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Diseases

Acute tubular necrosis

OVERVIEW

  • Highlights & Basics
  • Images

DIAGNOSIS

  • Diagnostic Approach
  • Risk Factors
  • History & Exam
  • Tests
  • Differential Diagnosis
  • Criteria
  • Screening

TREATMENT

  • Tx Approach
  • Tx Options
  • Emerging Tx
  • Prevention

FOLLOW-UP

  • Overview
  • Complications

REFERENCES

  • Citations
  • Guidelines
  • Credits

PATIENT RESOURCES

  • Patient Instructions

Highlights & Basics

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Key Highlights
  • An intrinsic acute kidney injury caused by ischemic or nephrotoxic injury to renal tubular epithelial cells, which results in tubular dysfunction or detachment from the basement membrane.

  • A history of hypotension, fluid depletion, or exposure to nephrotoxic agents is usually present.

  • In otherwise healthy individuals, when the underlying insult is corrected, the patient frequently has a good outcome with complete renal recovery.

  • There is no specific therapy for acute tubular necrosis apart from supportive care.

Quick Reference

  • History & Exam

    • Key Factors

      • Other Factors

        More information...
      • Diagnostics Tests

          More information...
        • Treatment Options

            More information...

          Definition

          Epidemiology

          Etiology

          Pathophysiology

          content by BMJ Group
          Last updated

          Images

          • Denuded basement membranes and presence of cells in the tubule lumen

            Denuded basement membranes and presence of cells in the tubule lumen

          Citations

            Key Articles

            • Gill N, Nally JV Jr, Fatica RA. Renal failure secondary to acute tubular necrosis: epidemiology, diagnosis, and management. Chest. 2005 Oct;128(4):2847-63.[Abstract]

            Other Online Resources

            • National Kidney Foundation: kidney disease

            Referenced Articles

            • 1. Kellum JA, Prowle JR. Paradigms of acute kidney injury in the intensive care setting. Nat Rev Nephrol. 2018 Apr;14(4):217-30.[Abstract]

            • 2. Abuelo JG. Normotensive ischemic acute renal failure. N Engl J Med. 2007 Aug 23;357(8):797-805.[Abstract]

            • 3. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Inter Suppl. 2012 Mar;2(1):1-138.[Full Text]

            • 4. Bellomo R, Kellum JA, Ronco C. Acute kidney injury. Lancet. 2012 Aug 25;380(9843):756-66.[Abstract]

            • 5. Gill N, Nally JV Jr, Fatica RA. Renal failure secondary to acute tubular necrosis: epidemiology, diagnosis, and management. Chest. 2005 Oct;128(4):2847-63.[Abstract]

            • 6. Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol. 2018 Oct;14(10):607-25.[Abstract]

            • 7. Kellum JA, Bellomo R, Ronco C. Kidney attack. JAMA. 2012 Jun 6;307(21):2265-6.[Abstract]

            • 8. United States Renal Data System. Chapter 6: Acute kidney injury. In: 2013 USRDS annual data report: Atlas of chronic kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases;2013:95-106.[Full Text]

            • 9. Bedford M, Stevens PE, Wheeler TW, et al. What is the real impact of acute kidney injury? BMC Nephrol. 2014 Jun 21;15:95.[Abstract][Full Text]

            • 10. Basile DP, Anderson MD, Sutton TA. Pathophysiology of acute kidney injury. Compr Physiol. 2012 Apr;2(2):1303-53.[Abstract][Full Text]

            • 11. Mangan C, Stott MC, Dhanda R. Renal physiology: blood flow, glomerular filtration and plasma clearance. Anaesth Intensive Care Med. 2018 May;19(5):254-7.

            • 12. Sharfuddin AA, Molitoris BA. Pathophysiology of ischemic acute kidney injury. Nat Rev Nephrol. 2011 Apr;7(4):189-200.[Abstract]

            • 13. Pannu N, James M, Hemmelgarn BR, et al. Modification of outcomes after acute kidney injury by the presence of CKD. Am J Kidney Dis. 2011 Aug;58(2):206-13.[Abstract]

            • 14. Saran R, Robinson B, Abbott KC, et al. US Renal Data System 2016 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis. 2017 Mar;69(3 suppl 1):A7-A8.[Abstract][Full Text]

            • 15. Waikar SS, Liu KD, Chertow GM. Diagnosis, epidemiology and outcomes of acute kidney injury. Clin J Am Soc Nephrol. 2008 May;3(3):844-61.[Abstract][Full Text]

            • 16. James MT, Grams ME, Woodward M, et al. A meta-analysis of the association of estimated GFR, albuminuria, diabetes mellitus, and hypertension with acute kidney injury. Am J Kidney Dis. 2015 Oct;66(4):602-12.[Abstract][Full Text]

            • 17. Brenner B. The kidney. 7th ed. Philadelphia, PA: WB Saunders; 2003: Chapter 27.

