Renal papillary necrosis with urinary tract obstruction: A case report

INTRODUCTION

Renal papillary necrosis (RPN) is a rare entity, which is defined as ischemic necrosis of the papilla in the medulla of the kidneys. It is recognized that a variety of etiological factors, such as analgesic nephropathy, diabetes mellitus, urinary obstruction and sickle cell hemoglobinopathy, may cause papillary necrosis[1]. It causes necrosis, detachment, and expulsion of the papilla into the urine, which leads to ureteric obstruction presenting with renal colic, acute kidney injury or urinary tract infection[2]. Ultrasound and computerized tomography imaging are relatively insensitive in detecting complicated papillary necrosis, especially when the papillary necrosis is complicated by the upper urinary tract occupying lesions.

This study reported a patient with an infected and obstructed kidney and the upper urinary tractoccupying lesions. We diagnosed renal papilla necrosis with flexible ureteroscopy, which revealed endoscopic characteristics of the disease so as to avoid unnecessary nephrectomy.

CASE PRESENTATION

Chief complaints

A 75-year-old woman presented with right flank pain, visible hematuria, and a fever (body temperature higher than 39 ℃) in the emergency unit.

History of present illness

The patient had a temperature of up to 39 ℃, and was admitted to the hospital as an emergency because antibiotic treatment was not effective in the clinic.

History of past illness

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

Personal and family history

Personal history and family history were not special.

企業銷售商品贈送有償取得的其他物品，在用友U8 V10.1財務軟件中業務核算流程與銷售贈送同類商品有所不同。企業購入其他物品時已明確用途作為贈品免費贈送，因此，應將其單獨入庫，且采購成本直接計入“銷售費用”；而發出時，將已計入進項稅額的增值稅作為進項稅額轉出。下面將從專門采購贈品、銷售發放贈品兩個角度闡述在用友U8 V10.1財務軟件中的業務核算流程。

Physical examination

Physical examination found percussion pain in the right kidney area.

數控機床是當前制造業中最基礎和最關鍵的設備，其中結合了很多學科知識，和其他設備相比，數控機床的結構與工作原理更加復雜。在這種情況下，數控機床在工作運行過程中很容易出現一些故障與問題，進而影響數控設備的正常工作。數控維修是數控專業中的關鍵課程，通過對課程的數字化，能夠加強學生的學習能力，進而培養學生的專業能力。在數字化課程建設過程中，主要是從以下幾方面進行實現：

Renal papillary necrosis secondary to pyelonephritis may lead to inflammatory hyperemia in the mucosa of the renal pelvis. However, renal papillary necrosis per se leads to necrosis and even shedding of the renal papillae as seen in flexible ureteroscopy. In addition, the necrotic structures of the renal papillae appear whitish and irregularly-shaped without blood supply, which should be differentiated from the upper urinary tract lesions such as renal pelvic carcinoma.

Laboratory examinations

Subsequent computed tomography urography (CTU) showed inflammatory exudation around the right kidney, and lesions of different sizes were found to be occupying the right renal calyces. The lesions were surrounded almost completely by the contrast during the excretory phase (Figure 2A and B). Punctate thickening was also observed in the right distal ureter. Flexible ureteroscopy was performed in order to make a definitive diagnosis of upper urinary tract lesions. We found that inflammatory hyperemia existed in the mucosa of the renal pelvis. There were numerous occupying lesions floating in the calyces and the upper ureter. The floating materials were whitish and irregularly-shaped without blood supply. Moreover, they appeared like soft and friable cottons. Some partial necrotic renal papillae were sloughing and attached to renal medulla by pedicles (Figure 3A). Meanwhile, some necrotic renal papillae have been sloughed completely, looked like cottons, and floated inside the renal calyces (Figure 3B). The lesion in the right distal ureter suggested by initial ultrasound examination was not found during the flexible ureteroscopy.

Imaging examinations

Ultrasonography revealed hydronephrosis of the right kidney and right distal ureteric lesions (Figure 1).

當方差g最大時，可以認為此時前景和背景差異最大，此時的灰度t是最佳閾值.最后，在雙邊濾波的基礎下對其進行OTSU閾值分割得到的結果如圖4、圖5所示.

Initial treatment

Given the presence of severe urinary tract infection and right hydronephrosis, urgent placement of a right ureteral double J stent was made. After urgent decompression of the upper urinary tract, antibiotics treatment, and diabetic control, the patient’s symptoms improved rapidly and her blood test results including complete blood count and renal function returned to normal.

Further examinations

Laboratory investigations showed a leukocytosis of 12.7 × 10/L with 93.6% neutrophils. Urine routine test was positive for leukocyte and glucose. Her renal function was abnormal since his serum creatinine reached a level of 333 μmol/L.

大直徑塞規尺寸的測量所引入的誤差還包括當被測塞規的溫度與標準溫度20℃不相等時，按照規程要求應進行等溫，標準件與被測塞規之間的溫度差≤0.3℃。假定被測塞規與標準件的線性膨脹系數為α=11.5×10-6℃-1，假定服從U形分布(b=0.7),最終被測塞規與標準件之間溫度差引入的不確定度分量u3為：

FINAL DIAGNOSIS

The flexible ureteroscopy confirmed renal papillary necrosis.

TREATMENT

We removed the necrotic and sloughed renal papillae by flexible ureteroscopy to prevent further obstruction. Pathological examination confirmed infarcted renal papilla accompanied with inflammatory exudations (Figure 4A and B).

OUTCOME AND FOLLOW-UP

Three months after discharge, follow-up CTU showed no obvious lesions in the renal pelvis.

