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Pediatric Acute Tubular Necrosis Medication

  • Author: Prasad Devarajan, MD, FAAP; Chief Editor: Craig B Langman, MD  more...
Updated: Jan 19, 2016

Medication Summary

Diuretic treatment may convert oliguric acute tubular necrosis (ATN) to nonoliguric ATN, although diuretics do not appear to alter the course of acute renal failure (ARF).

Hyperkalemia in ATN is a medical emergency that may be managed by shifting potassium into cells with sodium bicarbonate, glucose/insulin infusion, or beta agonists; by increasing potassium excretion with exchange resins (sodium polystyrene) or loop diuretics (furosemide); or by dialysis. Protecting the myocardium from hyperkalemia is managed with intravenous (IV) calcium.

Hyperphosphatemia may be initially managed with oral calcium to bind dietary phosphate. Oral citrate salts may be used to manage mild metabolic acidosis, whereas IV sodium bicarbonate is needed for severe metabolic acidosis.


Loop diuretics

Class Summary

In children with recent-onset oliguria from prerenal or toxic injury who are unresponsive to hydration, a trial of furosemide may convert the oliguric ATN to a nonoliguric type, which is managed more easily. These agents have a direct vasodilatory action and additionally may prevent tubular obstruction by increasing intratubular fluid flow.

Furosemide (Lasix)


Furosemide increases excretion of water by interfering with the chloride-binding cotransport system, which, in turn, inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule. It is used for ATN prevention in children with oliguria duration less than 48 hours who have not responded to adequate hydration. It may also be considered for oliguria in the presence of volume overload. Furosemide is also used for hyperkalemia to increase potassium excretion in the urine.


Alkalizing agents

Class Summary

Intravenous sodium bicarbonate and oral sodium citrate are used as buffers that break down to water and carbon dioxide after picking up free hydrogen ions, thus counteracting acidosis by raising blood pH. IV sodium bicarbonate is also used to manage hyperkalemia.

Sodium bicarbonate


Sodium bicarbonate is used to treat hyperkalemia. It causes a rapid shift of potassium into cells. The magnitude of the potassium intracellular shift varies; thus, bicarbonate is not reliable in lowering the potassium level by itself. It is also used emergently to manage severe metabolic acidosis.

Sodium citrate (Bicitra, Oracit)


Sodium citrate manages mild metabolic acidosis and is used as an alkalinizing agent when long-term maintenance of an alkaline urine is desirable.


Myocardium stabilizers

Class Summary

Intravenous calcium is primarily used to protect the myocardium from the deleterious effects of hyperkalemia (ie, arrhythmias) by antagonizing the potassium actions on the myocardial cell membrane. It does not lower serum potassium levels.

Calcium gluconate (Kalcinate)


Calcium gluconate is given intravenously to provide myocardial protection from hyperkalemia. It is indicated if hyperkalemia is accompanied by ominous electrocardiographic (ECG) changes beyond peaked T waves or if ECG changes persist after bicarbonate therapy.


Intracellular transporters

Class Summary

Insulin and glucose (dextrose) cause a transcellular shift of potassium into muscle cells, thereby lowering (temporarily) potassium serum levels.

Dextrose and insulin infusion


Dextrose and insulin infusion is used as an adjunct to bicarbonate therapy to promote intracellular shift of potassium.


Exchange resins

Class Summary

Sodium polystyrene sulfonate is an exchange resin that can be used to treat mild-to-moderate hyperkalemia. Each 1 mEq of potassium is exchanged for 1 mEq of sodium.

Sodium polystyrene sulfonate (Kayexalate)


Sodium polystyrene sulfonate is indicated in all cases of hyperkalemia because it is the only modality (other than diuretics and dialysis) that actually removes excessive potassium from the body. It exchanges sodium for potassium and binds it in the gut, primarily in the large intestine, and decreases total body potassium. Its onset of action after oral administration ranges from 2-12 hours and is longer when rectally administered.


Phosphate binders

Class Summary

ATN is frequently complicated by hyperphosphatemia and hypocalcemia, which respond to calcium-containing oral phosphate binders.

Calcium carbonate (Oystercal, Caltrate)


Calcium carbonate combines with dietary phosphate to form insoluble calcium phosphate, which is excreted in feces.

