Acute kidney injury: Difference between revisions
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==Background== | ==Background== | ||
*Majority of cases of community-acquired ARF is secondary to volume depletion | *Majority of cases of community-acquired ARF is secondary to volume depletion although consideration of pre-renal, post renal, and renal causes are important. | ||
===RIFLE Classification=== | ===RIFLE Classification=== | ||
*Risk - Serum | *Risk - Serum creatinine increased 1.5x baseline | ||
*Injury - Serum | *Injury - Serum creatinine increased 2.0x baseline | ||
*Failure - Serum | *Failure - Serum creatinine increased 3.0x baseline '''OR''' creatinine >4 and acute increase >0.5 | ||
*Loss - Complete loss of kidney function for >4wk | *Loss - Complete loss of kidney function for >4wk | ||
*[[ESRD]] - Need for renal replacement therapy for >3mo | *[[ESRD]] - Need for renal replacement therapy for >3mo | ||
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*Useful if patient's baseline creatinine is unknown | *Useful if patient's baseline creatinine is unknown | ||
**Stage 1: Kidney damage (e.g. proteinuria) and normal GFR; GFR >90 | **Stage 1: Kidney damage (e.g. proteinuria) and normal GFR; GFR >90 | ||
**Stage 2: Kidney damage (e.g. proteinuria) and mild | **Stage 2: Kidney damage (e.g. proteinuria) and mild decrease in GFR; GFR 60-89 | ||
**Stage 3: Moderate decrease in GFR; GFR >30-59 | **Stage 3: Moderate decrease in GFR; GFR >30-59 | ||
**Stage 4: Severe decrease in GFR; GFR 15-29 | **Stage 4: Severe decrease in GFR; GFR 15-29 | ||
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===Risk Factors=== | ===Risk Factors=== | ||
*[[Contrast-Induced Nephropathy|Radiocontrast agents]] | *[[Contrast-Induced Nephropathy|Radiocontrast agents]] | ||
** | **Especiallyif GFR <60, hypovolemic | ||
*Atherosclerosis | *Atherosclerosis | ||
*Chronic hypertension | *Chronic hypertension | ||
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****Crystal-induced nephropathy | ****Crystal-induced nephropathy | ||
***Myalgias, [[seizures]], recreational intoxication | ***Myalgias, [[seizures]], recreational intoxication | ||
****Pigment-induced ARF ([[ | ****Pigment-induced ARF ([[rhabdomyolysis]]) | ||
***Darkening urine and edema (esp with preceding pharyngitis or cutaneous infection) | ***Darkening urine and edema (esp with preceding pharyngitis or cutaneous infection) | ||
****Acute glomerulonephritis | ****Acute glomerulonephritis | ||
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*Hypovolemia | *Hypovolemia | ||
**GI: decreased intake, vomiting and diarrhea | **GI: decreased intake, vomiting and diarrhea | ||
**Hemorrhage | |||
**Pharmacologic: diuretics | **Pharmacologic: diuretics | ||
**Third spacing | **Third spacing | ||
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***Postobstructive diuresis | ***Postobstructive diuresis | ||
*[[Hypotension]] | *[[Hypotension]] | ||
** | **[[Sepsis]] | ||
**Decreased cardiac output | **Decreased cardiac output | ||
**[[Hepatorenal Syndrome]] | |||
***Ischemia/infarction | ***Ischemia/infarction | ||
***Valvulopathy | ***[[Valvular Disease|Valvulopathy]] | ||
**Pharmacologic | **Pharmacologic | ||
*** | ***[[Beta-blockers]] | ||
*** | ***[[Calcium-channel blockers]] | ||
***Antihypertensive medications | ***Antihypertensive medications | ||
**High | **[[High output heart failure]] | ||
***[[Thyrotoxicosis]] | ***[[Thyrotoxicosis]] | ||
***AV fistula | ***AV fistula | ||
*Renal artery and small-vessel disease | *Renal artery and small-vessel disease | ||
