DOI: 10.1148/rg.266065039
Renal Papillary Necrosis: Review and Comparison of Findings at Multi–Detector Row CT and Intravenous Urography1
Dae Chul Jung, MD,
Seung Hyup Kim, MD,
Sung Il Jung, MD,
Sung Il Hwang, MD and
Sun Ho Kim, MD
1 From the Department of Radiology, Seoul National University College of Medicine, 28 Yongon-Dong, Chongno-Gu, 110–744, Seoul, Republic of Korea (D.C.J., S.H.K.); Department of Radiology, Cheil General Hospital and Women’s Healthcare Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea (S.I.J.); Department of Radiology, Hallym University College of Medicine, Anyang, Republic of Korea (S.I.H.); and Department of Radiology, Dongguk University College of Medicine, Goyang, Republic of Korea (S. Ho Kim). Recipient of a Certificate of Merit for an education exhibit at the 2005 RSNA Annual Meeting. Received March 23, 2006; revision requested May 12 and received July 10; accepted July 11. All authors have no financial relationships to disclose.
View larger version (79K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 1. Intrarenal arterial anatomy. The main renal artery is divided into four or more segmental arteries that are further subdivided into lobar and interlobar arteries. At the base of each renal pyramid, the interlobar arteries branch into arcuate arteries, which parallel the renal contour along the corticomedullary junction. The arcuate arteries give rise to multiple radial arterial branches called interlobular arteries, which in turn have multiple side branches from the afferent arterioles to the glomeruli. Blood leaves the glomerular capillary network via efferent arterioles, which either form a secondary capillary network around the urinary tubules in the cortex or descend into the renal medulla as long, straight vascular loops called vasa recta. The vasa recta form wide and plentiful vascular bundles at the base of the medullary pyramid, but the bundles taper as they continue distally toward the apex and papilla; as a result, the papillary tip receives only a marginal blood supply, a predisposing factor for ischemia and the subsequent development of renal papillary necrosis.
|
|
View larger version (109K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2a. Early ischemic change in the medullary pyramid in a 50-year-old man with diabetes. (a) Contrast-enhanced parenchymal phase CT image shows multiple poorly marginated, hypoattenuated lesions (arrowheads) in the papillary regions and the excretion of contrast material into the renal pelvis (arrow). (b) Follow-up CT image obtained 1 year later shows that the lesions disappeared after predisposing conditions were corrected and the tissues involved in ischemia recovered.
|
|
View larger version (126K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 2b. Early ischemic change in the medullary pyramid in a 50-year-old man with diabetes. (a) Contrast-enhanced parenchymal phase CT image shows multiple poorly marginated, hypoattenuated lesions (arrowheads) in the papillary regions and the excretion of contrast material into the renal pelvis (arrow). (b) Follow-up CT image obtained 1 year later shows that the lesions disappeared after predisposing conditions were corrected and the tissues involved in ischemia recovered.
|
|
View larger version (123K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3a. Early ischemic change in the medullary pyramid in a 77-year-old woman with a ureteral stone. (a) Contrast-enhanced parenchymal phase CT image shows a hypoattenuated lesion (arrowhead) in the papillary region. (b) Follow-up CT image obtained 1 year later shows marked contraction of the left kidney, an irreversible result of continued ischemia.
|
|
View larger version (120K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 3b. Early ischemic change in the medullary pyramid in a 77-year-old woman with a ureteral stone. (a) Contrast-enhanced parenchymal phase CT image shows a hypoattenuated lesion (arrowhead) in the papillary region. (b) Follow-up CT image obtained 1 year later shows marked contraction of the left kidney, an irreversible result of continued ischemia.
|
|
View larger version (91K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 4. Early-stage renal papillary necrosis with necrotizing papillitis. Contrast-enhanced parenchymal phase CT image in a 47-year-old diabetic woman with flank pain, fever, and pyuria shows markedly swollen kidneys with hypoattenuated lesions (arrowheads) in papillary regions.
|
|
View larger version (88K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5a. (a) Contrast-enhanced CT image in a 71-year-old diabetic woman with clinical findings of acute pyelonephritis shows markedly swollen kidneys with hypoattenuated lesions (white arrowheads) in papillary regions and, at the right kidney periphery, a wedge-shaped lesion (black arrowheads). (b) Photograph of a gross section from the right kidney shows abscesses in the cortex (arrowheads) and hemorrhagic infarcts in papillary regions (arrows), findings indicative of pyonephrosis and necrotizing papillitis, respectively.
|
|
View larger version (125K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 5b. (a) Contrast-enhanced CT image in a 71-year-old diabetic woman with clinical findings of acute pyelonephritis shows markedly swollen kidneys with hypoattenuated lesions (white arrowheads) in papillary regions and, at the right kidney periphery, a wedge-shaped lesion (black arrowheads). (b) Photograph of a gross section from the right kidney shows abscesses in the cortex (arrowheads) and hemorrhagic infarcts in papillary regions (arrows), findings indicative of pyonephrosis and necrotizing papillitis, respectively.
|
|
View larger version (6K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 6. Schematic shows a normal calix (a), papillary (b) and medullary (c) forms of renal papillary necrosis, and caliceal blunting after papillary sloughing and epithelialization (d).
|
|
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7a. Papillary form of renal papillary necrosis in a 58-year-old woman who had taken nonsteroidal analgesics for several years. (a) IV urogram shows multiple clefts that extend from the fornices to the pyramid tips (arrows). (b, c) Contrast-enhanced excretory phase CT images show a cleft filled with urine and contrast material that extends from the fornices (arrow in b) to a pyramid tip (arrow in c).
