NP27 Nephrology

Parenchymal Kidney Diseases

Essential Med Notes 2015

Findings which Suggest Chronic Tubulointerstitial Nephritis

normal AG metabolic acidosis
hyperkalemia (out of proportion to degree of renal insufficiency)
polyuria, nocturia
partial or complete Fanconis syndrome
urine: mild proteinuria, few RBCs and WBCs, no RBC casts
U/S: shrunken kidneys with irregular contours
3. ACUTE TUBULAR NECROSIS
Definition
abrupt and sustained decline in GFR within minutes to days after ischemic/nephrotoxic insult
GFR reduced (this serves the purpose of avoiding life-threatening urinary loss of fluid and
electrolytes from non-functioning tubules)
Etiology
Acute Tubular Necrosis

Toxins

Exogenous
Antibiotics
Aminoglycosides
Cephalosporins
Amphotericin B
Antiviral (cidofovir)
Antineoplastics
Cisplatin
Methotrexate
Contrast media
Heavy metals
Other
Fluorinated anesthetic
Ethylene glycol

Ischemia

Endogenous
Endotoxins (bacterial)
Myoglobin
Hemoglobin

Decreased Circulating Volume

Hemorrhage including post-surgical
Skin losses
GI losses
Renal losses
Decreased Effective Circulating Volume
Heart failure
Liver failure
Sepsis
Anaphylaxis
Vessel Occlusion
Large or small renal artery involvement

Figure 16. Etiology of ATN

Clinical Presentation
typically presents as an abrupt rise in urea and Cr after a hypotensive episode, sepsis,
rhabdomyolysis, or administration of nephrotoxic drug
urine: high FENa+, pigmented-granular casts
Complications
hyperkalemia: can occur rapidly and cause serious arrhythmias
metabolic acidosis, decreased Ca2+, increased PO43-, hypoalbuminemia
Investigations
blood work: CBC, electrolytes, Cr, urea, Ca2+, PO43-, blood gases
urine: R&M, electrolytes, osmolality, microscopic urinalysis searching for pigmented granular casts
ECG
abdominal U/S
rule out other causes of prerenal/postrenal azotemia and intrinsic AKI (GN, AIN, vasculitis)
Therapy
largely supportive once underlying problem is corrected
loop diuretics may help manage volume overload and reduce tubular metabolic requirements to
allow for recovery (controversial)
consider early dialysis in severe/rapidly progressing cases to prevent uremic syndrome
Prevention
correct fluid balance before surgical procedures
for patients with chronic renal disease requiring radiographic contrast
give N-acetylcysteine 600-1200 mg PO bid day before and day of procedure, give intravenous
isotonic fluid (either NaCl or NaHCO3)
isotonic NaHCO3 at 3 mL/kg over 1 h before procedure and 1 mL/kg/h for 6 h postprocedure if not contraindicated
avoid giving diuretics, ACEI, cyclosporine on morning of procedure if possible
use renal-adjusted doses of nephrotoxic drugs in patients with renal insufficiency

Meta-Analysis: Effectiveness of Drugs for

Preventing Contrast-Induced Nephropathy
Ann Intern Med 2008;148:284-294
Purpose: To determine the effectiveness of
N-acetylcysteine, theophylline, fenoldopam,
dopamine, iloprost, statin, furosemide, or mannitol
on preventing nephropathy.
Study Selection: Only randomized, controlled
trials that used these agents in patients receiving
iodinated contrast.
Results: In the 41 RCTs included N-acetylcysteine
(RR=0.62 [0.44-0.88]) and theophylline (RR=0.49
[0.23-1.06]) reduced the risk of nephropathy more
than saline alone. Furosemide increased the risk
(RR=3.27 [1.48-7.26]). Other agents did not affect
risk of nephropathy.
Conclusion: N-acetylcysteine is more
renoprotective than hydration alone.