In the past, most researches on the RPN were a series of cases and works on radiological images on computerized tomography and magnetic resonance[5]. There were classic images described in the computerized tomography urography, such as ball in tee, lobster claw, signet ring or clubbed calyx to diagnosis RPN[1,6,7]. However, severe renal insufficiency resulting from ureteral obstruction was the contraindication of CTU since the intravascular contrast agents may potentially be nephrotoxic. However, at the same situation, this endoscopic examination does not have such a safety concern, The endoscopic examination is also great for the patient with upper urinary tract-occupying lesions since it may be used to rule out malignant tumor. In this case, this examination confirmed the diagnosis of RPN, and prevented unnecessary nephrectomy. The most important endoscopic feature of RPN was sloughed renal papillae appearing like the floating “cottons” in the pelvis. The sloughed papillae were soft, friable, whitish and irregularly-shaped without blood supply. So far, the endoscopic features of RPN have not been reported. The report revealed the imaging, clinical and endoscopic characteristics of PRN, which would help the clinicians distinguish RPN from the upper urinary tract-occupying lesions. In addition, the necrotic and sloughed renal papillae could be removed by flexible ureteroscopy so as to prevent further obstruction.

DISCUSSION

The acute obstruction of this patient's right kidney was probably caused by the sloughed renal papillae, as the ultrasonography legibly showed the right distal ureteric lesion. However, the ureteral lesion was not found during the ureteroscopy, which might have been excreted through the ureter since it was soft and friable. In addition, the ureteroscopy revealed that multiple necrotic and splintered renal papillae filled pelvis and the upper ureter, which confirmed the diagnosis of RPN. Fadel[2] reported a case of papillary necrosis that was with subsequent migration of a sloughed papilla into the ureteric orifice.

Renal papillary necrosis is a clinicopathological entity where any or all of the papillae undergo selective necrosis. It is typically thought to be caused by diabetes mellitus and urinary tract infection. The renal papillae are considered to be anatomically vulnerable to ischemia, which may be seen in diabetes-associated vascular disorder, or interstitial edema secondary to infection[1]. There have been some cases, in which rapid deterioration occurred and even progressed to death[3]. The early treatment of RPN is important for improving prognosis and reducing morbidity. It is essential to control the underlying problem, such as diabetes, infection, dehydration[4]. In cases of an infected and obstructed kidney, emergency decompression is imperative, and direct visualization may be required to allow for removal of the sloughed papilla and for relief of obstruction by emergency stent placement [2].

能源行業上市公司環境信息披露對CPA審計影響研究 … …………… 薛大維，張 寧，王甲山，朱志紅（3．1）

基于PSCAD/EMTDC電磁暫態仿真平臺，建立了電力系統模型，分別對電力系統輸電線路發生三相短路以及誤同期合閘進行了仿真計算，并分析了三相短路和誤同期合閘對電力系統的影響．該研究為電氣設備的選型、線路保護配置確定提供了理論依據，對電網初期設計和后期啟動調試具有重要參考價值．

新電商在帶給高職院校人才培養機遇的同時，也帶來了新的風險和挑戰。現階段，高職院校應把不斷探索培育與社會需求相吻合的高技能人才作為一個重點課題進行研究和實踐，才能培育出適應社會發展的新時代人才。

CONCLUSION

In summary, renal papillary necrosis and subsequent migration of a sloughed papilla into a ureter may occur in patients with the upper urinary tract-occupying lesions and urosepsis. The endoscopic ureteroscopy can identify renal papillary necrosis and remove the necrotic renal papilla to avoid further obstruction.

FOOTNOTES

Ye LF and Pan HH conceived the work; Pan HH, Luo YJ and Zhu QG conducted the work and acquired the data; Ye LF conducted the revision; all authors treated and provided care for the patient; all authors reviewed the manuscript.

礦化垃圾反應床中含有種類繁多的微生物，如分解纖維素、蛋白質、脂肪等的粘細菌、纖維弧菌、枯草芽孢桿菌、巨大芽孢桿菌等；分解芳香烴及其衍生物的假單胞菌、分枝桿菌、不動桿菌和節桿菌等；降解烷烴、酯類等的諾卡氏菌、鏈霉菌、棒狀桿菌、芽孢桿菌和某些真菌；以及微生物脫氮除磷所必需的亞硝酸菌、硝酸菌、反硝化細菌及聚磷菌等；這些微生物雖然生理生化功能不一，但環境溫度都是其新陳代謝的關鍵影響因素，在床體表層溫度15～25℃的范圍內，微生物活性較高，生化過程方可正常進行，溫度偏高或偏低都不利于微生物的生命活動，從而難以維持系統對污染物的降解能力。

Her medical history included poorly controlled type 2 diabetes mellitus (hemoglobin A1c 80 mmol/mol or 0.23 g/dL glucose levels).

The authors declare that they have no competing interests.

地方性震級ML由來已久，其測定公式（2）包含兩部分：一是儀器記錄的地面振幅的大小，二是與震中距相關的量規函數。新規范與舊規范的區別也主要體現在這兩部分。在振幅的量取上，主要是仿真方式的區別，新規范要求仿真成DD-1型，而舊規范則要求仿真為DD-1型或W.A.型，而在實際操作中，多仿真成W.A.型。在量規函數上，新規范將之前全國統一的量規函數根據地域的不同分成了五種，而西藏所采用的量規函數與舊規范所使用的量規函數在多數情況下相同，差異處多數為±0.1，極個別情況下達到±0.2。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

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China

Hong-Hong Pan 0000-0002-2401-6520; Yi-Jia Luo 0000-0003-3438-8341; Qing-Guo Zhu 0000-0002-0629-464X; Lie-Fu Ye 0000-0002-4917-607X.

Xing YX

A

Xing YX