Renal cortical necrosis

Case contributed by Albina Polianskaia
Diagnosis certain


Patient with mixed septic and hemorrhagic shock.

Patient Data

Age: 60 years
Gender: Male

Kidneys with reverse corticomedullary differentiation, non-enhancing cortex and a normal enhancing medulla (reverse rim sign) compatible with renal cortical necrosis. Portal venous gas. Bilateral adrenal gland hyperenhancement.

Colonic wall thickening is probably related to ischemic colitis. Bilateral femoral hematomas with signs of active bleeding/false aneurysm on the left.

Small amount of free fluid in paracolic gutters. Mild bilateral pleural effusion.

Case Discussion

The patient was admitted to ICU for septic shock (possible foci: abdominal and dog bite) complicated with hemorrhagic shock of iatrogenic origin. Emergency femoral lines/punctures were performed. Hemodynamic instability with the need for norepinephrine and dobutamine and severe sepsis with PCT>100 developed.

The patient eventually died of multiorgan failure.

Renal cortical necrosis is a rare form of acute renal failure characterized by ischemic destruction of all the elements of the renal cortex from significantly diminished renal arterial perfusion. In contrast-enhanced computed tomography it results in non-enhancement of the renal cortex in contrast to adequately enhancing renal medullae mimicking a retrograde renography. This CT finding (reverse rim sign) is diagnostic for renal cortical necrosis and usually results in permanent kidney injury.

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