Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Renal and patient outcomes after acute tubular necrosis

Orfeas Liangos, MD, FASN
Bertrand L Jaber, MD, MS, FASN
Section Editor
Paul M Palevsky, MD
Deputy Editor
Alice M Sheridan, MD


Most patients with acute tubular necrosis (ATN) spontaneously recover renal function. Recovery is usually heralded by an increase in urine output and a gradual return of the blood urea nitrogen (BUN) and serum creatinine concentration to or very near the previous baseline level [1-3].

Renal and patient outcomes following an episode of ATN are reviewed here. The terms "ATN" and "acute kidney injury (AKI)" are sometimes used interchangeably in the literature. Studies that discuss prolonged or severe AKI, particularly in the critical care setting, are predominantly focused on ATN. However, it is important to note that the term AKI encompasses more than just ischemic or postischemic intrinsic kidney injury, and, while ATN is its most common form, it is not the only form of AKI. Since epidemiologic studies cannot distinguish between the various forms of AKI, we use the term "AKI" in these cases.

The diagnosis, pathogenesis, and possible treatment of this disorder and issues related to the definition of AKI are discussed separately. (See "Diagnostic approach to the patient with subacute kidney injury in an outpatient setting" and "Etiology and diagnosis of prerenal disease and acute tubular necrosis in acute kidney injury (acute renal failure)" and "Pathogenesis and etiology of ischemic acute tubular necrosis" and "Possible prevention and therapy of ischemic acute tubular necrosis" and "Definition and staging criteria of acute kidney injury (acute renal failure)".)


The incidence and prevalence of ATN are not well known, which is due in part to differences in definition and characteristics of assessed patients. In addition, as noted above, epidemiologic studies of acute kidney injury (AKI) do not reliably identify the etiology.

In a meta-analysis that included 143 studies and >3.5 million patients, among hospitalized patients, the global incidence of AKI, as defined according to Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, was estimated to be 22 percent [4]. The KDIGO definition of AKI is discussed elsewhere (see "Definition and staging criteria of acute kidney injury (acute renal failure)"). However, a more recent cross-sectional study of 97 intensive care units (ICUs) from 33 countries and based on data from 1802 patients during their first week of ICU admission showed a much higher AKI burden. Fifty-seven and three-tenths percent of enrolled patients fulfilled the KDIGO criteria for AKI (95% CI 55.0-59.6) [5].