Contributor Information and Disclosures

Prasad Devarajan, MD, FAAP Louise M Williams Endowed Chair in Pediatrics, Professor of Pediatrics and Developmental Biology, Director of Nephrology and Hypertension, Director of the Nephrology Fellowship Program, Medical Director of the Kidney Stone Center, Co-Director of the Institutional Office of Pediatric Clinical Fellowships, Director of Clinical Nephrology Laboratory, CEO of Dialysis Unit, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine

Prasad Devarajan, MD, FAAP is a member of the following medical societies: American Heart Association, American Society of Nephrology, American Society of Pediatric Nephrology, National Kidney Foundation, Society for Pediatric Research

Disclosure: Received none from Coinventor on patents submitted for the use of NGAL as a biomarker of kidney injury for none.

Chief Editor

Craig B Langman, MD The Isaac A Abt, MD, Professor of Kidney Diseases, Northwestern University, The Feinberg School of Medicine; Division Head of Kidney Diseases, The Ann and Robert H Lurie Children's Hospital of Chicago

Craig B Langman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society of Nephrology, International Society of Nephrology

Disclosure: Received income in an amount equal to or greater than $250 from: Alexion Pharmaceuticals; Raptor Pharmaceuticals; Eli Lilly and Company; Dicerna<br/>Received grant/research funds from NIH for none; Received grant/research funds from Raptor Pharmaceuticals, Inc for none; Received grant/research funds from Alexion Pharmaceuticals, Inc. for none; Received consulting fee from DiCerna Pharmaceutical Inc. for none.


Richard Neiberger, MD, PhD Director of Pediatric Renal Stone Disease Clinic, Associate Professor, Department of Pediatrics, Division of Nephrology, University of Florida College of Medicine and Shands Hospital

Richard Neiberger, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Medical Research, American Medical Association, American Society of Nephrology, American Society of Pediatric Nephrology, Christian Medical & Dental Society, Florida Medical Association, International Society for Peritoneal Dialysis, International Society of Nephrology, National Kidney Foundation, New York Academy of Sciences, Shock Society, Sigma Xi, Southern Medical Association, Southern Society for Pediatric Research, and Southwest Pediatric Nephrology Study Group

Disclosure: The Osler Institute Honoraria Speaking and teaching

Adrian Spitzer, MD Professor, Department of Pediatrics, Albert Einstein College of Medicine; Director of NIH Training Program, Children's Hospital at Montefiore Medical Center

Adrian Spitzer, MD is a member of the following medical societies: American Academy of Pediatrics, American Federation for Medical Research, American Pediatric Society, American Society of Nephrology, American Society of Pediatric Nephrology, International Society of Nephrology, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Robert Woroniecki, MD Assistant Professor, Department of Pediatrics, Section of Pediatric Nephrology, Albert Einstein College of Medicine, Children's Hospital of Montefiore

Disclosure: Nothing to disclose.

  1. Andreoli SP. Acute renal failure. Curr Opin Pediatr. 2002 Apr. 14(2):183-8. [Medline].

  2. American Society of Nephrology. American Society of Nephrology Renal Research Report. J Am Soc Nephrol. 2005 Jul. 16(7):1886-903. [Medline]. [Full Text].

  3. Andreoli SP. Management of acute renal failure. Barratt TM, Avner ED, Harmon W, eds. Pediatric Nephrology. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999. 1119-34.

  4. Bellomo R, Ronco C, Kellum JA. 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. 2004 Aug. 8(4):R204-12. [Medline]. [Full Text].

  5. Brady HR, Brenner BM, Clarkson MR. Acute renal failure. Brenner BM, Rector FC, eds. Brenner and Rector's the Kidney. 6th ed. Philadelphia, PA: WB Saunders Co; 2000. 1201-62.

  6. Devarajan P, Goldstein SL. Acute renal failure. Kher KK, Schnaper HW, Makker SP. Clinical Pediatric Nephrology. 2nd ed. Oxon, UK: Informa Healthcare; 2007. 363-376.

  7. Lameire N, Van Biesen W, Vanholder R. Acute renal failure. Lancet. 2005 Jan 29-Feb 4. 365(9457):417-30. [Medline].

  8. Mehta RL, Chertow GM. Acute renal failure definitions and classification: time for change?. J Am Soc Nephrol. 2003 Aug. 14(8):2178-87. [Medline]. [Full Text].

  9. Schrier RW, Wang W, Poole B, Mitra A. Acute renal failure: definitions, diagnosis, pathogenesis, and therapy. J Clin Invest. 2004 Jul. 114(1):5-14. [Medline]. [Full Text].

  10. Warnock DG. Towards a definition and classification of acute kidney injury. J Am Soc Nephrol. 2005 Nov. 16(11):3149-50. [Medline].