**Embolism: thrombotic, septic, cholesterol | **Embolism: thrombotic, septic, cholesterol | ||
**Thrombosis: atherosclerosis, vasculitis, sickle cell disease | **Thrombosis: atherosclerosis, [[vasculitis]], [[sickle cell disease]] | ||
**Dissection | **Dissection | ||
**Pharmacologic | **Pharmacologic | ||
***NSAIDs | ***[[NSAIDs]] | ||
***ACEI/ARB | ***[[ACEI]]/[[ARB]] | ||
****Observed shortly after initiation of therapy | ****Observed shortly after initiation of therapy | ||
**Microvascular thrombosis | **Microvascular thrombosis | ||
***Preeclampsia | ***[[Preeclampsia]] | ||
***HUS | ***[[Hemolytic Uremic Syndrome (HUS)]] | ||
***DIC | ***[[Thrombotic Thrombocytopenic Purpura (TTP)]] | ||
*** | ***[[Disseminated Intravascular Coagulation (DIC)]] | ||
*** | ***[[Vasculitis]] | ||
**Hypercalcemia | ***[[Sickle Cell Disease]] | ||
**[[Hypercalcemia]] | |||
===Intrinsic=== | ===Intrinsic=== | ||
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***Caused by more advanced disease due to the prerenal causes | ***Caused by more advanced disease due to the prerenal causes | ||
*Nephrotoxins | *Nephrotoxins | ||
**Aminoglycosides, [[Contrast-Induced Nephropathy|radiocontrast]], amphotericin, heme pigments ([[ | **[[Aminoglycosides]], [[Contrast-Induced Nephropathy|radiocontrast]], [[amphotericin B]], heme pigments ([[rhabdomyolysis]], hemolysis) | ||
**Obstruction | **Obstruction | ||
***Uric acid, calcium oxalate, myeloma, amyloid | ***Uric acid, calcium oxalate from [[Ethylene Glycol Toxicity]], [[Multiple myeloma]] (immunoglobin light chains), amyloid | ||
***Pharmacologic: sulfonamide, triamterene, acyclovir, indinavir | ***Pharmacologic: sulfonamide, triamterene, [[acyclovir]], indinavir | ||
*Interstitial diseases | *Interstitial diseases | ||
**Acute interstitial nephritis: typically a drug reaction ([[NSAIDs]], antibiotics, [[phenytoin]]) | **Acute interstitial nephritis: typically a drug reaction ([[NSAIDs]], [[Penicillins]] and antibiotics, [[Diuretics]], [[phenytoin]]) | ||
**Infection: bilateral pyelonephritis, | **Infection: bilateral pyelonephritis, [[Legionella]], [[Hantavirus]] | ||
**Infiltrative disease: sarcoidosis, lymphoma | **Infiltrative disease: sarcoidosis, lymphoma | ||
**Autoimmune diseases: [[SLE]] | **Autoimmune diseases: [[SLE]] | ||
*Glomerular diseases | *Glomerular diseases | ||
**Rapidly progressive glomerulonephritis | **Rapidly progressive glomerulonephritis | ||
***Goodpasture, granulomatosis with polyangiitis (Wegener's) [[HSP]], [[SLE]], membranoproliferative GN | ***Goodpasture, [[granulomatosis with polyangiitis]] (Wegener's) [[HSP]], [[SLE]], membranoproliferative GN | ||
**Postinfectious glomerulonephritis | **Postinfectious [[glomerulonephritis]] | ||
*Small-vessel diseases | *Small-vessel diseases | ||
**Microvascular thrombosis | **Microvascular thrombosis | ||
***Preeclampsia, [[HUS]], [[DIC]], [[ | ***[[Preeclampsia]], [[HUS]], [[DIC]], [[Thrombotic Thrombocytopenic Purpura (TTP)|TTP]], vasculitis (PAN, SCD, atheroembolism) | ||
**Malignant hypertension | **[[Malignant hypertension]] | ||
**Scleroderma | **[[Scleroderma]] | ||
**Renal vein thrombosis | **Renal vein thrombosis | ||
*[[Abdominal compartment syndrome]] | |||
*[[Hepatorenal syndrome]] | |||
*[[Cardiorenal syndrome]] | |||
===Postrenal=== | ===Postrenal=== | ||
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***Blood clot | ***Blood clot | ||
**Urethra and bladder outlet | **Urethra and bladder outlet | ||
***Phimosis or urethral stricture (male preponderance) | ***[[Phimosis]] or urethral stricture (male preponderance) | ||
***Neurogenic bladder | ***Neurogenic bladder | ||
**** | ****[[Diabetes mellitus]], spinal cord disease, multiple sclerosis, Parkinson's | ||
****Pharmacologic: anticholinergics, a-adrenergic antagonists, | ****Pharmacologic: anticholinergics, a-adrenergic antagonists, opioids | ||
*Adults | *Adults | ||
**Urethra and bladder outlet | **Urethra and bladder outlet | ||
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****SCD, DM, pyelonephritis | ****SCD, DM, pyelonephritis | ||
