Acute kidney injury - Revision history

Aidan at 02:04, 10 October 2022

2022-10-10T02:04:54Z

← Older revision		Revision as of 02:04, 10 October 2022
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	*An inability of the kidneys to maintain body homeostasis, usually defined by an acute increase in creatinine		*An inability of the kidneys to maintain body homeostasis, usually defined by an acute increase in creatinine
			*Novel biomarkers are under development to complement creatinine, and are generally classified into:
			**Stress markers
			**Damage markers
			**Functional markers, including cystatin C

	==KDIGO Staging==		=== KDIGO Staging ===
	{\| class="wikitable"		{\| class="wikitable"
	!Stage		!Stage

Aidan at 01:40, 10 October 2022

2022-10-10T01:40:17Z

← Older revision		Revision as of 01:40, 10 October 2022
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	==~~Definition~~==		==Background==

	*An inability of the kidneys to maintain body homeostasis, usually defined by an acute increase in creatinine		*An inability of the kidneys to maintain body homeostasis, usually defined by an acute increase in creatinine

	==~~AKIN~~ ~~Stage~~==		==KDIGO Staging==

	{\| class="wikitable"		{\| class="wikitable"
	!Stage		!Stage
	!Serum ~~creatinine~~		!Serum Creatinine
			!Urine Output
	!Or, urine output
	\|-		\|-
	\|1		\|1
	\|~~Creatinine increase ≥26~~.5 ~~umol/L or~~ 1.~~5-2~~ times baseline		\|1.5 to 1.9 times baseline, or
			≥26.5 μmol/L increase
	\|~~<~~0.~~5ml~~/kg/h for 6h		\|<0.5 mL/kg/h for 6-12 hours
	\|-		\|-
	\|2		\|2
	\|~~Creatinine~~ ~~increase~~ 2-3 times baseline		\|2 to 2.9 times baseline
	\|~~<~~0.~~5ml~~/kg/h for ~~12h~~		\|<0.5 mL/kg/h for ≥12 hours
	\|-		\|-
	\|3		\|3
	\|~~Creatinine increase >~~3 times baseline, or ~~creatinine~~ ~~≥354 umol/L increased by at least 44 umol~~/L, or ~~need~~ ~~for~~ ~~dialysis~~		\|3 times baseline, or ≥353.6 μmol/L, or started renal replacement therapy
	\|~~<~~0.~~3ml~~/kg/h for ~~24h~~		\|<0.3 mL/kg/h for ≥24 hours, or anuria for ≥12 hours
	\|}		\|}

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	==Clinical Manifestations==		==Clinical Manifestations==

	===Clinical ~~clues~~ of ~~etiology~~===		===Clinical Clues of Etiology===

	{\| class="wikitable"		{\| class="wikitable"
			!
	!Type		!Type
	!History		!History
	!Examination		!Examination
	\|-		\|-
	\|Prerenal		\| colspan="2" \|Prerenal
	\|Volume loss (e.g. vomiting, diarrhea, diuretics, hemorrhage, burns)<br />Thirst and reduced fluid intake<br />Heart failure or cirrhosis		\|Volume loss (e.g. vomiting, diarrhea, diuretics, hemorrhage, burns)<br />Thirst and reduced fluid intake<br />Heart failure or cirrhosis
	\|Weight loss, orthostatic hypotension and tachycardiac, poor skin turgor, signs of heart failure or liver failure		\|Weight loss, orthostatic hypotension and tachycardiac, poor skin turgor, signs of heart failure or liver failure
	\|-		\|-
	\|Intrinsic renal		\| rowspan="4" \|Intrinsic renal
	\|
	\|
	\|-
	\|ATN		\|ATN
	\|History of nephrotoxic medications, hypotension, trauma or myalgias suggestion rhabdo, CT contrast		\|History of nephrotoxic medications, hypotension, trauma or myalgias suggestion rhabdo, CT contrast
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	\|Livedo reticularis, fundoscopy showing malignant hypertension, abdominal bruits		\|Livedo reticularis, fundoscopy showing malignant hypertension, abdominal bruits
	\|-		\|-
	\|Post-renal		\| colspan="2" \|Post-renal
	\|Urinary urgency or hesitancy, gross hematuria, polyuria, stones, medications, cancer		\|Urinary urgency or hesitancy, gross hematuria, polyuria, stones, medications, cancer
	\|Bladder distension, pelvic mass, prostate enlargement		\|Bladder distension, pelvic mass, prostate enlargement