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

  12. Devarajan P. Update on Mechanisms of Ischemic Acute Kidney Injury. J Am Soc Nephrol. 2006 Jun. 17(6):1503-1520. [Medline].

  13. Safirstein RL. Acute renal failure: from renal physiology to the renal transcriptome. Kidney Int Suppl. 2004 Oct. S62-6. [Medline].

  14. Siegel NJ, Van Why SK, Devarajan P. Pathogenesis of acute renal failure. Barratt TM, Avner ED, Harmon W, eds. Pediatric Nephrology. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999. 1109-18.

  15. Humes HD, Buffington DA, MacKay SM, et al. Replacement of renal function in uremic animals with a tissue- engineered kidney. Nat Biotechnol. 1999 May. 17(5):451-5. [Medline].

  16. Hirschberg R, Kopple J, Lipsett P, et al. Multicenter clinical trial of recombinant human insulin-like growth factor I in patients with acute renal failure. Kidney Int. 1999 Jun. 55(6):2423-32. [Medline].

  17. Devarajan P. Cellular and molecular derangements in acute tubular necrosis. Curr Opin Pediatr. 2005 Apr. 17(2):193-9. [Medline].

  18. Nolan CR, Anderson RJ. Hospital-acquired acute renal failure. J Am Soc Nephrol. 1998 Apr. 9(4):710-8. [Medline].

  19. Mentser M, Bunchman T. Nephrology in the pediatric intensive care unit. Semin Nephrol. 1998 May. 18(3):330-40. [Medline].

  20. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005 Nov. 16(11):3365-70. [Medline].

  21. Goldstein SL. Pediatric acute renal failure: demographics and treatment. Contrib Nephrol. 2004. 144:284-90. [Medline].

  22. Hui-Stickle S, Brewer ED, Goldstein SL. Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001. Am J Kidney Dis. 2005 Jan. 45(1):96-101. [Medline].

  23. Liano F, Pascual J. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int. 1996 Sep. 50(3):811-8. [Medline].

  24. Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med. 2004 Jul 8. 351(2):159-69. [Medline].

  25. Bellomo R, Ronco C. Indications and criteria for initiating renal replacement therapy in the intensive care unit. Kidney Int Suppl. 1998 May. 66:S106-9. [Medline].

  26. Foley RN, Sexton DJ, Reule S, Solid C, Chen SC, Collins AJ. End-stage renal disease attributed to acute tubular necrosis in the United States, 2001-2010. Am J Nephrol. 2015. 41 (1):1-6. [Medline].

  27. Badr KF, Ichikawa I. Prerenal failure: a deleterious shift from renal compensation to decompensation. N Engl J Med. 1988 Sep 8. 319(10):623-9. [Medline].

  28. Karlowicz MG, Adelman RD. Nonoliguric and oliguric acute renal failure in asphyxiated term neonates. Pediatr Nephrol. 1995 Dec. 9(6):718-22. [Medline].

  29. Klahr S, Miller SB. Acute oliguria. N Engl J Med. 1998 Mar 5. 338(10):671-5. [Medline].

  30. Rabb H, Colvin RB. Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine. N Engl J Med. 2007 Oct 11. 357(15):1531-41. [Medline].

  31. Devarajan P. The future of pediatric acute kidney injury management-biomarkers. Semin Nephrol. 2008 Sep. 28(5):493-8. [Medline].

  32. Parikh CR, Devarajan P. New biomarkers of acute kidney injury. Crit Care Med. 2008 Apr. 36(4 Suppl):S159-65. [Medline].

  33. Nixon JN, Biyyam DR, Stanescu L, Phillips GS, Finn LS, Parisi MT. Imaging of pediatric renal transplants and their complications: a pictorial review. Radiographics. 2013 Sep. 33(5):1227-51. [Medline].

  34. Perico N, Cattaneo D, Sayegh MH, Remuzzi G. Delayed graft function in kidney transplantation. Lancet. 2004 Nov 13-19. 364(9447):1814-27. [Medline].

  35. DuBose TD Jr, Warnock DG, Mehta RL, et al. Acute renal failure in the 21st century: recommendations for management and outcomes assessment. Am J Kidney Dis. 1997 May. 29(5):793-9. [Medline].

  36. Flynn JT. Causes, management approaches, and outcome of acute renal failure in children. Curr Opin Pediatr. 1998 Apr. 10(2):184-9. [Medline].

  37. Mehta RL, Pascual MT, Soroko S, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004 Oct. 66(4):1613-21. [Medline].

  38. Schrier RW. Need to intervene in established acute renal failure. J Am Soc Nephrol. 2004 Oct. 15(10):2756-8. [Medline]. [Full Text].