***Tumor: Ureter, uterus, prostate, bladder, colon, rectum; retroperitoneal lymphoma | ***Tumor: Ureter, uterus, prostate, bladder, colon, rectum; retroperitoneal lymphoma | ||
***Retroperitoneal fibrosis: idiopathic, tuberculosis, sarcoidosis, propranolol | ***Retroperitoneal fibrosis: idiopathic, [[tuberculosis]], [[sarcoidosis]], [[propranolol]] | ||
***Stricture: TB, radiation, schistosomiasis, NSAIDs | ***Stricture: [[TB]], [[Radiation exposure|radiation]], [[schistosomiasis]], [[NSAIDs]] | ||
***Miscellaneous | ***Miscellaneous | ||
****Aortic aneurysm | ****[[Abdominal aortic aneurysm|Aortic aneurysm]] | ||
****Pregnant uterus | ****Pregnant uterus | ||
****IBD | ****IBD | ||
****Trauma | ****Trauma | ||
== | ==Evaluation== | ||
*Prerenal | *Prerenal | ||
**BUN/ | **BUN/creatinine ratio > 20 | ||
**FeNa <1% ((urine sodium/plasma sodium) / (urine creatinine / serum creatinine)) | **FeNa <1% ((urine sodium/plasma sodium) / (urine creatinine / serum creatinine)) | ||
***< 2% for neonates | ***< 2% for neonates | ||
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*Urine | *Urine | ||
*Prostate exam | *Prostate exam | ||
* | *[[Urinalysis]], urine sodium, urine creatinine, urine urea | ||
*ECG (hyperkalemia) | *[[ECG]] (hyperkalemia) | ||
*Chronic renal failure features | |||
**Anemia, thrombocytopenia | |||
**Iron studies with low Fe, low TIBC, low iron saturation, normal ferritin | |||
**Secondary rise in PTH, high phos, low calcium | |||
===Imaging=== | ===Imaging=== | ||
*CXR | *[[CXR]] | ||
*Evidence of volume overload, | *Evidence of volume overload, pneumonia | ||
*US | *US | ||
**Test of choice in setting of acute renal failure | **Test of choice in setting of acute renal failure | ||
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**Useful to determine cause of post renal failure (identification of abdominal masses etc.) | **Useful to determine cause of post renal failure (identification of abdominal masses etc.) | ||
**Should generally not be used with IV contrast due to potential risk for [[Contrast-Induced Nephropathy|CIN]] | **Should generally not be used with IV contrast due to potential risk for [[Contrast-Induced Nephropathy|CIN]] | ||
**Indicated if hydronephrois found on | **Indicated if hydronephrois found on [[ultrasound]] in order to define the location of obstruction | ||
==Management== | ==Management== | ||
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**Also: | **Also: | ||
***Na <115 or >165 mEq/L | ***Na <115 or >165 mEq/L | ||
*** | ***creatinine > 10 | ||
***BUN >100 | ***BUN >100 | ||
*See [[Dialysis catheter placement]] | |||
*See [[Austere peritoneal dialysis]] | |||
===Phlebotomy to Treat [[Pulmonary Edema]]=== | |||
*Possible last ditch effort to tide patient over to formal dialysis if hours away | |||
*If traditional pulmonary edema treatments are not working for [[SCAPE]] patient, one may attempt to remove 200-300 cc of blood as a bridge to dialysis<ref>Eiser AR et al. Phlebotomy for pulmonary edema in dialysis patients. Clin Nephrol. 1997 Jan;47(1):47-9.</ref> | |||
*If Hb too low, may consider temporary venous tourniquets on each leg proximally q30 min to reduce preload volume to the heart, alternating legs | |||
==Disposition== | ==Disposition== | ||
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==See Also== | ==See Also== | ||
*[[Hyperkalemia]] | *[[Hyperkalemia]] | ||
*[[ | *[[Renal ultrasound]] | ||
*[[Hypertensive emergency]] | *[[Hypertensive emergency]] | ||
==External Links== | ==External Links== | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:Renal]] | [[Category:Renal]] |
Revision as of 16:08, 21 April 2019
Background
- Majority of cases of community-acquired ARF is secondary to volume depletion although consideration of pre-renal, post renal, and renal causes are important.