Aidan: /* Differential Diagnosis */ linkified

2020-08-10T21:23:55Z

Differential Diagnosis: linkified

← Older revision		Revision as of 21:23, 10 August 2020
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	*Pre-renal: decreased renal perfusion		*Pre-renal: decreased renal perfusion
	**Hypovolemia		**[[Hypovolemia]]
	**Blood loss		**[[Blood loss]]
	**Shock		**[[Shock]]
	**Sepsis		**[[Sepsis]]
	**Heart failure		**[[Heart failure]]
	**Vomiting and diarrhea		**[[Vomiting]] and [[diarrhea]]
	*Renal/intrinsic		*Renal/intrinsic
	**Glomerulonephritis (GN): glomerular damage		**[[Glomerulonephritis]] (GN): glomerular damage
	***Primary		***Primary
	****Minimal change (in children)		****Minimal change (in children)
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	***Secondary		***Secondary
	****Focal sclerosing or diffuse (in diabetic patients)		****Focal sclerosing or diffuse (in diabetic patients)
	****Lupus, multiple myeloma, and amyloidosis		****[[Lupus]], [[multiple myeloma]], and [[amyloidosis]]
	**Acute tubular necrosis (ATN): tubular damage		**[[Acute tubular necrosis]] (ATN): tubular damage
	***Ischemia from prerenal disease		***[[Ischemia]] from prerenal disease
	***Toxins		***Toxins
	***Drugs		***Drugs
	****Aminoglycosides		****[[Aminoglycosides]]
	****Amphotericin		****[[Amphotericin B\|Amphotericin]]
	****Cisplatin		****[[Cisplatin]]
	***Pigments: hemoglobin, myoglobin		***Pigments: hemoglobin, myoglobin
	***Proteins: immunoglobulin light chains (e.g. multiple myeloma)		***Proteins: immunoglobulin light chains (e.g. [[multiple myeloma]])
	***Crystals		***Crystals
	****Uric acid		****[[Gout\|Uric acid]]
	****Acyclovir		****[[Acyclovir]]
	****Methotrexate		****[[Methotrexate]]
	****Indinavir		****[[Indinavir]]
	****Oral ~~NaPO4~~		****Oral sodium phosphate
	***Contrast-induced		***Contrast-induced
	**Acute interstitial nephritis (AIN): interstitial damage		**[[Acute interstitial nephritis]] (AIN): interstitial damage
	***Allergic		***Allergic
	****Antibiotics: beta-lactams, ~~sulfas~~		****Antibiotics: [[Β-lactams\|beta-lactams]], [[sulfonamides]]
	****~~NSAIDs~~		****[[NSAID]]
	****~~PPIs~~		****[[PPI]]
	***Infective		***Infective
	****Pyelonephritis		****[[Pyelonephritis]]
	****Legionellosis		****[[Legionellosis]]
	***Infiltration		***Infiltration
	****Sarcoidosis		****[[Sarcoidosis]]
	****Lymphoma		****[[Lymphoma]]
	****Leukemia		****[[Leukemia]]
	***Autoimmune		***Autoimmune
	****Sjögren's syndrome		****[[Sjögren syndrome]]
	****TINU syndrome		****[[TINU syndrome]]
	****IgG4 disease		****[[IgG4 disease]]
	****Systemic lupus ~~erythematosis (SLE)~~		****[[Systemic lupus erythematosus]]
	***Small vessel disease		***Small vessel disease
	****Cholesterol emboli		****Cholesterol emboli
	****Thrombotic microangiopathy		****[[Thrombotic microangiopathy]]
	*****HUS/TTP		*****[[HUS]]/[[TTP]]
	*****DIC		*****[[DIC]]
	*****Preeclampsia		*****[[Preeclampsia]]
	*****Anti-phospholipid syndrome (APS)		*****[[Anti-phospholipid syndrome]] (APS)
	*****Malignant hypertension		*****[[Malignant hypertension]]
	*****Scleroderma renal crisis		*****[[Scleroderma renal crisis]]
	*Post-renal (obstructive)		*Post-renal (obstructive)
	**Bladder neck		**Bladder neck
	***BPH or prostate cancer (in men)		***[[BPH]] or [[prostate cancer]] (in men)
	***Cervical cancer (in women)		***[[Cervical cancer]] (in women)
	**Neurogenic bladder		**[[Neurogenic bladder]]
	***Anticholinergics		***[[Anticholinergics]]
	**Ureteral (bilateral)		**Ureteral (bilateral)
	***Malignancy		***[[Malignancy]]
			***[[Lymphadenopathy]]
	***LAN
	***Retroperitoneal fibrosis		***[[Retroperitoneal fibrosis]]
	***Nephrolithiasis		***[[Nephrolithiasis]]