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Apr 2017. | This topic last updated: Aug 01, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Myers BD, Moran SM. Hemodynamically mediated acute renal failure. N Engl J Med 1986; 314:97.
  2. Lewers DT, Mathew TH, Maher JF, Schreiner GE. Long-term follow-up of renal function and histology after acute tubular necrosis. Ann Intern Med 1970; 73:523.
  3. Georgaki-Angelaki HN, Steed DB, Chantler C, Haycock GB. Renal function following acute renal failure in childhood: a long term follow-up study. Kidney Int 1989; 35:84.
  4. Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: a meta-analysis. Clin J Am Soc Nephrol 2013; 8:1482.
  5. Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 2015; 41:1411.
  6. Waikar SS, Curhan GC, Wald R, et al. Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 2006; 17:1143.
  7. Hsu RK, McCulloch CE, Dudley RA, et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol 2013; 24:37.
  8. Ali T, Khan I, Simpson W, et al. Incidence and outcomes in acute kidney injury: a comprehensive population-based study. J Am Soc Nephrol 2007; 18:1292.
  9. Hsu CY, McCulloch CE, Fan D, et al. Community-based incidence of acute renal failure. Kidney Int 2007; 72:208.
  10. Myers BD, Miller DC, Mehigan JT, et al. Nature of the renal injury following total renal ischemia in man. J Clin Invest 1984; 73:329.
  11. Molitoris BA, Dahl R, Geerdes A. Cytoskeleton disruption and apical redistribution of proximal tubule Na(+)-K(+)-ATPase during ischemia. Am J Physiol 1992; 263:F488.
  12. Fish EM, Molitoris BA. Alterations in epithelial polarity and the pathogenesis of disease states. N Engl J Med 1994; 330:1580.
  13. Spurney RF, Fulkerson WJ, Schwab SJ. Acute renal failure in critically ill patients: prognosis for recovery of kidney function after prolonged dialysis support. Crit Care Med 1991; 19:8.
  14. Conger JD, Robinette JB, Schrier RW. Smooth muscle calcium and endothelium-derived relaxing factor in the abnormal vascular responses of acute renal failure. J Clin Invest 1988; 82:532.
  15. Morgera S, Kraft AK, Siebert G, et al. Long-term outcomes in acute renal failure patients treated with continuous renal replacement therapies. Am J Kidney Dis 2002; 40:275.
  16. Schiffl H. Renal recovery from acute tubular necrosis requiring renal replacement therapy: a prospective study in critically ill patients. Nephrol Dial Transplant 2006; 21:1248.
  17. Lo LJ, Go AS, Chertow GM, et al. Dialysis-requiring acute renal failure increases the risk of progressive chronic kidney disease. Kidney Int 2009; 76:893.
  18. Wald R, Quinn RR, Luo J, et al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA 2009; 302:1179.
  19. Ishani A, Xue JL, Himmelfarb J, et al. Acute kidney injury increases risk of ESRD among elderly. J Am Soc Nephrol 2009; 20:223.
  20. Chawla LS, Amdur RL, Shaw AD, et al. Association between AKI and long-term renal and cardiovascular outcomes in United States veterans. Clin J Am Soc Nephrol 2014; 9:448.
  21. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int 2012; 81:442.
  22. Bucaloiu ID, Kirchner HL, Norfolk ER, et al. Increased risk of death and de novo chronic kidney disease following reversible acute kidney injury. Kidney Int 2012; 81:477.
  23. Jones J, Holmen J, De Graauw J, et al. Association of complete recovery from acute kidney injury with incident CKD stage 3 and all-cause mortality. Am J Kidney Dis 2012; 60:402.
  24. Pannu N, James M, Hemmelgarn B, et al. Association between AKI, recovery of renal function, and long-term outcomes after hospital discharge. Clin J Am Soc Nephrol 2013; 8:194.
  25. Schmitt R, Coca S, Kanbay M, et al. Recovery of kidney function after acute kidney injury in the elderly: a systematic review and meta-analysis. Am J Kidney Dis 2008; 52:262.
  26. Hsu CY, Chertow GM, McCulloch CE, et al. Nonrecovery of kidney function and death after acute on chronic renal failure. Clin J Am Soc Nephrol 2009; 4:891.
  27. Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294:813.
  28. Thakar CV, Arrigain S, Worley S, et al. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol 2005; 16:162.
  29. Mehta RL, Pascual MT, Soroko S, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004; 66:1613.
  30. Zhang L, Wang M, Wang H. Acute renal failure in chronic kidney disease--clinical and pathological analysis of 104 cases. Clin Nephrol 2005; 63:346.
  31. Silvester W, Bellomo R, Cole L. Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 2001; 29:1910.
  32. Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int 2008; 74:101.
  33. Metcalfe W, Simpson M, Khan IH, et al. Acute renal failure requiring renal replacement therapy: incidence and outcome. QJM 2002; 95:579.
  34. Turney JH, Marshall DH, Brownjohn AM, et al. The evolution of acute renal failure, 1956-1988. Q J Med 1990; 74:83.
  35. Barton IK, Hilton PJ, Taub NA, et al. Acute renal failure treated by haemofiltration: factors affecting outcome. Q J Med 1993; 86:81.
  36. McCarthy JT. Prognosis of patients with acute renal failure in the intensive-care unit: a tale of two eras. Mayo Clin Proc 1996; 71:117.
  37. Schrier RW, Wang W. Acute renal failure and sepsis. N Engl J Med 2004; 351:159.
  38. Bagshaw SM, Laupland KB, Doig CJ, et al. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care 2005; 9:R700.
  39. de Mendonça A, Vincent JL, Suter PM, et al. Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score. Intensive Care Med 2000; 26:915.
  40. Metnitz PG, Krenn CG, Steltzer H, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002; 30:2051.
  41. Liaño F, Pascual J. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int 1996; 50:811.
  42. Hou SH, Bushinsky DA, Wish JB, et al. Hospital-acquired renal insufficiency: a prospective study. Am J Med 1983; 74:243.