  39. Star RA. Treatment of acute renal failure. Kidney Int. 1998 Dec. 54(6):1817-31. [Medline].

  40. Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005 Aug 17. 294(7):813-8. [Medline].

  41. Forni LG, Hilton PJ. Continuous hemofiltration in the treatment of acute renal failure. N Engl J Med. 1997 May 1. 336(18):1303-9. [Medline].

  42. Hakim RM, Wingard RL, Parker RA. Effect of the dialysis membrane in the treatment of patients with acute renal failure. N Engl J Med. 1994 Nov 17. 331(20):1338-42. [Medline].

  43. Himmelfarb J, Tolkoff Rubin N, Chandran P, et al. A multicenter comparison of dialysis membranes in the treatment of acute renal failure requiring dialysis. J Am Soc Nephrol. 1998 Feb. 9(2):257-66. [Medline].

  44. Ellis EN, Pearson D, Belsha CW, Berry PL. Use of pump-assisted hemofiltration in children with acute renal failure. Pediatr Nephrol. 1997 Apr. 11(2):196-200. [Medline].

  45. Gambaro G, Bertaglia G, Puma G, D'Angelo A. Diuretics and dopamine for the prevention and treatment of acute renal failure: a critical reappraisal. J Nephrol. 2002 May-Jun. 15(3):213-9. [Medline].

  46. Lameire NH, De Vriese AS, Vanholder R. Prevention and nondialytic treatment of acute renal failure. Curr Opin Crit Care. 2003 Dec. 9(6):481-90. [Medline].

  47. Vijayan A, Miller SB. Acute renal failure: prevention and nondialytic therapy. Semin Nephrol. 1998 Sep. 18(5):523-32. [Medline].

  48. Cantarovich F, Rangoonwala B, Lorenz H, et al. High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebo-controlled, multicenter trial. Am J Kidney Dis. 2004 Sep. 44(3):402-9. [Medline].

  49. Bonventre JV, Zuk A. Ischemic acute renal failure: an inflammatory disease?. Kidney Int. 2004 Aug. 66(2):480-5. [Medline].

  50. Brezis M, Rosen S. Hypoxia of the renal medulla--its implications for disease. N Engl J Med. 1995 Mar 9. 332(10):647-55. [Medline].

  51. Friedewald JJ, Rabb H. Inflammatory cells in ischemic acute renal failure. Kidney Int. 2004 Aug. 66(2):486-91. [Medline].

  52. Lieberthal W, Levine JS. Mechanisms of apoptosis and its potential role in renal tubular epithelial cell injury. Am J Physiol. 1996 Sep. 271(3 Pt 2):F477-88. [Medline].

  53. Mendley SR, Langman CB. Acute renal failure in the pediatric patient. Adv Ren Replace Ther. 1997 Apr. 4(2 Suppl 1):93-101. [Medline].

  54. Moghal NE, Brocklebank JT, Meadow SR. A review of acute renal failure in children: incidence, etiology and outcome. Clin Nephrol. 1998 Feb. 49(2):91-5. [Medline].

  55. Molitoris BA. Putting the actin cytoskeleton into perspective: pathophysiology of ischemic alterations. Am J Physiol. 1997 Apr. 272(4 Pt 2):F430-3. [Medline].

  56. Molitoris BA, Sutton TA. Endothelial injury and dysfunction: role in the extension phase of acute renal failure. Kidney Int. 2004 Aug. 66(2):496-9. [Medline].

  57. Racusen LC. The morphologic basis of acute renal failure. Molitoris BA, Finn WF eds. Acute Renal Failure. Philadelphia, PA: WB Saunders; 2004. 1-12.

  58. Siegel NJ, Devarajan P, Van Why S. Renal cell injury: metabolic and structural alterations. Pediatr Res. 1994 Aug. 36(2):129-36. [Medline].

Common causes of oliguric versus nonoliguric acute renal failure in children.
Metabolic alterations in tubule cells following acute tubular necrosis.
Compensatory mechanisms that maintain glomerular filtration rate despite a reduction in renal perfusion pressure.
Pathogenesis of acute tubular necrosis (macrovascular changes).
Alterations in tubule cell morphology in acute tubular necrosis.
Table. Urinary Indexes in Acute Tubular Necrosis vs Prerenal Failure
  ATN Prerenal
Urine specific gravity 1010 >1020
Urine sodium (mEq/L) >40 < 10
Urine/plasma creatinine < 20 >40
FENa (%) >2 < 1
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