Acute Tubular Necrosis Differential Diagnoses

  • Author: Edgar V Lerma, MD, FACP, FASN, FAHA; Chief Editor: Vecihi Batuman, MD, FACP, FASN   more...
 
Updated: Jun 28, 2011
 
 

Diagnostic Considerations

The diagnosis of acute tubular necrosis (ATN) is made on a clinical basis, that is, with the help of a detailed and accurate history, a thorough physical examination, and pertinent laboratory examinations and imaging studies.

Ischemic ATN may be considered part of the spectrum of prerenal azotemia, and indeed, ischemic ATN and prerenal azotemia have the same causes and risk factors (see Etiology). Urinalysis and urine electrolytes can be used to differentiate the 2 disorders (see Workup).

Renal vasculitis must be quickly differentiated from ATN. In patients with clinical and urinary findings suggesting renal vasculitis (eg, acute onset of rash, arthralgias, hypertension, proteinuria, microscopic hematuria), the diagnosis needs to be established quickly, with renal biopsy, so that appropriate immunomodulatory therapy can be initiated.

Also see Nephritis, Interstitial and Acute Obstructive Uropathy Imaging.

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Edgar V Lerma, MD, FACP, FASN, FAHA  Clinical Associate Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Research Director, Internal Medicine Training Program, Advocate Christ Medical Center; Consulting Staff, Associates in Nephrology, SC

Edgar V Lerma, MD, FACP, FASN, FAHA is a member of the following medical societies: American Heart Association, American Medical Association, American Society of Hypertension, American Society of Nephrology, Chicago Medical Society, Illinois State Medical Society, National Kidney Foundation, and Society of General Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Mahendra Agraharkar, MD, MBBS, FACP, FASN  Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, and National Kidney Foundation

Disclosure: South Shore DaVita Dialysis Center Ownership interest Other

Brent Kelly, MD  Resident Physician, Department of Internal Medicine, University of Texas Medical Branch School of Medicine

Brent Kelly, MD is a member of the following medical societies: Alpha Omega Alpha and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

F John Gennari, MD  Associate Chair for Academic Affairs, Robert F and Genevieve B Patrick Professor, Department of Medicine, University of Vermont College of Medicine

F John Gennari, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

George R Aronoff, MD  Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine

George R Aronoff, MD is a member of the following medical societies: American Federation for Medical Research, American Society of Nephrology, Kentucky Medical Association, and National Kidney Foundation

Disclosure: Nothing to disclose.

Chief Editor

Vecihi Batuman, MD, FACP, FASN  Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System

Vecihi Batuman, MD, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, and International Society of Nephrology

Disclosure: Nothing to disclose.

References

  1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. [Medline]. [Full Text].

  2. Lewington A, Kanagasundaram S, UK Renal Association. Clinical Practice Guidelines: Acute Kidney Injury. 5th Edition, 2011. Final Version March 8 2011. Available at http://www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx. Accessed June 28, 2011.

  3. Verghese E, Ricardo SD, Weidenfeld R, et al. Renal primary cilia lengthen after acute tubular necrosis. J Am Soc Nephrol. Jul 16 2009;[Medline].

  4. [Guideline] Verbalis JG, Goldsmith SR, Greenberg A, Schrier RW, Sterns RH. Hyponatremia treatment guidelines 2007: expert panel recommendations. Am J Med. Nov 2007;120(11 Suppl 1):S1-21. [Medline].

  5. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. Aug 2004;8(4):R204-12. [Medline]. [Full Text].

  6. American College of Radiology. ACR Appropriateness Criteria: Renal Failure. Available at http://bit.ly/ewIXV5. Accessed September 10, 2010.

  7. Perdiz LB, Furtado GH, Linhares MM, et al. Incidence and risk factors for surgical site infection after simultaneous pancreas-kidney transplantation. J Hosp Infect. Aug 2009;72(4):326-31. [Medline].

  8. Mattoso R, Khouri N, de Jesus L, et al. Risk factors for graft dysfunction in the late period of renal transplantation. Transplant Proc. Jun 2009;41(5):1594-8. [Medline].

  9. Devarajan P. Emerging biomarkers of acute kidney injury. Contrib Nephrol. 2007;156:203-12. [Medline].

  10. Mueller C, Buerkle G, Buettner HJ, et al. Prevention of contrast media-associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. Feb 11 2002;162(3):329-36. [Medline].

