Acute tubular necrosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 20 Aug 2025

Last updated: 29 Sep 2020

An intrinsic acute kidney injury caused by ischemic or nephrotoxic injury to renal tubular epithelial cells, which results in tubular dysfunction or detachment from the basement membrane.

A history of hypotension, fluid depletion, or exposure to nephrotoxic agents is usually present.

In otherwise healthy individuals, when the underlying insult is corrected, the patient frequently has a good outcome with complete renal recovery.

There is no specific therapy for acute tubular necrosis apart from supportive care.

Definition

Acute kidney injury (AKI) is a common syndrome with a wide variety of etiologies and pathophysiologic processes, characterized by a rapid decrease in renal excretory function over a period of minutes to days.[1][2] According to the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, AKI severity is classified into three stages depending on the serum creatinine level or the extent of oliguria.[3]

Acute tubular necrosis (ATN) is an intrinsic AKI that follows a condition of severe and persistent hypoperfusion or toxic injury of epithelial cells causing detachment of the basement membrane and tubular dysfunction.[4]

History and exam

Key diagnostic factors

oliguria or anuria
hypotension
tachycardia

Full details

Other diagnostic factors

poor oral intake and anorexia
malaise
thirst
dizziness
orthopnea/dyspnea
edema

Full details

Risk factors

chronic kidney disease (CKD)
chronic hypertension
diabetes mellitus
advanced age
low-perfusion states
sepsis
major surgery
exposure to nephrotoxic agents
exposure to radiocontrast media
exposure to endogenous toxins

Full details

Diagnostic investigations

1st investigations to order

basic metabolic profile (including BUN and creatinine)
BUN-to-creatinine ratio
urine sodium concentration
urine osmolality
fractional excretion of sodium
fractional excretion of BUN
urinalysis for sediment
CBC
coagulation studies
urinary myoglobin

Full details

Investigations to consider

arterial blood gases (ABG)
platelet aggregation studies
ultrasound
ECG
inferior vena cava (IVC) diameter measured by ultrasound
renal biopsy
serum and urinary biomarkers

Full details

Treatment algorithm

ACUTE

acute tubular necrosis (ATN)

Contributors

Authors

Maria Jesus Lloret Cora, MD, MSc

Consulting Staff

Nephrology Department

Fundació Puigvert

Barcelona

Spain

Disclosures

MJLC declares that she has no competing interests.

Leonor Fayos de Arizon, MD

Resident

Nephrology Department

Fundació Puigvert

Barcelona

Spain

Disclosures

LFA declares that she has no competing interests.

Acknowledgements

Dr Maria Jesus Lloret Cora would like to gratefully acknowledge Dr Roser Torra, the previous contributor to this topic.

Disclosures

RT declares that she has no competing interests.

Peer reviewers

Ajay Kumar, MD, FACP

Medical Director

Blood Management

Cleveland Clinic

Cleveland

Disclosures

AK has received a fee for speaking about perioperative blood management from Ortho-Biotech and has also received reimbursement from medscape.com for the education webcast of the same presentation.

Irfan Moinuddin, MD

Assistant Professor

Chicago Medical School

Rosalind Franklin University

Lombard

Disclosures

IM declares that he has no competing interests.

Robert Tompkins, MD

Associate Professor

Department of Family Medicine

University of Texas Health Science Center

Tyler

Disclosures

RT declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

Gill N, Nally JV Jr, Fatica RA. Renal failure secondary to acute tubular necrosis: epidemiology, diagnosis, and management. Chest. 2005 Oct;128(4):2847-63. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Prerenal azotemia
- Intrinsic renal azotemia
More Differentials
Guidelines
- KDIGO clinical practice guideline for acute kidney injury
More Guidelines
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Acute tubular necrosis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

acute tubular necrosis (ATN)

Contributors

Authors

Maria Jesus Lloret Cora, MD, MSc

Disclosures

Leonor Fayos de Arizon, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Ajay Kumar, MD, FACP

Disclosures

Irfan Moinuddin, MD

Disclosures

Robert Tompkins, MD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice