eMedicine Specialties > Nephrology > Acute Kidney Failure

Acute Tubular Necrosis: Follow-up

Author: Edgar V Lerma, MD, Clinical Associate Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Consulting Staff, Associates in Nephrology, SC
Coauthor(s): Brent Kelly, MD, Resident Physician, Department of Internal Medicine, University of Texas Medical Branch School of Medicine; Mahendra Agraharkar, MD, MBBS, FACP, FASN, Clinical Associate Professor of Medicine, Baylor College of Medicine, President & CEO, Space City Associates of Nephrology
Contributor Information and Disclosures

Updated: Aug 28, 2009

Follow-up

Complications

  • ATN and ARF have several complications.
  • Electrolyte abnormalities
    • Hyperkalemia: Higher levels are associated with ECG abnormalities (eg, peaked T waves, prolonged PR interval, P wave flattening, widened QRS) and risk of developing life-threatening arrhythmias (eg, ventricular tachycardia or fibrillation, complete heart block, bradycardia, asystole). Arrhythmias have been reported in up to 30% of patients. In addition to these worrisome cardiac effects, hyperkalemia can also lead to neuromuscular dysfunction and, potentially, respiratory failure.
    • Hyponatremia
    • Hyperphosphatemia
    • Hypermagnesemia
    • Hypocalcemia: Hypocalcemia may be secondary to both deposition of calcium phosphate and reduced levels of 1,25 dihydroxyvitamin D. It is usually asymptomatic, but hypocalcemia may result in nonspecific ECG changes, muscle cramps, or seizures.
    • Metabolic acidosis
  • Intravascular volume overload: In its most severe manifestation, this may lead to respiratory failure from pulmonary edema.
  • Hypertension: Hypertension is suspected to mainly be due to salt and water retention. About 25% of patients with ARF develop some hypertension.
  • Uremic syndrome: This may manifest as pericardial disease, GI symptoms (ie, nausea, vomiting, cramping), and/or neurologic symptoms (ie, lethargy, confusion, asterixis, seizures).
  • Anemia: Anemia may develop from many possible causes. Indeed, erythropoiesis is reduced in ARF, but platelet dysfunction is also observed in the setting of uremia, which may predispose to hemorrhage. In addition, volume overload may lead to hemodilution, and red cell survival time may be decreased.
  • Polyuric phase of ATN: This complication can lead to hypovolemia and create a setting for prerenal azotemia and perpetuation of ATN. One must be wary of the potential for multiple electrolyte deficiencies (eg, hypokalemia, hypocalcemia) during this period as a result of increased urinary excretion.
  • Infections: Infections remain the leading cause of morbidity and mortality and can occur in 30-70% of patients with ARF. Infections are more likely in these patients because of an impaired immune system (eg, uremia, inappropriate use of antibiotics) and because of increased use of indwelling catheters and intravenous needles.

Prognosis

  • As mentioned earlier, the mortality rate of ATN is about 50%. However, this is probably related more to the severity of the underlying disease than to ATN itself. For example, the mortality rate in patients with ATN after sepsis or severe trauma is much higher (about 60%) than the mortality rate in patients with ATN that is nephrotoxin related (about 30%). However, remember the following points:
    • First, patients with oliguric ATN have a worse prognosis than patients with nonoliguric ATN. This probably is related to more severe necrosis and more significant disturbances in electrolyte balance.
    • Second, a rapid increase in serum creatinine (ie, > 3 mg/dL) probably also indicates a poorer prognosis. Again, this probably reflects a more serious underlying disease.
  • Of the survivors of ATN, approximately 50% have some impairment of renal function. Some (about 5%) continue to undergo a decline in renal function. About 5% never recover kidney function and require dialysis.

Patient Education

 


More on Acute Tubular Necrosis

Overview: Acute Tubular Necrosis
Differential Diagnoses & Workup: Acute Tubular Necrosis
Treatment & Medication: Acute Tubular Necrosis
Follow-up: Acute Tubular Necrosis
Multimedia: Acute Tubular Necrosis
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
Acute Renal Failure
Acute Tubular Necrosis [Pediatrics: General Medicine]
Azotemia
Kidney Transplantation, Surgical Complications
Kidney, Trauma
Oliguria
Renal Failure, Acute

Clinical guidelines:
ACR Appropriateness Criteria® renal failure. American College of Radiology - Medical Specialty Society.  1995 (revised 2005).  8 pages. [NGC Update Pending] NGC:004615

Clinical trials:
Allogeneic Multipotent Stromal Cell Treatment for Acute Kidney Injury Following Cardiac Surgery

Sensitivity and Specificity of NGAL in an Emergency Room Population

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Keywords

acute tubular necrosis, renal failure, kidney failure, acute renal failure, tubular necrosis, end-stage renal disease, acute kidney failure, intrinsic renal disease, acute ischemic nephropathy, ischemic acute tubular necrosis, nephrotoxic acute tubular necrosis

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Contributor Information and Disclosures

Author

Edgar V Lerma, MD, Clinical Associate Professor of Medicine, Section of Nephrology, Department of Medicine, University of Illinois at Chicago College of Medicine; Consulting Staff, Associates in Nephrology, SC
Edgar V Lerma, MD 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)

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.

Mahendra Agraharkar, MD, MBBS, FACP, FASN, Clinical Associate Professor of Medicine, Baylor College of Medicine, President & 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

Medical Editor

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.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

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.

CME Editor

Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine
Rebecca J Schmidt, DO, FACP, FASN is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Medical Association, American Society of Nephrology, International Society of Nephrology, National Kidney Foundation, Renal Physicians Association, and West Virginia State Medical Association
Disclosure: Abbott Grant/research funds Speaking and teaching; Genzyme Honoraria Consulting; Amgen Honoraria Speaking and teaching; Ortho Biotech Honoraria Speaking and teaching

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.

 
 
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