RIFLE Classification
- Risk - Serum creatinine increased 1.5x baseline
- Injury - Serum creatinine increased 2.0x baseline
- Failure - Serum creatinine increased 3.0x baseline OR creatinine >4 and acute increase >0.5
- Loss - Complete loss of kidney function for >4wk
- ESRD - Need for renal replacement therapy for >3mo
Chronic Kidney Disease Stages
- Useful if patient's baseline creatinine is unknown
- Stage 1: Kidney damage (e.g. proteinuria) and normal GFR; GFR >90
- Stage 2: Kidney damage (e.g. proteinuria) and mild decrease in GFR; GFR 60-89
- Stage 3: Moderate decrease in GFR; GFR >30-59
- Stage 4: Severe decrease in GFR; GFR 15-29
- Stage 5: Kidney failure (dialysis or kidney transplant needed); GFR <15
Risk Factors
- Radiocontrast agents
- Especiallyif GFR <60, hypovolemic
- Atherosclerosis
- Chronic hypertension
- Chronic kidney disease
- NSAIDs
- ACEI/ARB
- Sepsis
- Hypercalcemia
- Hepatorenal syndrome
Clinical Features
- Acute renal failure itself has few symptoms until severe uremia develops:
- Nausea/vomiting, drowsiness, fatigue, confusion, coma
- Patients more likely to present with symptoms related to underlying cause:
- Prerenal
- Thirst, orthostatic light-headedness, decreasing urine output
- Intrinsic
- Flank pain, hematuria
- Nephrolithiasis
- Papillary necrosis
- Crystal-induced nephropathy
- Myalgias, seizures, recreational intoxication
- Pigment-induced ARF (rhabdomyolysis)
- Darkening urine and edema (esp with preceding pharyngitis or cutaneous infection)
- Acute glomerulonephritis
- Fever, arthralgia, rash
- Acute interstitial nephritis
- Cough, dyspnea, hemoptysis
- Goodpasture, granulomatosis with polyangiitis (Wegener's)
- Flank pain, hematuria
- Postrenal
- Alternating oliguria and polyuria is pathognomonic of obstruction
- Anuria
- Prerenal
Etiologies
Prerenal
- Hypovolemia
- GI: decreased intake, vomiting and diarrhea
- Hemorrhage
- Pharmacologic: diuretics
- Third spacing
- Skin losses: fever, burns
- Miscellaneous
- Hypoaldosteronism
- Salt-losing nephropathy
- Postobstructive diuresis
- Hypotension
- Sepsis
- Decreased cardiac output
- Hepatorenal Syndrome
- Ischemia/infarction
- Valvulopathy
- Pharmacologic
- Beta-blockers
- Calcium-channel blockers
- Antihypertensive medications
- High output heart failure
- Thyrotoxicosis
- AV fistula
- Renal artery and small-vessel disease
- Embolism: thrombotic, septic, cholesterol
- Thrombosis: atherosclerosis, vasculitis, sickle cell disease
- Dissection
- Pharmacologic
- Microvascular thrombosis
- Hypercalcemia
Intrinsic
- Tubular diseases
- Ischemic acute tubular necrosis
- Caused by more advanced disease due to the prerenal causes
- Ischemic acute tubular necrosis
- Nephrotoxins
- Aminoglycosides, radiocontrast, amphotericin B, heme pigments (rhabdomyolysis, hemolysis)
- Obstruction
- Uric acid, calcium oxalate from Ethylene Glycol Toxicity, Multiple myeloma (immunoglobin light chains), amyloid
- Pharmacologic: sulfonamide, triamterene, acyclovir, indinavir
- Interstitial diseases
- Acute interstitial nephritis: typically a drug reaction (NSAIDs, Penicillins and antibiotics, Diuretics, phenytoin)
- Infection: bilateral pyelonephritis, Legionella, Hantavirus
- Infiltrative disease: sarcoidosis, lymphoma
- Autoimmune diseases: SLE
- Glomerular diseases
- Rapidly progressive glomerulonephritis
- Goodpasture, granulomatosis with polyangiitis (Wegener's) HSP, SLE, membranoproliferative GN
- Postinfectious glomerulonephritis
- Rapidly progressive glomerulonephritis
- Small-vessel diseases
- Microvascular thrombosis
- Preeclampsia, HUS, DIC, TTP, vasculitis (PAN, SCD, atheroembolism)
- Malignant hypertension
- Scleroderma
- Renal vein thrombosis
- Microvascular thrombosis
- Abdominal compartment syndrome
- Hepatorenal syndrome
- Cardiorenal syndrome
Postrenal
- Infants and children
- Urethra and bladder outlet
- Anatomic malformations
- Urethral atresia
- Meatal stenosis
- Anterior and posterior urethral valves