            • 18. Cheung CM, Ponnusamy A, Anderton JG. Management of acute renal failure in the elderly patient: a clinician's guide. Drugs Aging. 2008;25(6):455-76.[Abstract]

            • 19. Prowle J, Bagshaw SM, Bellomo R. Renal blood flow, fractional excretion of sodium and acute kidney injury: time for a new paradigm? Curr Opin Crit Care. 2012 Dec;18(6):585-92.[Abstract]

            • 20. Ostermann M, Liu K. Pathophysiology of AKI. Best Pract Res Clin Anaesthesiol. 2017 Sep;31(3):305-14.[Abstract]

            • 21. Mehran R, Dangas GD, Weisbord SD. Contrast-associated acute kidney injury. N Engl J Med. 2019 May 30;380(22):2146-55.[Abstract]

            • 22. McDonald JS, McDonald RJ, Carter RE, et al. Risk of intravenous contrast material-mediated acute kidney injury: a propensity score-matched study stratified by baseline-estimated glomerular filtration rate. Radiology. 2014 Apr;271(1):65-73.[Abstract][Full Text]

            • 23. ACR Committee on Drugs and Contrast Media. ACR manual on contrast media. 2020 [internet publication].[Full Text]

            • 24. Sousa-Uva M, Neumann FJ, Ahlsson A, et al. 2018 ESC/EACTS guidelines on myocardial revascularization. Eur J Cardiothorac Surg. 2019 Jan 1;55(1):4-90.[Abstract][Full Text]

            • 25. Weisbord SD, Gallagher M, Jneid H, et al. Outcomes after angiography with sodium bicarbonate and acetylcysteine. N Engl J Med. 2018 Feb 15;378(7):603-14.[Abstract][Full Text]

            • 26. Bosch X, Poch E, Grau JM. Rhabdomyolysis and acute kidney injury. N Engl J Med. 2009 Jul 2;361(1):62-72.[Abstract]

            • 27. Cavanaugh C, Perazella MA. Urine sediment examination in the diagnosis and management of kidney disease: core curriculum 2019. Am J Kidney Dis. 2019 Feb;73(2):258-72.[Abstract][Full Text]

            • 28. Tenorio Cañamas M, Galeano Alvarez C, Rodríguez Mendiola N, et al. Differential diagnosis of acute renal failure [in Spanish]. Revista de Nefrologia. 2010 Oct;3(2):1-58.[Full Text]

            • 29. Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int. 2002 Dec;62(6):2223-9.[Abstract][Full Text]

            • 30. Claure-Del Granado R, Mehta RL. Fluid overload in the ICU: evaluation and management. BMC Nephrol. 2016 Aug 2;17(1):109.[Abstract][Full Text]

            • 31. Parikh CR, Lu JC, Coca SG, et al. Tubular proteinuria in acute kidney injury: a critical evaluation of current status and future promise. Ann Clin Biochem. 2010 Jul;47(Pt 4):301-12.[Abstract][Full Text]

            • 32. Makris K, Spanou L. Acute kidney injury: diagnostic approaches and controversies. Clin Biochem Rev. 2016 Dec;37(4):153-75.[Abstract][Full Text]

            • 33. Waring WS, Moonie A. Earlier recognition of nephrotoxicity using novel biomarkers of acute kidney injury. Clin Toxicol (Phila). 2011 Oct;49(8):720-8.[Abstract]

            • 34. Huang Y, Don-Wauchope AC. The clinical utility of kidney injury molecule 1 in the prediction, diagnosis and prognosis of acute kidney injury: a systematic review. Inflamm Allergy Drug Targets. 2011 Aug;10(4):260-71.[Abstract]

            • 35. Clerico A, Galli C, Fortunato A, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as biomarker of acute kidney injury: a review of the laboratory characteristics and clinical evidences. Clin Chem Lab Med. 2012 Feb 15;50(9):1505-17.[Abstract]

