cause. Transaminases may be increased in relative hypovolemic states (eg, septic shock Sepsis and Septic Shock Sepsis is a clinical syndrome of life-threatening organ dysfunction caused by a dysregulated response to infection. In septic shock, there is critical reduction in tissue perfusion; acute failure... read more , postpartum hemorrhage Postpartum Hemorrhage Postpartum hemorrhage is blood loss of > 1000 mL or blood loss accompanied by symptoms or signs of hypovolemia within 24 hours after childbirth. Diagnosis is clinical. Treatment depends on... read more ). If DIC is suspected, coagulation studies are done. They may detect low fibrinogen levels, increased fibrin-degradation products, and increasing prothrombin time (PT)/INR and partial thromboplastin time (PTT). Urinalysis typically detects proteinuria and hematuria.

Treatment of Renal Cortical Necrosis

  • Treatment of underlying cause

  • Preservation of renal function

Treatment is directed at the underlying disorder and at preserving renal function (eg, with early dialysis).

Prognosis for Renal Cortical Necrosis

Prognosis of renal cortical necrosis was poor in the past, with mortality > 50% in the first year. More recently, with aggressive supportive therapy, 1-year mortality can be about 20%, and up to 20% of survivors may recover some renal function.

Key Points

  • Renal cortical necrosis is rare, typically occurring in neonates and in pregnant or postpartum women with sepsis or pregnancy complications.

  • Suspect the diagnosis in patients at risk who develop typical symptoms (eg, gross hematuria, flank pain, decreased urine output, fever, hypertension).

  • Confirm the diagnosis with renal imaging or renal biopsy.

  • Treat the underlying disorder.

Drugs Mentioned In This Article

Drug Name Select Trade
Aluvea , BP-50% Urea , BP-K50, Carmol, CEM-Urea, Cerovel, DermacinRx Urea, Epimide-50, Gord Urea, Gordons Urea, Hydro 35 , Hydro 40, Kerafoam, Kerafoam 42, Keralac, Keralac Nailstik, Keratol, Keratol Plus, Kerol, Kerol AD, Kerol ZX, Latrix, Mectalyte, Nutraplus, RE Urea 40, RE Urea 50 , Rea Lo, Remeven, RE-U40, RYNODERM , U40, U-Kera, Ultra Mide 25, Ultralytic-2, Umecta, Umecta Nail Film, URALISS, Uramaxin , Uramaxin GT, Urea, Ureacin-10, Ureacin-20, Urealac , Ureaphil, Uredeb, URE-K , Uremez-40, Ure-Na, Uresol, Utopic, Vanamide, Xurea, X-VIATE
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