  43. Loef BG, Epema AH, Smilde TD, et al. Immediate postoperative renal function deterioration in cardiac surgical patients predicts in-hospital mortality and long-term survival. J Am Soc Nephrol 2005; 16:195.
  44. Liangos O, Wald R, O'Bell JW, et al. Epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey. Clin J Am Soc Nephrol 2006; 1:43.
  45. Xue JL, Daniels F, Star RA, et al. Incidence and mortality of acute renal failure in Medicare beneficiaries, 1992 to 2001. J Am Soc Nephrol 2006; 17:1135.
  46. Coca SG, Peixoto AJ, Garg AX, et al. The prognostic importance of a small acute decrement in kidney function in hospitalized patients: a systematic review and meta-analysis. Am J Kidney Dis 2007; 50:712.
  47. Welten GM, Schouten O, Chonchol M, et al. Temporary worsening of renal function after aortic surgery is associated with higher long-term mortality. Am J Kidney Dis 2007; 50:219.
  48. Newsome BB, Warnock DG, McClellan WM, et al. Long-term risk of mortality and end-stage renal disease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction. Arch Intern Med 2008; 168:609.
  49. Coca SG, Yusuf B, Shlipak MG, et al. Long-term risk of mortality and other adverse outcomes after acute kidney injury: a systematic review and meta-analysis. Am J Kidney Dis 2009; 53:961.
  50. Liaño F, Felipe C, Tenorio MT, et al. Long-term outcome of acute tubular necrosis: a contribution to its natural history. Kidney Int 2007; 71:679.
  51. Siew ED, Peterson JF, Eden SK, et al. Outpatient nephrology referral rates after acute kidney injury. J Am Soc Nephrol 2012; 23:305.
  52. Waikar SS, Curhan GC, Ayanian JZ, Chertow GM. Race and mortality after acute renal failure. J Am Soc Nephrol 2007; 18:2740.
  53. El-Shahawy MA, Agbing LU, Badillo E. Severity of illness scores and the outcome of acute tubular necrosis. Int Urol Nephrol 2000; 32:185.
  54. Liaño F, Gallego A, Pascual J, et al. Prognosis of acute tubular necrosis: an extended prospectively contrasted study. Nephron 1993; 63:21.
  55. Cantarovich F, Verho MT. A simple prognostic index for patients with acute renal failure requiring dialysis. French Multicentric Prospective Study on Furosemide in Acute Renal Failure Requiring Dialysis. Ren Fail 1996; 18:585.
  56. Chertow GM, Lazarus JM, Paganini EP, et al. Predictors of mortality and the provision of dialysis in patients with acute tubular necrosis. The Auriculin Anaritide Acute Renal Failure Study Group. J Am Soc Nephrol 1998; 9:692.
  57. Chertow GM, Soroko SH, Paganini EP, et al. Mortality after acute renal failure: models for prognostic stratification and risk adjustment. Kidney Int 2006; 70:1120.
  58. Joyce VR, Smith MW, Johansen KL, et al. Health-related quality of life as a predictor of mortality among survivors of AKI. Clin J Am Soc Nephrol 2012; 7:1063.
  59. Parker RA, Himmelfarb J, Tolkoff-Rubin N, et al. Prognosis of patients with acute renal failure requiring dialysis: results of a multicenter study. Am J Kidney Dis 1998; 32:432.
  60. Mehta RL, Pascual MT, Gruta CG, et al. Refining predictive models in critically ill patients with acute renal failure. J Am Soc Nephrol 2002; 13:1350.
  61. Tran DD, Oe PL, de Fijter CW, et al. Acute renal failure in patients with acute pancreatitis: prevalence, risk factors, and outcome. Nephrol Dial Transplant 1993; 8:1079.
  62. Weisberg LS, Allgren RL, Genter FC, Kurnik BR. Cause of acute tubular necrosis affects its prognosis. The Auriculin Anaritide Acute Renal Failure Study Group. Arch Intern Med 1997; 157:1833.
  63. Fiaccadori E, Lombardi M, Leonardi S, et al. Prevalence and clinical outcome associated with preexisting malnutrition in acute renal failure: a prospective cohort study. J Am Soc Nephrol 1999; 10:581.
  64. Obialo CI, Okonofua EC, Nzerue MC, et al. Role of hypoalbuminemia and hypocholesterolemia as copredictors of mortality in acute renal failure. Kidney Int 1999; 56:1058.
  65. Schiffl H, Lang SM, König A, et al. Biocompatible membranes in acute renal failure: prospective case-controlled study. Lancet 1994; 344:570.
  66. 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; 9:257.
  67. Alonso A, Lau J, Jaber BL. Biocompatible hemodialysis membranes for acute renal failure. Cochrane Database Syst Rev 2005; :CD005283.
  68. Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality. A cohort analysis. JAMA 1996; 275:1489.
  69. Clermont G, Acker CG, Angus DC, et al. Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 2002; 62:986.
  70. Abosaif NY, Tolba YA, Heap M, et al. The outcome of acute renal failure in the intensive care unit according to RIFLE: model application, sensitivity, and predictability. Am J Kidney Dis 2005; 46:1038.
  71. Bagshaw SM, Mortis G, Doig CJ, et al. One-year mortality in critically ill patients by severity of kidney dysfunction: a population-based assessment. Am J Kidney Dis 2006; 48:402.
  72. 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; 16:3365.
  73. Lassnigg A, Schmidlin D, Mouhieddine M, et al. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004; 15:1597.
  74. Uchino S, Bellomo R, Goldsmith D, et al. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med 2006; 34:1913.
  75. Kuitunen A, Vento A, Suojaranta-Ylinen R, Pettilä V. Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg 2006; 81:542.
  76. Lafrance JP, Miller DR. Acute kidney injury associates with increased long-term mortality. J Am Soc Nephrol 2010; 21:345.
  77. Wu VC, Wu CH, Huang TM, et al. Long-term risk of coronary events after AKI. J Am Soc Nephrol 2014; 25:595.
  78. Hsu CY, Liu KD. Cardiovascular events after AKI: a new dimension. J Am Soc Nephrol 2014; 25:425.
  79. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:8.
  80. Hsu CY, Hsu RK, Yang J, et al. Elevated BP after AKI. J Am Soc Nephrol 2016; 27:914.