Acute tubular necrosis medical therapy

According to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines, management approach of acute tubular necrosis include examination of all patients thoroughly to identify the cause, precipitating factors, and comorbid conditions leading to a rapid reduction in GFR, which may be reversible and regular monitor patients for serum creatinine, BUN, and urine output to assess the severity of renal damage.

• Acute tubular necrosis, which is usually reversible. It may be associated with high morbidity and mortality. Early recognition and management are essential for a better outcome.^[1]
• According to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 guidelines, management approach of acute tubular necrosis include,
  • Examine all patients thoroughly to identify the cause, precipitating factors, and comorbid conditions leading to a rapid reduction in GFR, which may be reversible.
  • Regularly monitor patients for serum creatinine, BUN, and urine output to assess the severity of renal damage.
  • Assess volume status and manage it accordingly.
    • Hypovolemia: Proper hydration or isotonic saline administration can be helpful in treating volume depletion.
    • Hypervolemia: The only indication of using diuretics in acute renal failure to manage volume overload status.
  • Avoiding or minimizing the dosage of nephrotoxic medications, and radiocontrast media.
  • According to KDIGO guidelines, following medications have no role in the management and outcome of acute tubular necrosis:^[2][3]
    • Diuretics, except to treat hypervolemia
    • Atrial natriuretic peptide
    • Dopamine
    • Fenoldopam
  • Appropriate management of electrolyte and acid-base imbalance:
    • Hyperkalemia: Hyperkalemia is a life-threatening complication associated with acute tubular necrosis.
      • Preferred regimen (1): Insulin (eg, intravenous injection of 10-15u of short-acting insulin) along with 50ml of dextrose. Insulin along with dextrose may cause influx of potassium into the cell due to activation of sodium-potassium ATPase.
      • Preferred regimen (2): Calcium (eg, calcium gluconate), does not lower elevated potassium levels but, it helps to decrease myocardial contractility, thus by preventing arrythmias.
      • Preferred regimen (3): Dialysis in severe and refractory cases.
    • Metabolic acidosis:
      • Preferred regimen: Sodium bicarbonate can be given to treat metabolic acidosis.
  • Renal replacement therapy:
    • Indications for renal replacement therapy include:
      • Severe hyperkalemia
      • Hypervolemia
      • Uremia
      • Severe metabolic alkalosis

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