Esson Matthew L, Schrier Robert W
University of Colorado Health Sciences Center, Box B178, 4200 East 9th Avenue, Denver, CO 80262, USA.
Ann Intern Med. 2002 Nov 5;137(9):744-52. doi: 10.7326/0003-4819-137-9-200211050-00010.
Acute tubular necrosis (ATN) is common in hospitalized patients, particularly in the intensive care unit. Over the past four decades, the mortality rate from ATN has remained at 50% to 80%.
To review recent studies of diagnosis and treatment strategies for ATN.
MEDLINE search for all clinical studies of therapies for ATN, supplemented by a review of the references of the identified articles.
Prospective studies and major retrospective studies evaluating therapies for ATN.
Data on the study sample, interventions performed, results, side effects, and duration of follow-up.
Early diagnosis of ATN by exclusion of prerenal and postrenal causes of acute renal failure, examination of urinary sediment, and analysis of urine measures (for example, fractional excretion of sodium in the absence of diuretics) can allow the early involvement of nephrologists and improve survival. Enteral rather than parenteral hyperalimentation in severely malnourished patients may improve survival. Sepsis causes 30% to 70% of deaths in patients with ATN; therefore, avoidance of intravenous lines, bladder catheters, and respirators is recommended. Because septic patients are vasodilated, large volumes of administered fluid accumulate in the lung interstitium of these patients. This condition necessitates ventilatory support, which when prolonged leads to acute respiratory distress syndrome, multiorgan failure, and increased mortality. More aggressive dialysis (for example, given daily) with biocompatible membranes may improve survival in some patients with acute renal failure.
New information about the importance of early diagnosis and supportive care for patients with ATN has emerged. However, randomized trials of these interventions are needed to test their effect on the morbidity and mortality of ATN.
急性肾小管坏死（ATN）在住院患者中很常见，尤其是在重症监护病房。在过去的四十年里，ATN的死亡率一直保持在50%至80%。
回顾近期关于ATN诊断和治疗策略的研究。
通过MEDLINE搜索所有关于ATN治疗的临床研究，并补充对已识别文章参考文献的综述。
评估ATN治疗方法的前瞻性研究和主要回顾性研究。
关于研究样本、实施的干预措施、结果、副作用和随访时间的数据。
通过排除急性肾衰竭的肾前性和肾后性病因、检查尿沉渣以及分析尿液指标（例如，在未使用利尿剂的情况下钠的分数排泄）对ATN进行早期诊断，可使肾病学家早期介入并提高生存率。对于严重营养不良的患者，肠内营养而非肠外营养可能会提高生存率。脓毒症导致ATN患者30%至70%的死亡；因此，建议避免使用静脉输液管、膀胱导管和呼吸机。由于脓毒症患者血管扩张，大量输入的液体在这些患者的肺间质中积聚。这种情况需要通气支持，而通气支持时间过长会导致急性呼吸窘迫综合征、多器官功能衰竭和死亡率增加。使用生物相容性膜进行更积极的透析（例如每日透析）可能会提高一些急性肾衰竭患者的生存率。
已经出现了关于ATN患者早期诊断和支持性护理重要性的新信息。然而，需要对这些干预措施进行随机试验，以测试它们对ATN发病率和死亡率的影响。