- Anatomic malformations
- Ureter
- Anatomic malformations
- Vesicoureteral reflux (female preponderance)
- Ureterovesical junction obstruction
- Ureterocele
- Retroperitoneal tumor
- Anatomic malformations
- Urethra and bladder outlet
- All ages
- Various locations in GU tract
- Trauma
- Blood clot
- Urethra and bladder outlet
- Phimosis or urethral stricture (male preponderance)
- Neurogenic bladder
- Diabetes mellitus, spinal cord disease, multiple sclerosis, Parkinson's
- Pharmacologic: anticholinergics, a-adrenergic antagonists, opioids
- Various locations in GU tract
- Adults
- Urethra and bladder outlet
- BPH
- Cancer of prostate, bladder, cervix, or colon
- Obstructed catheters
- Ureter
- Calculi, uric acid crystals
- Papillary necrosis
- SCD, DM, pyelonephritis
- Tumor: Ureter, uterus, prostate, bladder, colon, rectum; retroperitoneal lymphoma
- Retroperitoneal fibrosis: idiopathic, tuberculosis, sarcoidosis, propranolol
- Stricture: TB, radiation, schistosomiasis, NSAIDs
- Miscellaneous
- Aortic aneurysm
- Pregnant uterus
- IBD
- Trauma
- Urethra and bladder outlet
Evaluation
- Prerenal
- BUN/creatinine ratio > 20
- FeNa <1% ((urine sodium/plasma sodium) / (urine creatinine / serum creatinine))
- < 2% for neonates
- Urine osm >500
- Urine sodium < 20 mEq/L
- Specific gravity > 1.020
- Fractional excretion of urea < 35%
- Microscopic analysis
- Hyaline casts
- Instrinsic
- FeNa >1%
- > 2.5% for neonates
- Urine Osm <350
- Urine sodium > 40 mEq/L
- Specific gravity < 1.020
- Fractional excretion of urea > 50%
- Microscopic analysis
- Acute glomerulonephritis: RBCs, casts
- Acute tubular necrosis: protein, tubular epithelial cells
- FeNa >1%
- Postrenal
- FeNa >1%
- Urine Osm <350
Work-up
- Urine
- Prostate exam
- Urinalysis, urine sodium, urine creatinine, urine urea
- ECG (hyperkalemia)
- Chronic renal failure features
- Anemia, thrombocytopenia
- Iron studies with low Fe, low TIBC, low iron saturation, normal ferritin
- Secondary rise in PTH, high phos, low calcium
Imaging
- CXR
- Evidence of volume overload, pneumonia
- US
- Test of choice in setting of acute renal failure
- Bladder size (post-void)
- Hydronephrosis
- IVC collapsibility (prerenal)
- CT
- Useful to determine cause of post renal failure (identification of abdominal masses etc.)
- Should generally not be used with IV contrast due to potential risk for CIN
- Indicated if hydronephrois found on ultrasound in order to define the location of obstruction
Management
Treat underlying cause
- Prerenal: IVF
- Intrinsic: Depends on cause
- Obstruction:
- Note: Postobstructive diuresis can result in significant volume loss and death
- Typically occurs when obstruction has been prolonged / has resulted in renal failure
- Admit patients with persistent diuresis of >250 mL/h for >2hr
- Foley Catheter, consider Coude Catheter
- Suprapubic (if Coude fails)
- Note: Postobstructive diuresis can result in significant volume loss and death
Dialysis
- Indicated for:
- A: Acidosis (severe)
- E: Electrolyte abnormality (e.g. uncontrolled hyperkalemia)
- I: Ingestions (lithium, ASA, methanol, ethylene glycol, theophylline)
- O: Overload (volume) with persistent hypoxia
- U: Uremic pericarditis/encephalopathy/bleeding dyscrasia
- Also:
- Na <115 or >165 mEq/L
- creatinine > 10
- BUN >100
- See Dialysis catheter placement
- See Austere peritoneal dialysis
Phlebotomy to Treat Pulmonary Edema
- Possible last ditch effort to tide patient over to formal dialysis if hours away
- If traditional pulmonary edema treatments are not working for SCAPE patient, one may attempt to remove 200-300 cc of blood as a bridge to dialysis[1]
- If Hb too low, may consider temporary venous tourniquets on each leg proximally q30 min to reduce preload volume to the heart, alternating legs
Disposition
- Admit
See Also
External Links
References
- ↑ Eiser AR et al. Phlebotomy for pulmonary edema in dialysis patients. Clin Nephrol. 1997 Jan;47(1):47-9.