	==Clinical Manifestations==		==Clinical Manifestations==

Aidan: /* AKIN Stage */

2020-08-10T21:19:53Z

AKIN Stage

Show changes

Aidan: Text replacement - "Clinical Presentation" to "Clinical Manifestations"

2020-07-19T13:45:43Z

Text replacement - "Clinical Presentation" to "Clinical Manifestations"

← Older revision		Revision as of 13:45, 19 July 2020
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	*** Nephrolithiasis		*** Nephrolithiasis

	== Clinical ~~Presentation~~ ==		== Clinical Manifestations ==

	=== Clinical clues of etiology ===		=== Clinical clues of etiology ===

Maintenance script: Imported from text file

2020-07-04T01:17:21Z

Imported from text file

New page

== Definition ==

* An inability of the kidneys to maintain body homeostasis, usually defined by an acute increase in creatinine

== AKIN Stage ==

{|
! Stage
! Serum creatinine
! Or, urine output
|-
| 1
| Creatinine increase ≥26.5 umol/L or 1.5-2 times baseline
| <0.5ml/kg/h for 6h
|-
| 2
| Creatinine increase 2-3 times baseline
| <0.5ml/kg/h for 12h
|-
| 3
| Creatinine increase >3 times baseline, or creatinine ≥354 umol/L increased by at least 44 umol/L, or need for dialysis
| <0.3ml/kg/h for 24h
|}

== Differential Diagnosis ==

* Pre-renal: decreased renal perfusion
** Hypovolemia
** Blood loss
** Shock
** Sepsis
** Heart failure
** Vomiting and diarrhea
* Renal/intrinsic
** Glomerulonephritis (GN): glomerular damage
*** Primary
**** Minimal change (in children)
**** Membranous (in adults)
**** Focal sclerosing (in HIV patients)
*** Secondary
**** Focal sclerosing or diffuse (in diabetic patients)
**** Lupus, multiple myeloma, and amyloidosis
** Acute tubular necrosis (ATN): tubular damage
*** Ischemia from prerenal disease
*** Toxins
*** Drugs
**** Aminoglycosides
**** Amphotericin
**** Cisplatin
*** Pigments: hemoglobin, myoglobin
*** Proteins: immunoglobulin light chains (e.g. multiple myeloma)
*** Crystals
**** Uric acid
**** Acyclovir
**** Methotrexate
**** Indinavir
**** Oral NaPO4
*** Contrast-induced
** Acute interstitial nephritis (AIN): interstitial damage
*** Allergic
**** Antibiotics: beta-lactams, sulfas
**** NSAIDs
**** PPIs
*** Infective
**** Pyelonephritis
**** Legionellosis
*** Infiltration
**** Sarcoidosis
**** Lymphoma
**** Leukemia
*** Autoimmune
**** Sjögren's syndrome
**** TINU syndrome
**** IgG4 disease
**** Systemic lupus erythematosis (SLE)
*** Small vessel disease
**** Cholesterol emboli
**** Thrombotic microangiopathy
***** HUS/TTP
***** DIC
***** Preeclampsia
***** Anti-phospholipid syndrome (APS)
***** Malignant hypertension
***** Scleroderma renal crisis
* Post-renal (obstructive)
** Bladder neck
*** BPH or prostate cancer (in men)
*** Cervical cancer (in women)
** Neurogenic bladder
*** Anticholinergics
** Ureteral (bilateral)
*** Malignancy
*** LAN
*** Retroperitoneal fibrosis
*** Nephrolithiasis

