We use the following criteria 1. Meets criteria for AKI 2. Creatinine levels expected to take more than 72 hours to return towards baseline following resuscitation with IV fluid/hydration 3. Some sources will also look at a cloudy, muddy urine and cast cells
We rarely do the lab studies that are confirmatory - Urine sodium concentration and Franctional excretion of sodium (FENa).
I don't think it is a requisite to have the muddy brown casts, but it helps to confirm ATN. We had a denial once because there wasn't a renal ultrasound done, and one because it wasn't confirmed with urine sodium concentration. (!)
I had a similar issue in a denial and I reviewed the case with one of our nephrologist for her opinion.
The nephrologist commented that the UA may have been taken before the kidneys were able to flush out the casts. Lack of casts are not a reason to deny ATN.
If you wish, use the 'search' feature and find even more discussions: such as this from Dr. Kennedy, on this topic.
Acute tubular necrosis (ATN): An acute kidney injury due to an endogenous (tumor lysis syndrome, rhabdomyolysis, severe sepsis, hemolysis) or exogenous toxin (ethylene glycol, aminoglycoside, radiology contrast, certain chemotherapy), is known to cause ATN, or renal ischemia. This is more common in patients with hemorrhage shock or with hypotension in the setting of using nonsteroidal anti-inflammatory drugs or angiotensin converting enzyme inhibitors.
Other precipitating causes, such as renal obstruction, profound hypovolemia, and other renal diseases (acute interstitial nephritis) are excluded. Creatinine elevation typically lasts over three days. While urine studies (urine microscopy, fractional excretion of sodium test) are strongly recommended, they are not required to make a presumptive diagnosis, especially if documented at the time of discharge in reasonable circumstances. References include Brenner and Rector’s The Kidney, 2-Volume Set and National Kidney Foundation Primer on Kidney Diseases (Sixth Edition).
I was interested in this one. We have had several denials lately based on the single fact that we did not have muddy brown casts present in urine.
Not all types of ATN will
present with casts. Many will, some won't. The finding is
used as confirmatory evidence but can't be fully used as an exclusionary
criterion.
From the post above: References include Brenner and Rector’s The Kidney, 2-Volume Set and National Kidney Foundation Primer on Kidney Diseases (Sixth Edition).
Does anyone know where I can find these without purchasing the book? I am looking to use the reference citation as part of an appeal.
Question posed by staff today and I'm curious for group discussion:
1) Attending is documenting AKI; consultant documents AKI with likely ATN.
2) Attending is documenting AKI; consultant documents AKI with ATN.
In the first example, the question/comments are - since the consultant diagnosis meets criteria for an uncertain diagnosis, then should the query be sent to attending to concur (assuming it is not PDX, but ATN would result in only MCC on the chart)?
In second example, would both AKI and ATN be coded without the attending needing to concur with the diagnosis of ATN?
As you can imagine, there are differing opinions, and I am interested on how you handle these scenarios in your organization.
Comments
1. Meets criteria for AKI
2. Creatinine levels expected to take more than 72 hours to return towards baseline following resuscitation with IV fluid/hydration
3. Some sources will also look at a cloudy, muddy urine and cast cells
We rarely do the lab studies that are confirmatory - Urine sodium concentration and Franctional excretion of sodium (FENa).
I had a similar issue in a denial and I reviewed the case with one of our nephrologist for her opinion.
The nephrologist commented that the UA may have been taken before the kidneys were able to flush out the casts. Lack of casts are not a reason to deny ATN.
I did overturn the denial.
If you wish, use the 'search' feature and find even more discussions: such as this from Dr. Kennedy, on this topic.
Acute tubular necrosis (ATN): An acute kidney injury due to an endogenous (tumor lysis syndrome, rhabdomyolysis, severe sepsis, hemolysis) or exogenous toxin (ethylene glycol, aminoglycoside, radiology contrast, certain chemotherapy), is known to cause ATN, or renal ischemia. This is more common in patients with hemorrhage shock or with hypotension in the setting of using nonsteroidal anti-inflammatory drugs or angiotensin converting enzyme inhibitors.
Other precipitating causes, such as renal obstruction, profound hypovolemia, and other renal diseases (acute interstitial nephritis) are excluded. Creatinine elevation typically lasts over three days. While urine studies (urine microscopy, fractional excretion of sodium test) are strongly recommended, they are not required to make a presumptive diagnosis, especially if documented at the time of discharge in reasonable circumstances. References include Brenner and Rector’s The Kidney, 2-Volume Set and National Kidney Foundation Primer on Kidney Diseases (Sixth Edition).
From the post above: References include Brenner and Rector’s The Kidney, 2-Volume Set and National Kidney Foundation Primer on Kidney Diseases (Sixth Edition).
Does anyone know where I can find these without purchasing the book? I am looking to use the reference citation as part of an appeal.
Thank you!
Quote
Question posed by staff today and I'm curious for group discussion:
1) Attending is documenting AKI; consultant documents AKI with likely ATN.
2) Attending is documenting AKI; consultant documents AKI with ATN.
In the first example, the question/comments are - since the consultant diagnosis meets criteria for an uncertain diagnosis, then should the query be sent to attending to concur (assuming it is not PDX, but ATN would result in only MCC on the chart)?
In second example, would both AKI and ATN be coded without the attending needing to concur with the diagnosis of ATN?
As you can imagine, there are differing opinions, and I am interested on how you handle these scenarios in your organization.