            • 36. Puthumana J, Ariza X, Belcher JM, et al. Urine interleukin 18 and lipocalin 2 are biomarkers of acute tubular necrosis in patients with cirrhosis: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2017 Jul;15(7):1003-1013.e3.[Abstract]

            • 37. Jia HM, Huang LF, Zheng Y, et al. Prognostic value of cell cycle arrest biomarkers in patients at high risk for acute kidney injury: a systematic review and meta-analysis. Nephrology (Carlton). 2017 Nov;22(11):831-7.[Abstract][Full Text]

            • 38. Parikh CR, Mansour SG. Perspective on clinical application of biomarkers in AKI. J Am Soc Nephrol. 2017 Jun;28(6):1677-85.[Abstract][Full Text]

            • 39. Kanbay M, Kasapoglu B, Perazella MA. Acute tubular necrosis and pre-renal acute kidney injury: utility of urine microscopy in their evaluation - a systematic review. Int Urol Nephrol. 2010 Jun;42(2):425-33.[Abstract]

            • 40. Hammond NE, Taylor C, Finfer S, et al. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: an international cross-sectional study. PLoS One. 2017 May 12;12(5):e0176292.[Abstract][Full Text]

            • 41. Myburgh JA, Mythen MG. Resuscitation fluids. N Engl J Med. 2013 Sep 26;369(13):1243-51.[Abstract][Full Text]

            • 42. Zayed YZM, Aburahma AMY, Barbarawi MO, et al. Balanced crystalloids versus isotonic saline in critically ill patients: systematic review and meta-analysis. J Intensive Care. 2018 Aug 17;6:51.[Abstract][Full Text]

            • 43. Prowle JR, Kirwan CJ, Bellomo R. Fluid management for the prevention and attenuation of acute kidney injury. Nat Rev Nephrol. 2014 Jan;10(1):37-47.[Abstract]

            • 44. National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication].[Full Text]

            • 45. Barrett BJ, Parfey PS. Clinical practice. Preventing nephropathy induced by contrast medium. N Engl J Med. 2006 Jan 26;354(4):379-86.[Abstract]

            • 46. Bagshaw SM, Gibney RTN, Kruger P, et al. The effect of low-dose furosemide in critically ill patients with early acute kidney injury: a pilot randomized blinded controlled trial (the SPARK study). J Crit Care. 2017 Dec;42:138-46.[Abstract]

            • 47. Schetz M, Forni LG, Joannidis M. Does this patient with AKI need RRT? Intensive Care Med. 2016 Jul;42(7):1155-8.[Abstract]

            • 48. Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018 Oct 11;379(15):1431-42.[Abstract][Full Text]

            • 49. Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016 May 24-31;315(20):2190-9.[Abstract][Full Text]

            • 50. Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000 Jul 1;356(9223):26-30.[Abstract]

            • 51. Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int. 2006 Oct;70(7):1312-7.[Abstract]

            • 52. Ronco C. Continuous renal replacement therapies for the treatment of acute renal failure in intensive care patients. Clin Nephrol. 1993 Oct;40(4):187-98.[Abstract]

            • 53. Hulse M, Rosner MH. Drugs in development for acute kidney injury. Drugs. 2019 Jun;79(8):811-21.[Abstract]

            • 54. Kelly KJ, Plotkin Z, Vulgamott SL, et al. P53 mediates the apoptotic response to GTP depletion after renal ischemia-reperfusion: protective role of a p53 inhibitor. J Am Soc Nephrol. 2003 Jan;14(1):128-38.[Abstract][Full Text]

            • 55. Nakatani T, Kim T, Uchida J, et al. Hepatocyte growth factor ameliorates renal hemodynamic disorder after ischemia/reperfusion. Int J Mol Med. 2002 Aug;10(2):217-9.[Abstract]

            • 56. Golestaneh L, Melamed ML, Hostetter TH. Uremic memory: the role of acute kidney injury in long-term outcomes. Kidney Int. 2009 Oct;76(8):813-4.[Abstract][Full Text]

            • 57. Brito GA, Balbi AL, Abrão JM, et al. Long-term outcome of patients followed by nephrologists after an acute tubular necrosis episode. Int J Nephrol. 2012;2012:361528.[Abstract]

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