Acute tubular necrosis natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Chandrakala Yannam, MD [2]

Acute tubular necrosis may usually develop through 3 phases, initiation, maintenance and recovery. Common complications of acute tubular necrosis include electrolyte imbalance(eg, hyperkalemia, hyperphosphatemia, hypocalcemia, and metabolic acidosis), platelet dysfunction, uremia, and altered consciousness or coma. Prognosis depends on the underlying etiology and severity of kidney damage. When compared to ischemic acute tubular necrosis, nephrotoxic and mixed acute tubular necrosis have the good prognosis.

• Acute tubular necrosis may usually develop through 3 phases, include^[1]
  • Phase of initiation
  • Maintenance phase
  • Phase of recovery
• Renal injury by ischemia, hypoxia, and nephrotoxins can occur in initiation phase.
• After a renal injury, it may progress to renal failure depending upon the severity. once the acute renal failure is evident, there is marked decrease in glomerular filtration rate (GFR) resulting in oliguria.
• Oliguria leads to accumulation of metabolic waste products and uremia. Uremia may responsible for altered mental status, cognitive impairment, and other complications.
• The duration of maintenance phase may vary from days to weeks.
• Maintenance phase is followed by a recovery phase which may usually last upto 3-6 weeks. Polyuria can occur due to decreased concentration capacity of kidneys in the maintenance phase.
• Eventually kidney recovery may take place resulting in normal glomerular filtration rate (GFR).

• Common complications of acute tubular necrosis include:^[2]
  • Hyperkalemia
  • Hyponatraemia
  • Metabolic acidosis
  • Hypomagnesemia
  • Fluid retention
  • Hyperphosphatemia
  • Bleeding diathesis due to platelet dysfunction
  • Oliguria
  • Uremia
  • Pericarditis and pericardial effusion
  • Infection
  • Shock
  • Stupor or coma

• Prognosis of acute tubular necrosis depends on the underlying etiology responsible for the tubular damage.^[3][4]
• Prognosis is generally good in nephrotoxic acute tubular necrosis with mortality rate approximately 10%.
• Prognosis of ischemic acute tubular necrosis depends on early diagnosis and treatment of underlying condition causing renal ischemia with mortality rate approximately 30%.
• Poor prognostic factors associated with increased mortality include:^[5]
  • Mechanical ventilation
  • Hypotension
  • Oliguria
  • Cardiogenic shock
  • Coma
  • Sepsis
  • Parenteral nutrition

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