NECROSIS Mc Warsame Amoud School Of Medicine Dec 18, 2018 Introduction
• Acute tubular necrosis (ATN) is the most common
cause of acute kidney injury (AKI) • ATN is typically found in hospitalized patients due to toxic or ischemic insult to tubular epithelium resulting in intrinsic kidney injury. • It is characterized by adequate renal perfusion to maintain tubular integrity but not to sustain glomerular filtration. Pathophysiology
• Ischemic or toxic injury to tubular epithelial cells leading
to intrinsic kidney injury. • Typically severe loss of renal function with minimal histopathologic evidence of widespread necrosis. • ATN is generally caused by an acute event, either ischemic or toxic. • Hypovolemic states: Hemorrhage, volume depletion from gastrointestinal (GI) or renal losses, burn, etc
Causes • Low cardiac output states: Heart
failure and other diseases of myocardium, valvulopathy, arrhythmia, pericardial diseases, tamponade • Systemic vasodilation: Sepsis, anaphylaxis • Disseminated intravascular coagulation • Exogenous nephrotoxins that cause ATN • Aminoglycoside-related toxicity occurs in 10-30% of patients receiving Causes of aminoglycosides, even when blood levels are in apparently therapeutic Nephrotoxic ranges. • Risk factors for ATN in these patients acute tubular include the following: – Preexisting liver or renal necrosis disease – Concomitant use of other nephrotoxins Advanced age – Shock – Female sex Cont’…. Radiographic contrast media can cause contrast-induced nephropathy (CIN) or radiocontrast nephropathy (RCN); • This commonly occurs in patients with several risk factors, such as • Elevated baseline serum creatinine, • Preexisting renal insufficiency, • Underlying diabetic nephropathy, • Chronic heart failure [CHF], or • High or repetitive doses of contrast media, as well as • Volume depletion and • Concomitant use of diuretics, ACE inhibitors, or ARBs. Cont’…….
• Other exogenous nephrotoxins
that can cause ATN include the following: – Amphotericin B – Cyclosporine and tacrolimus – Sulfa drugs – Acyclovir Cont’…….
hospitalized patients reported to account for; – About 38% of all acute kidney injury cases. – About 76% of acute kidney injury cases in intensive care units. Diagnosis
• ATN is diagnosed as AKI in context of ischemic or toxic
injury to kidney generally in hospitalized patients • Characteristic findings of ATN on laboratory tests include – Urine osmolality < 350-400mOsm/kg – Urinary sediment analysis showing muddy brown casts, renal tubular epithelial cells, granular casts. – Fractional excretion of sodium > 2% – Urine to plasma creatinine ration < 20 Treatment
• Stop exposure o nephrotoxic agents if possible.
• Monitor and adjust fluid and electrolyte balance to minimize volume depletion or overload, hyponatremia, hyperkalemia, hyperphosphatemia and hypermagnesemia. • Identify and treat any infectious cause • Nutritional support • Diuretics not recommended to treat AKI except in management of volume overload (KDIGO, Grade C). – Furosemide in patients with AKI does not appear to reduce Medical mortality or improve renal recovery but may shorten Therapies duration of dialysis. – High dose furosemide may increase urine output but does not appear to reduce mortality or need for dialysis in patients with AKI requiring dialysis. Cont’…….
• Atrial natriuretic peptide (ANP)
– KDIGO suggests avoiding ANP to treat AKI due to risk of hypotension outweighing limited evidence of benefit. – Low dose ANP might reduce need for renal replacement therapy (RRT) in patients with AKI • Low dose dopamine does not appear to reduce need RRT or mortality in patients with AKI Complications
• ATN reported to be the cause of AKI
– 38% of hospitalized patients with AKI – 76% of patients in intensive care unit with AKI • Other complications include; Hyperkalemia, volume overload and pulmonary edema, metabolic acidosis, anemia, CKD etc Prognosis
• Survival of acute tubular necrosis associated with good
prognosis for renal recovery – 56% - 60% reported to have full recovery – 5% - 11% of patients reported to require long-term dialysis. • Of patients with ATN who require dialysis, reported mortality 50% - 80% • Prevention is strongly recommended by avoiding shock- induced AKI, postoperative AKI, and preventing contrast-induced AKI END.