== Clinical Presentation ==

=== Clinical clues of etiology ===

{|
! Type
! History
! Examination
|-
| Prerenal
| Volume loss (e.g. vomiting, diarrhea, diuretics, hemorrhage, burns)<br/>Thirst and reduced fluid intake<br/>Heart failure or cirrhosis
| Weight loss, orthostatic hypotension and tachycardiac, poor skin turgor, signs of heart failure or liver failure
|-
| Intrinsic renal
|
|
|-
| ATN
| History of nephrotoxic medications, hypotension, trauma or myalgias suggestion rhabdo, CT contrast
| Muscle tenderness, compartment syndrome, volume status
|-
| GN
| Lupus, systemic sclerosis, rash, arthritis, uveitis, weight loss, fatigue, HCV infection, HIV infection, hematuria, foamy urine, cough, sinusitis, hemoptysis
| Periorbital, sacral, and lower-extremity edema; rash; oral or nasal ulcers
|-
| AIN
| Medication use (antiiotics, PPIs), rash, arthralgias, fever, infection
| Fever, drug rash
|-
| Vascular
| Nephrotic syndrome, trauma, flank pain, anticoagulation, vascular surgery
| Livedo reticularis, fundoscopy showing malignant hypertension, abdominal bruits
|-
| Post-renal
| Urinary urgency or hesitancy, gross hematuria, polyuria, stones, medications, cancer
| Bladder distension, pelvic mass, prostate enlargement
|}

'''Source:''' Rahman M, Shad F, and Smith MC. [https://www.aafp.org/afp/2012/1001/p631.html Acute kidney injury: A guide to diagnosis and management]. ''Am Fam Physician''. 2012;86(7):631-639.

== Investigations ==

* Laboratory
** Urinalysis and microscopy
*** Granular casts (from heme), suggesting ATN
*** Red blood cell casts, suggesting GN
** Urine sodium
*** <10mmol/L suggests pre-renal, unless diuresed
** Urea to creatinine ratio
*** Increased ratio suggests pre-renal cause
** Extended electrolytes
* Renal ultrasound, for possible obstruction

=== Fractional excretion of sodium (FENa) ===

$FENa = \frac{U_{Na} \div U_{Cr}}{S_{Na} \div S_{Cr}} = \frac{U_{Na} \times S_{Cr}}{S_{Na} \times U_{Cr}}$

{|
! FENa
! Etiology
|-
| <1%
| Pre-renal
|-
| 1 to 4%<br/> >2%
| Intrinsic renal<br/> Acute tubular necrosis (ATN)
|-
| >4%
| Post-obstructive
|}

== Management ==

* Treatment depends on etiology
** Prerenal: Fluid challenge
** Renal: Stop nephrotoxic medications
** Post-renal: Nephrostomy tubes
* Dialysis if
** Acidosis
** Electrolyte imbalance (K+)
** Intoxication (drugs, alcohols)
** Overloaded fluid (heart failure)
** Uremia (pericarditis, neurological symptoms)

== Prognosis ==

* Increased risk of developing CKD with
** Increasing age
** Female sex
** AKIN stage
** Absolute increase in serum creatinine
** Albuminuria

[[Category:Nephrology]]