Prevalence and associations of symptomatic renal papillary necrosis in sickle cell anemia patients in South-Eastern Nigeria.

AIM: To assess the prevalence and associations of symptomatic renal papillary necrosis (RPN) in sickle cell anemia patients. PATIENTS AND METHODS: The case notes of homozygous hemoglobin (Hb) S patients diagnosed with RPN were retrospectively assessed. Diagnosis was based on microscopic hematuria and positive ultrasound findings. Their steady state diastolic blood pressure, Hb, leukocyte count, platelet count, serum direct bilirubin, and aspartate transaminase, were obtained by automated analyzers. These were evaluated for any relationship with the occurrence of RPN. RESULTS: Two hundred and twenty patients were assessed aged 6-55 years with a median age of 24 years. The prevalence of symptomatic RPN was found to be 2.3%. RPN was positively associated with the female gender (Chi-square P value 0.001), but not with any other clinical or laboratory variable. However, other predictors of disease severity were positively associated with RPN such as age, diastolic blood pressure 0.180 (P = 0.016), serum aspartate transaminase, serum bilirubin 0.145 (0.027), Hb, and leukocyte count - 0.155 (P = 0.003). CONCLUSION: The prevalence of symptomatic RPN is low in this group of homozygous S patients and occurs more commonly in females. Improvement in care for these patients will reduce these chronic complications.

Mucormycosis of the transplanted kidney with renal papillary necrosis.

The occurrence of renal allograft mucormycosis is uncommon, but its association with renal papillary necrosis has not been reported. We describe such an association in a patient who survived on peritoneal dialysis after nephrectomy and antifungal therapy.

The epidemiology of acute pyelonephritis in South Korea, 1997-1999.

Acute pyelonephritis causes significant morbidity, tends to recur, and can be fatal; however, little is known regarding its epidemiology. In this paper, the authors describe the epidemiology of acute pyelonephritis in South Korea by using nationwide heath insurance claims data from 1997 to 1999. The National Health Insurance System of South Korea covers almost the entire population (99%). The overall average annual incidence rate of pyelonephritis in 1997-1999 was 35.7 per 10,000 population (male, 12.6; female, 59.0). Approximately one of every seven patients was hospitalized (incidence per 10,000: inpatients, 5.5; outpatients, 30.1). Incidence varied with age and was higher in the summer season. Following an initial episode, the risk of a second episode within 12 months was 9.2% for females and 5.7% for males; by contrast, the risk of a fifth episode within a year following a fourth episode was 50.0% for females and 53.0% for males. Female sex (hazard ratio = 1.89, 95% confidence interval: 1.60, 2.23), advancing age, outpatient treatments (hazard ratio = 1.35, 95% confidence interval: 1.14, 1.60), and medical aid (hazard ratio = 1.23, 95% confidence interval: 1.08, 1.40) increased the risk of any recurrence. Pyelonephritis has a clear seasonal pattern and high rate of recurrence. The incidence of hospitalization for pyelonephritis in South Korea is similar to that in the United States and Canada.

Renal papillary necrosis.

Renal papillary necrosis (RPN) is a significant problem in human beings, especially in England and in Australia where it has been reported to account for 15% to 20% of patients needing renal transplants. Many compounds, including aspirin, phenacetin, phenylbutazone, indomethacin, mefenamic acid, flufenamic acid, fenoprofin, naproxen, and ibuprofen have been linked to renal papillary necrosis in human beings. Although the exact mechanism of RPN is unknown, there are several theories that have good scientific evidence behind them. Study of RPN in animals as models for the disease in human beings is limited by several factors, including anatomical differences between human beings and most animal species as well as technical difficulties in studying the renal papilla.

Pregnancy outcome in women with reflux nephropathy and the inheritance of vesico-ureteric reflux.

In women with reflux nephropathy, we investigated whether pre-existing hypertension and impaired renal function influence the rates of preeclampsia, renal function deterioration and preterm birth. The infants were investigated for vesico-ureteric reflux (VUR). A prospective audit of 54 pregnancies in 46 women with reflux nephropathy was performed. Preeclampsia complicated 24% of pregnancies and was increased in women with pre-existing hypertension (42%) compared with normotensive women (14%), (RR 3.0 (95% CI 1.1-7.8)). Nine (18%) women experienced deterioration in renal function during pregnancy Women with mild or moderate renal impairment were at increased risk of renal function deterioration (RR 12.7 (95% CI 1.6-98.5); RR 19.8 (95% CI 2.6-155)), respectively A third of infants were delivered preterm. The risk of preterm birth was increased if the mother had pre-existing hypertension (p = 0.01) or moderate renal impairment (p = 0.002). Seventeen (43%) of the 40 infants who underwent micturating cystourethrography had VUR, consistent with autosomal dominant inheritance with reduced penetrance. In reflux nephropathy, pre-existing hypertension was associated with an increased risk of preeclampsia and pre-existing renal impairment with deterioration in renal function. Infants of women with reflux nephropathy should be screened for VUR.

Renal papillary necrosis in a hemodialysis patient.

We present the first case report of bilateral renal papillary necrosis developing in a patient on hemodialysis. A 37-year-old hypertensive male with chronic glomerulonephritis had a normal retrograde pyelogram one year prior to initiation of hemodialysis. After two years of maintenance dialysis, he presented with gross hematuria and was found to have extensive bilateral renal papillary necrosis. His only predisposing factor was hepatic cirrhosis. It is postulated that recurrent hypotensive episodes associated with hemodialysis may lead to renal papillary necrosis in predisposed individuals. This diagnosis should be considered in hemodialysis patients who develop hematuria.

