Renal papillary necrosis in poorly controlled diabetes: BMJ
A 66-year-old woman presented with a 1-day history of sharp left flank pain. This was associated with nausea and diarrhoea, without fever or urinary symptoms. Her medical history includes type 2 diabetes mellitus on insulin therapy but with suboptimal control (haemoglobin A1c 80 mmol/mol or 0.23 g/dL glucose levels) and related complications including chronic kidney disease, retinopathy, peripheral neuropathy, hypertension, sickle cell trait, obesity and osteoarthritis. Blood investigations demonstrated leucocytosis (white cell count 12.7×109/L) and deranged renal function (creatinine 150 µmol/L; baseline 110 µmol/L). Urine dipstick test was positive for nitrites, ketones and glucose and urine culture isolated mixed growth of bacteria with Candida.

A CT abdomen/pelvis, initially planned on the working diagnosis of acute diverticulitis, revealed a mild left-sided hydroureteronephrosis associated with perinephric inflammatory stranding. Left posterolateral bladder wall thickening and left distal ureteric enhancement were also highlighted. The patient was commenced on intravenous co-amoxiclav for the treatment of urosepsis. Though she remained afebrile, on the following day her blood investigations significantly worsened (white cell count 19.7×109/L, C reactive protein 429 mg/L and creatinine 429 µmol/L) and emergency diagnostic cystoscopy and insertion of a left ureteric stent was planned.

The bladder appeared normal but a lump of necrotic soft-tissue could be seen protruding from the left ureteric orifice, in keeping with a sloughed renal papilla wedged at the vesicoureteric junction. This was removed intact with biopsy forceps and a 6 French/22 cm ureteric stent was inserted. Postoperatively, the patient’s symptoms rapidly improved and her blood tests including renal function returned to baseline.

She was discharged on oral antibiotic therapy and had successful stent removal 2 weeks later. Histological analysis confirmed an infarcted renal papilla with focal necroinflammatory bacterial colonisation of the residual medullary collecting ducts. In the following months, the patient remained well with stable renal function and a renogram demonstrated adequate renal drainage with no obstruction. She was referred to the Endocrine Team for optimisation of her diabetic control.

Learning points
• Renal papillary necrosis is associated with poorly controlled diabetes and can lead to ureteric obstruction presenting with renal colic, acute kidney injury or urinary sepsis.

• In cases of an infected and obstructed kidney, emergency decompression is imperative, and direct visualisation may be required to allow for removal of the sloughed papilla followed by emergency stent for relief of obstruction.

• It is essential to gain optimal diabetic control to avoid renal papillary necrosis which could lead to sloughed papilla.

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