Acute Tubular Necrosis
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Introduction
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Results from a massive insult.
Nephrotoxic
- radiocontrast dye
- antibiotics (aminoglycosides)
- chemo
- heavy metals
- animal/plant toxins
- endogenous (hemoglobin, myoglobin)
- crystals (uric acids
ischemic, either hemodynamic or shock
Pathophysiology
Tubule cells die for various reasons, then slough off. The resulting casts can cause obstructions.
Ischemia
endo- and exotoxins
Signs and Symptoms
- history
- physical exam
History
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Progressive rate of rise of sCr
metabolic acidosis, hyperkalemia, hypocalcemia, inc or dec phos
granular or epithelial casts
FeNa >2, UNa >40 mmol/L
Diagnostic Imaging
Differential Diagnosis
Treatments
Prevention
Identify pts at risk
volume status
avoid nephrotoxins
caution with diuretics
rhabdomyolisis/hemolysis
- aggressive hydration and
- mannitol/HCO3 diuresis
uric acid: allopurinol, HCO3
contrast: prehydration, mucomyst
Consequences and Course
50% mortality
Oliguric 1-16 weeks, avg 1-2 weeks
diuretic 1-2 weeks
recovery 3-12 months
Resources and References
Topic Development
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