Renal papillary necrosis in Kuwait.

In 2,158 consecutive routine urograms, 85 patients (51 males and 34 females) were found to have typical changes of renal papillary necrosis, an incidence of 3.9% (2.8% in males, 9.4% in females). The changes were bilateral in 60 patients (71.6%) and unilateral in 25 (29.4%). 3 patients were diabetics, 4 had sickle cell anaemia and 7 had obstructive uropathy. 19 patients admitted to analgesic abuse. The remaining 52 patients were idiopathic but a combination of analgesic abuse and dehydration may have been the cause in this group. The possible reasons for the high incidence of RPN especially in females in this hot desert environment are discussed. The literature on the subject is briefly reviewed.

Renal papillary necrosis in the east coast of Peninsular Malaysia.

Six hundred and one intravenous Urograms (IVU) done at the General Hospital, Kuala Trengganu from 1981 to 1985 were reviewed retrospectively for Renal Papillary Necrosis (RPN). It was found that 1.3% of IVUs had RPN. There was a higher incidence of RPN amongst males as compared to females. RPN occurred more commonly in the younger age groups.

Renal papillary necrosis: an update.

The clinical and diagnostic features of renal papillary necrosis (RPN) of 27 patients were studied. Diabetes mellitus was the most frequent (56%) condition associated with RPN. Analgesic abuse, sickle hemoglobinopathy and urinary tract obstruction were present in 4 patients each; in 6 of these 12 patients these conditions were present as a coexistent disease with diabetes mellitus. There was evidence of an acute or chronic infection of the urinary tract in 18 patients, as a coexistent condition with another underlying disease that itself can cause RPN in 14 patients and as the only cause of RPN in another 4. Thus, the presence of more than one diagnostic condition which might be implicated in the causation of RPN was present in 15 patients or 55% of the cases in this series. When infection was excluded, six patients or 22% of the cases had two coexisting diseases, each of which has been implicated as a cause of RPN. This observation underlines the multifactorial nature of this entity and might explain why RPN is not encountered more frequently in each of the various primary diseases with which it has been associated. The average age of the patients at the time of diagnosis was 53 years for women and 56 years for men. Only six of the patients were younger than 40 years, and three of these had sickle hemoglobinopathy. The diagnosis of RPN was based on x-ray findings in eight patients, on the histologic examination of papillary tissue in urine in one, and on autopsy findings in the rest. Papillary necrosis was bilateral in three-fourths of the cases. The clinical picture varied. Most of the patients (67%) presented with chills and fever. Flank pain and dysuria were present in 11 patients (41%). As a rule oliguria was rare and progressive uremia was uncommon. In cases diagnosed at post-mortem, the patients had succumbed to infection or to a primary severe extrarenal disorder with the possibility of RPN having been entertained clinically in only half these cases prior to autopsy.

Phenacetin and analgesic nephropathy.

A prospective survey of 322 autopsies of adults conducted some months after phenacetin was removed from a popular compound analgesic showed to reduction in the incidence of advanced or earlier forms of analgesic nephropathy from levels noted in an earlier survey. Apparently active nephropathy was seen in persons taking two different compound analgesics, neither now containing phenacetin. Crystals observed in early and intermediate analgesic nephropathy had no diagnostic significance and represented a tissue breakdown product.

[Analgesic nephropathy]. / Analgetikanephropathie.

Analgesic nephropathy is characterized by poor clinical symptoms. Abnormal urinary findings are rare. The disease is usually discovered if advanced renal damage has occurred with elevated serum creatinine, papillary necrosis, microhematuria and renal colics. There is abundant evidence, that abuse of phenacetin leads to analgesic nephropathy. Aspirin may have only an additive effect with phenacetin in causing renal damage. The primary medullary changes caused by phenacetin or one o f its metabolites are: Interstitial fibrosis, thickening of tubular basement membrane, loss of tubular epithelium and finally destruction of the loops of Henle. The consequence of these histological changes is a loss of urinary concentrating ability, one of the earliest findings in analgesic nephropathy. Inflammatory cell infiltration and involvement of the renal cortex with corresponding functional defects are secondary. Intravenous pyelography reveals in this stage of the disease symmetrically shrunken kidneys with a smooth wavy outline, whereby in contrast to the pyelonephritic changes the prtrusions correspond with the renal calyces. Papillary necrosis with the typical "halo shacow" in the pyelogramm rarely leads to the discovery of the disease.--Cessation of phenacetin consumption is usually associated with stabilization of renal funciton in patients with serum creatinine levels below 1.5 mg percent; with elevated serum creatinine there is a slow progression of the disease.--Analgesic nephropathy may be prevented by high fluid intake and avoidance of more than 150 g phenacetin per year respectively 0.5 g per day. Coffein, a constituent of many preparations, has a protective effect only with sufficient fluid intake.--The socio-economic importance of the analgesic nephropathy is given by the fact, that in the German Federal Republic 10 percent and in Australia even 20 percent of the patients requiring recurrent dialysis suffer from analgesic nephropathy. The following measures have been found to be effective in order to reduce phenacetin abuse: 1. Preparations containing phenacetin subject to prescription. 2. No advertising in newspapers and television. 3. Detailed information about kidney damaging effect of phenacetin on each packaging.