Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute tubular necrosis (ATN)

1st line – supportive care

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ACUTE
|
acute tubular necrosis (ATN)
1st line – 

supportive care

There is no specific therapy for ATN apart from supportive care in maintaining volume status and controlling electrolyte and acid-base abnormalities.[5]

Nephrotoxins should be ceased (preferable) or if this is not possible, dose should be decreased.

The underlying cause of volume contraction or blood loss needs to be treated along with restoring euvolaemia and haemodynamic stability.

Crystalloid (normal saline or lactated Ringer's) is sufficient in most cases for volume expansion.

In the absence of haemorrhagic shock, isotonic crystalloids rather than colloids (albumin or starches) can be used as initial management for expansion of intravascular volume in patients at risk for acute kidney injury (AKI) or with AKI.[3] Nevertheless, there is controversy and contradictory information in the literature when comparing balanced crystalloids versus normal isotonic saline in the critical care patient.[40]

Volume expansion with normal saline has been demonstrated to be beneficial in reducing the risk of contrast-induced nephropathy in patients at risk of contrast-induced AKI.[44][Evidence C] Target doses of normal saline at 1 mL/kg/hour have been demonstrated to have benefit.[45]

Most studies suggest starting fluid therapy at least 1 hour before contrast and maintaining for 3-6 hours after. It is important to maintain a good diuretic rate >150 mL/hour after the procedure in order to achieve a euvolaemic diuresis. Current guidelines from the American College of Radiology recommend administration of 100 mL/hour intravenous isotonic saline for 6 to 12 hours before and 4 to 12 hours after radiocontrast exposure.[23] The European Society of Cardiology guidelines on myocardial revascularisation recommend intravenous isotonic saline 1-1.5 mL/kg/hour for 12 hours before and up to 24 hours after the procedure.[24] For outpatient or urgent procedures, administration of isotonic saline 1 to 3 hours before and 6 hours after could be beneficial.

Haemorrhage requires blood product replacement.

Diuretics should not be used to treat ATN, except in the management of volume overload.[3]

The use of vasopressors in conjunction with fluids is recommended in patients with vasomotor shock with, or at risk for, AKI.[3] Vasopressors are used under specialist guidance.

Consider – renal replacement therapy

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ACUTE
|
acute tubular necrosis (ATN)
|
with severe acidosis or volume overload refractory to diuretics or hyperkalaemia or uraemia
Consider – 

renal replacement therapy

Additional treatment recommended for SOME patients in selected patient group

Nephrologist consultation recommended.

Conventional haemodialysis is used in haemodynamically stable patients.

Other modes of renal replacement include the continuous renal replacement therapies (CRRT). Major commonly used modalities include continuous venovenous haemofiltration (CVVH), continuous venovenous haemodialysis (CVVHD), and continuous venovenous haemodiafiltration (CVVHDF).

CRRT is most beneficial in haemodynamically unstable patients (e.g., patients with sepsis or severe congestive heart failure) or those in whom aggressive ultra-filtration within the conventional 4- to 6-hour treatment of haemodialysis would not be tolerated.

Prolonged intermittent renal replacement therapies (PIRRT) combine characteristics of both techniques and could be indicated in unstable patients with low doses of vasoactive drugs.

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines provide recommendations on renal replacement therapy for acute kidney injury.[3]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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