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Acute tubular necrosis

Acute tubular necrosis or (ATN) is a medical condition involving the death of tubular cells that form the tubule that transports urine to the ureters while reabsorbing 99% of the water (and highly concentrating the salts and metabolic byproducts). Tubular cells continually replace themselves and if the cause of ATN is removed then recovery is likely. ATN presents with acute renal failure to the point that the two concepts are used interchangeably. more...

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It may be classified as either toxic or ischemic. Toxic ATN occurs when the tubular cells are exposed to a toxic substance (nephrotoxic ATN). Ischemic ATN occurs when the tubular cells do not get enough oxygen, a condition they are highly senistive to due to their very high metabolism.

Toxic ATN

Toxic ATN can be caused by free hemoglobin or myoglobin, by medication such as antibiotics and cytostatic drugs, or by intoxication (ethylene glycol, "anti-freeze").

Histopathology: Toxic ATN is characterized by proximal tubular epithelium necrosis (no nuclei, intense eosinophilic homogeneous cytoplasm, but preserved shape) due to a toxic substance (poisons, organic solvents, drugs, heavy metals). Necrotic cells fall into the tubule lumen, obliterating it, and determining acute renal failure. Basement membrane is intact, so the tubular epithelium regeneration is possible. Glomeruli are not affected.

Ischemic ATN

Ischemic ATN can be caused when the kidneys are not sufficiently perfused for a long amount of time (i.e. renal artery stenosis) or during shock. Hypoperfusion can also be caused by embolism of the renal arteries.

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Third-trimester nausea may flag acute fatty liver
From OB/GYN News, 12/1/04 by Mary Ann Moon

WASHINGTON -- Acute fatty liver of pregnancy must be ruled out in any woman who presents in the third trimester with nausea, vomiting, epigastric pain, or malaise, Michael F. Fesenmeier, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The disorder is rare, estimated to affect only 1 in 7,000-16,000 pregnancies. But it is deadly. Maternal and neonatal mortality rates of 75% have been reported in some studies.

"Physicians must be diligent in diagnosing acute fatty liver of pregnancy, and be prepared for its high morbidity and mortality," said Dr. Fesenmeier of the University of Cincinnati Medical Center.

He and his associates assessed the clinical presentations and outcomes of all 16 women treated for acute fatty liver of pregnancy (AFLP) at three tertiary-care centers in Ohio and Kentucky between 1993 and 2003. The average gestational age at diagnosis was 35.2 weeks (range, 30.0-37.2 weeks). There were 13 singleton and 3 twin pregnancies.

Nausea and vomiting were the most common presenting symptoms, affecting 12 patients (75%). The average duration of nausea and vomiting before the women presented for emergency care was 3-4 days, but some women went undiagnosed for much longer, including one who was undiagnosed for 3 weeks. That patient died within a month of delivery.

Other symptoms included epigastric pain in seven patients (43%), jaundice in six (38%), malaise in five (31%), and loss of consciousness in one (6%), he said in a poster presentation at the meeting.

There were two maternal deaths from multiorgan failure (12.5% maternal mortality) and three fetal deaths (15% infant mortality). Ten women (62%) developed acute tubular necrosis, seven (43%) developed pulmonary edema, seven (43%) developed disseminated intravascular coagulation, and six (38%) developed pancreatitis.

The average length of stay was 15 days, with a range of 5-58 days. Three women were referred for liver transplantation at hospital discharge.

Clinical and laboratory findings of AFLP often overlap with those of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), and pancreatitis. "We recommend that patients who present with nausea, vomiting, epigastric pain, or malaise in the third trimester should receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of AFLP," Dr. Fesenmeier said.

BY MARY ANN MOON

Contributing Writer

COPYRIGHT 2004 International Medical News Group
COPYRIGHT 2004 Gale Group

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