Acute tubular necrosis
ICD-10 N17.0 · ICD-11 GB52

Acute Tubular Necrosis in Critically Ill Patients: What to Do When General Supportive Management Has Not Maintained Target Plasma Glucose

Clinical Scenario

This protocol applies to critically ill patients with acute tubular necrosis who have undergone general supportive management — including intravascular volume expansion, vasopressor support, nutritional support, and insulin therapy — but have not achieved the required metabolic control. Escalation to a next-line intervention is indicated.

Previous Treatment — Failure Condition

General supportive management — the initial treatment line — aimed to maintain plasma glucose at 110–149 mg/dl in critically ill patients. When this target is not achieved, the protocol described here represents the structured next step.

Next-Line Treatment Approach

The next-line approach centres on renal replacement therapy (RRT), with the specific modality chosen according to the patient's haemodynamic status and neurological condition. Anticoagulation during RRT is determined by individual patient risk factors. The full selection criteria, sequencing, and decision rules are in the complete protocol.

Instant Access to Structured Evidence-Based Regimens

References

  • Initiate RRT emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist.
  • We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients.
  • We suggest using CRRT, rather than intermittent RRT, for AKI patients with acute brain injury or other causes of increased intracranial pressure or generalized brain edema.
  • We recommend using anticoagulation during RRT in AKI if a patient does not have an increased bleeding risk or impaired coagulation and is not already receiving systemic anticoagulation.
  • For anticoagulation in intermittent RRT, we recommend using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants.
  • For anticoagulation in CRRT, we suggest using regional citrate anticoagulation rather than heparin in patients who do not have contraindications for citrate.
  • For anticoagulation during CRRT in patients who have contraindications for citrate, we suggest using either unfractionated or low-molecular-weight heparin, rather than other anticoagulants.
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