A 50-year-old man comes to his primary care PA’s office for routine follow-up. He was recently diagnosed with osteoarthritis of the knees four weeks ago and was initiated on analgesic medications. Past medical history is significant for diabetes mellitus. Current medications include metformin, naproxen and acetaminophen. His vitals and physical exam are within normal limits. Laboratory results are as follows. Laboratory value Results Reference range 4 weeks ago Today Serum chemistry Sodium 138 mEq/L 137 mEq/L 136-146 mEq/L Potassium 4 mEq/L 4.1 mEq/L 3.5-5 mEq/L Bicarbonate 24 mEq/L 25 mEq/L 22-28 mEq/L Chloride 96 mEq/L 94 mEq/L 95-105 mEq/L Creatinine 1.1 mg/dL 1.6 mg/dL 0.6-1.2 mg/dL Urinalysis Protein 100 mg/day 102 mg/day <150 mg/day Cast None None None Blood None None None Changes to which of the following anatomic regions is most likely accountable for this patient’s rise in creatinine?

Renal papillary necrosis is a condition in which impaired blood supply to the kidneys leads to diffuse ischemia and subsequent necrosis of the renal papilla. Risk factors for renal papillary necrosis include diabetes, sickle cell anemia, and certain medications such as non-steroidal anti-inflammatory drugs (NSAIDs). Symptoms may include fever, flank pain, and blood in the urine. Treatment may include antibiotics, pain management, and in severe cases, surgery.

Renal papillary necrosis

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Laboratory value	Results	Reference range
	4 weeks ago	Today
Serum chemistry
Sodium	138 mEq/L	137 mEq/L	136-146 mEq/L
Potassium	4 mEq/L	4.1 mEq/L	3.5-5 mEq/L
Bicarbonate	24 mEq/L	25 mEq/L	22-28 mEq/L
Chloride	96 mEq/L	94 mEq/L	95-105 mEq/L
Creatinine	1.1 mg/dL	1.6 mg/dL	0.6-1.2 mg/dL
Urinalysis
Protein	100 mg/day	102 mg/day	<150 mg/day
Cast	None	None	None
Blood	None	None	None