  11. Merten GJ, Burgess WP, Gray LV, et al. Prevention of contrast-induced nephropathy with sodium bicarbonate: a randomized controlled trial. JAMA. May 19 2004;291(19):2328-34. [Medline].

  12. Tepel M, van der Giet M, Schwarzfeld C, et al. Prevention of radiographic-contrast-agent-induced reductions in renal function by acetylcysteine. N Engl J Med. Jul 20 2000;343(3):180-4. [Medline].

  13. Dent CL, Ma Q, Dastrala S, et al. Plasma neutrophil gelatinase-associated lipocalin predicts acute kidney injury, morbidity and mortality after pediatric cardiac surgery: a prospective uncontrolled cohort study. Crit Care. 2007;11(6):R127. [Medline].

  14. du Cheyron D, Daubin C, Poggioli J, et al. Urinary measurement of Na+/H+ exchanger isoform 3 (NHE3) protein as new marker of tubule injury in critically ill patients with ARF. Am J Kidney Dis. Sep 2003;42(3):497-506. [Medline].

  15. Han WK, Bailly V, Abichandani R, et al. Kidney Injury Molecule-1 (KIM-1): a novel biomarker for human renal proximal tubule injury. Kidney Int. Jul 2002;62(1):237-44. [Medline].

  16. Hirsch R, Dent C, Pfriem H, et al. NGAL is an early predictive biomarker of contrast-induced nephropathy in children. Pediatr Nephrol. Dec 2007;22(12):2089-95. [Medline].

  17. Mehta R, Kellum JA, Levin A. From acute renal failure to acute kidney injury: what's changed?. Nephrology Self-Assessment Program. 2007;6(5):281.

  18. Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007;11(2):R31. [Medline]. [Full Text].

  19. Mishra J, Dent C, Tarabishi R, et al. Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet. Apr 2-8 2005;365(9466):1231-8. [Medline].

  20. Mishra J, Ma Q, Kelly C, et al. Kidney NGAL is a novel early marker of acute injury following transplantation. Pediatr Nephrol. Jun 2006;21(6):856-63. [Medline].

  21. Mishra J, Mori K, Ma Q, et al. Amelioration of ischemic acute renal injury by neutrophil gelatinase-associated lipocalin. J Am Soc Nephrol. Dec 2004;15(12):3073-82. [Medline].

  22. Parikh CR, Jani A, Melnikov VY, et al. Urinary interleukin-18 is a marker of human acute tubular necrosis. Am J Kidney Dis. Mar 2004;43(3):405-14. [Medline].

  23. van Timmeren MM, Vaidya VS, van Ree RM, et al. High urinary excretion of kidney injury molecule-1 is an independent predictor of graft loss in renal transplant recipients. Transplantation. Dec 27 2007;84(12):1625-30. [Medline].

  24. Wagener G, Jan M, Kim M, et al. Association between increases in urinary neutrophil gelatinase-associated lipocalin and acute renal dysfunction after adult cardiac surgery. Anesthesiology. Sep 2006;105(3):485-91. [Medline].

  25. Zhou H, Hewitt SM, Yuen PS, et al. Acute kidney injury biomarkers - needs, present status, and future promise. Nephrol Self Assess Program. Mar 2006;5(2):63-71. [Medline].

 
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A photomicrograph of renal biopsy shows renal medulla, which is composed mainly of renal tubules. Patchy or diffuse denudation of the renal tubular cells is observed, suggesting acute tubular necrosis (ATN) as the cause of acute kidney injury (AKI).
Acute tubular necrosis (ATN). Flattening of the renal tubule cells due to tubular dilation.
Acute tubular necrosis. Intratubular cast formation.
Acute tubular necrosis. Intratubular obstruction due to the denuded epithelium and cellular debris. Note that the denuded tubular epithelial cells clump together due to rearrangement of intercellular adhesion molecules (ICAM).
Sloughing of cells, which is responsible for the formation of granular casts, a feature of acute tubular necrosis (ATN).
Table. Laboratory Findings Used to Differentiate Prerenal Azotemia From ATN
Finding Prerenal Azotemia ATN and/or Intrinsic Renal Disease
Urine osmolarity



(mOsm/kg)



>500< 350
Urine sodium



(mmol/d)



< 20>40
Fractional excretion of sodium (FENa)



(%)



< 1>2
Fractional excretion of urea



(%)



< 35>50
Urine sedimentBland and/or nonspecificMay show muddy brown granular casts
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