Patient handout

Acute Kidney Injury — Intrinsic ATN Mechanism

PRODUCTION

1. Your condition

This handout is for acute kidney injury — intrinsic atn mechanism. Your care team identified this based on: muddy-brown granular casts + renal tubular epithelial cells on urine micro (kdigo 2012 aki).

Other reasons your team may use this plan: fena >2% + bun:cr <15 + urine osm <350 (kdigo 2012 aki; carvounis 2002); sepsis / septic shock + sustained hypoperfusion + aki (ssc 2026; kdigo 2012 aki); aminoglycoside, vancomycin trough/auc, contrast, cisplatin, methotrexate exposure (kdigo 2012 aki).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
discontinue_nephrotoxin	—	—	—	KDIGO 2012 AKI — first-line action; review every drug for renal dosing + alternative selection
vancomycin	AUC-targeted 400-600 mg·h/L; load 25 mg/kg; trough goal removed	IV	per AUC	Rybak ASHP/IDSA/PIDS 2020 PMID 32658968 — AUC-targeted dosing reduces nephrotoxicity vs trough-only (KDIGO 2012 AKI)
leucovorin	15 mg/m² q6h until methotrexate <0.1 µmol/L	IV	q6h	Methotrexate ATN rescue + urinary alkalinization to urine pH >7.5; route oncology (KDIGO 2012 AKI)

Plan: Intrinsic ATN supportive + sub-phenotype-specific (avoid over-resuscitation; sub-phenotype-targeted antidote/replacement) (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)

3. When to call your provider

Contact your care team if any of the following happen:

Sustained eGFR <60 at 3 months → neph.ckd.core.v1 (KDIGO 2024 CKD)
Recurrent AKI → nephrology comprehensive evaluation (KDIGO 2012 AKI)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

Ischemic ATN — shock with sustained hypoperfusion; sepsis-AKI is most common ICU phenotype (KDIGO 2012 AKI; SSC 2026)
Rhabdomyolysis-ATN — CK >5000 U/L + myoglobinuria + hyperK; crush/exertion/seizure/statin/drug (KDIGO 2012 AKI)
Tumor lysis syndrome — hyperK + hyperPhos + hyperuricemia + hypoCa post-chemo or hematologic malignancy (Cairo-Bishop)(life-threatening)
Cisplatin or methotrexate ATN — chemo-specific tubular toxicity; cisplatin amifostine + hydration, methotrexate leucovorin rescue + urinary alkalinization (KDIGO 2012 AKI)
Myeloma cast nephropathy — proteinuria + free light chains + AKI in plasma cell dyscrasia (KDIGO 2012 AKI)
Pigment nephropathy from hemoglobinuria — intravascular hemolysis (TMA, severe G6PD crisis, transfusion reaction, snake venom) (KDIGO 2012 AKI)
Renal calciphylaxis (calcific uremic arteriolopathy) — rare; CKD/ESRD + calcium-phosphate dysregulation + warfarin association (KDIGO 2024 CKD)
KDIGO Stage 3 intrinsic ATN — Cr ≥3× baseline OR Cr ≥4.0 OR UOP <0.3 mL/kg/h × 24h OR anuria ≥12h OR RRT initiated (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)

5. Follow-up

Recheck Cr 1 wk post-discharge; nephrology outpatient; 3-month + 12-month eGFR for CKD progression; permanent NSAID/aminoglycoside avoidance counselling; contrast-avoidance card if CI-AKI history (KDIGO 2012 AKI; KDIGO 2024 CKD)

6. Sources

Guideline: KDIGO 2012 AKI Guideline (binding) + KDIGO 2026 AKI/AKD draft (public review) + STARRT-AKI NEJM 2020 + AKIKI NEJM 2016 + IDEAL-ICU NEJM 2018 + PRESERVE NEJM 2018 + SMART/SALT-ED NEJM 2018 + Rybak 2020 vanco AUC + Coiffier 2008 TLS/rasburicase + Howard 2011 tumor lysis + Bosch 2009 rhabdomyolysis + SSC 2026