|
|
View larger version (129K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7b. Papillary form of renal papillary necrosis in a 58-year-old woman who had taken nonsteroidal analgesics for several years. (a) IV urogram shows multiple clefts that extend from the fornices to the pyramid tips (arrows). (b, c) Contrast-enhanced excretory phase CT images show a cleft filled with urine and contrast material that extends from the fornices (arrow in b) to a pyramid tip (arrow in c).
|
|
View larger version (112K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 7c. Papillary form of renal papillary necrosis in a 58-year-old woman who had taken nonsteroidal analgesics for several years. (a) IV urogram shows multiple clefts that extend from the fornices to the pyramid tips (arrows). (b, c) Contrast-enhanced excretory phase CT images show a cleft filled with urine and contrast material that extends from the fornices (arrow in b) to a pyramid tip (arrow in c).
|
|
View larger version (89K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8a. Focal papillary necrosis of the medullary form in a 69-year-old woman. (a) IV urogram shows a teardrop-shaped papillary cavity in the upper polar calix of the left kidney (arrowhead). (b, c) Reformatted coronal (b) and axial (c) contrast-enhanced CT images from the excretory phase show a small cavity (arrow) in the central portion of the papilla, extending from the fornix.
|
|
View larger version (144K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8b. Focal papillary necrosis of the medullary form in a 69-year-old woman. (a) IV urogram shows a teardrop-shaped papillary cavity in the upper polar calix of the left kidney (arrowhead). (b, c) Reformatted coronal (b) and axial (c) contrast-enhanced CT images from the excretory phase show a small cavity (arrow) in the central portion of the papilla, extending from the fornix.
|
|
View larger version (114K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 8c. Focal papillary necrosis of the medullary form in a 69-year-old woman. (a) IV urogram shows a teardrop-shaped papillary cavity in the upper polar calix of the left kidney (arrowhead). (b, c) Reformatted coronal (b) and axial (c) contrast-enhanced CT images from the excretory phase show a small cavity (arrow) in the central portion of the papilla, extending from the fornix.
|
|
View larger version (153K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 9. Triangular cavity that communicates with the collecting system in a 68-year-old woman with a recurrent urinary tract infection due to a large pelvic stone. Reformatted coronal contrast-enhanced CT image shows a triangular excavation in the upper polar calix (arrowheads) of the left kidney and advanced scarring of the right kidney.
|
|
View larger version (87K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10a. Diffuse papillary calcifications in a 62-year-old man with renal papillary necrosis due to long-term use of analgesics. Posteroanterior radiograph (a) and axial unenhanced CT image (b) show multiple calcifications (arrows) in the medullae of both kidneys.
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 10b. Diffuse papillary calcifications in a 62-year-old man with renal papillary necrosis due to long-term use of analgesics. Posteroanterior radiograph (a) and axial unenhanced CT image (b) show multiple calcifications (arrows) in the medullae of both kidneys.
|
|
View larger version (76K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11a. Diffuse bilateral renal papillary necrosis in a 50-year-old woman with tuberculosis. (a) IV urogram shows blunt-tipped calices (arrows) in both kidneys. (b, c) Contrast-enhanced CT images from the excretory phase in the right (b) and left (c) kidneys show blunt-tipped calices (arrow), features that correspond to the IV urographic findings.
|
|
View larger version (137K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11b. Diffuse bilateral renal papillary necrosis in a 50-year-old woman with tuberculosis. (a) IV urogram shows blunt-tipped calices (arrows) in both kidneys. (b, c) Contrast-enhanced CT images from the excretory phase in the right (b) and left (c) kidneys show blunt-tipped calices (arrow), features that correspond to the IV urographic findings.
|
|
View larger version (130K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 11c. Diffuse bilateral renal papillary necrosis in a 50-year-old woman with tuberculosis. (a) IV urogram shows blunt-tipped calices (arrows) in both kidneys. (b, c) Contrast-enhanced CT images from the excretory phase in the right (b) and left (c) kidneys show blunt-tipped calices (arrow), features that correspond to the IV urographic findings.
|
|
View larger version (124K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12a. Loss of renal cortex in a 44-year-old woman with a recurrent urinary tract infection. (a) IV urogram shows blunt-tipped calices (arrows) in the left kidney. (b) Contrast-enhanced CT image from the excretory phase shows caliceal blunting and severe cortical thinning in the kidney (arrow).
|
|
View larger version (132K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 12b. Loss of renal cortex in a 44-year-old woman with a recurrent urinary tract infection. (a) IV urogram shows blunt-tipped calices (arrows) in the left kidney. (b) Contrast-enhanced CT image from the excretory phase shows caliceal blunting and severe cortical thinning in the kidney (arrow).
|
|
View larger version (103K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 13. Loss of renal cortex in a 22-year-old woman with chronic renal failure due to long-standing vesicoureteral reflux. Contrast-enhanced CT image from the parenchymal phase shows a triangular area of hypoattenuation in an atrophic left kidney (arrow).
|
|
View larger version (80K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14a. Focal papillary necrosis in a 61-year-old man with a neuropathic bladder. (a) Longitudinal color Doppler US image shows blunting of the upper polar calices (arrows), which are bordered by arcuate vessels (arrowheads). (b) IV urogram shows focal blunting of the upper polar calices (arrows).
|
|
View larger version (137K):
[in this window]
[in a new window]
[Download PPT slide]
|
Figure 14b. Focal papillary necrosis in a 61-year-old man with a neuropathic bladder. (a) Longitudinal color Doppler US image shows blunting of the upper polar calices (arrows), which are bordered by arcuate vessels (arrowheads). (b) IV urogram shows focal blunting of the upper polar calices (arrows).
|
|
Copyright © 2006 by the Radiological Society of North America.
