Diagnostic approach to the patient with acute kidney injury (acute renal failure) or chronic kidney disease
- Pedram Fatehi, MD, MPH
Pedram Fatehi, MD, MPH
- Assistant Clinical Professor of Medicine
- Stanford University School of Medicine
- Chi-yuan Hsu, MD, MSc
Chi-yuan Hsu, MD, MSc
- Professor of Medicine
- University of California, San Francisco
Patients with kidney disease may have a variety of different clinical presentations. Some have symptoms or signs that are directly referable to the kidney (gross hematuria) or to associated extrarenal manifestations (edema, hypertension, signs of uremia). Many patients are asymptomatic and are incidentally found to have an elevated serum creatinine concentration, abnormal urine studies (such as proteinuria or microscopic hematuria), or abnormal radiologic imaging of the kidneys. Specific disorders are more likely to be either acute or chronic in duration, thereby narrowing the differential diagnosis among patients presenting with similar clinical findings related to the kidney.
An overview of the diagnostic approach to the patient with kidney disease is presented in this topic review. The major components to this approach are:
●Careful history taking and physical examination
●Assessment of renal function by estimation of the glomerular filtration rate (GFR) (see 'Evaluation' below)
- Harper L, Savage CO. ANCA-associated renal vasculitis at the end of the twentieth century--a disease of older patients. Rheumatology (Oxford) 2005; 44:495.
- Hedger N, Stevens J, Drey N, et al. Incidence and outcome of pauci-immune rapidly progressive glomerulonephritis in Wessex, UK: a 10-year retrospective study. Nephrol Dial Transplant 2000; 15:1593.
- Rose BD. Pathophysiology of Renal Disease, 2nd ed., McGraw-Hill, New York 1987. p.41.
- Moghazi S, Jones E, Schroepple J, et al. Correlation of renal histopathology with sonographic findings. Kidney Int 2005; 67:1515.
- Manley JA, O'Neill WC. How echogenic is echogenic? Quantitative acoustics of the renal cortex. Am J Kidney Dis 2001; 37:706.
- Platt JF, Rubin JM, Bowerman RA, Marn CS. The inability to detect kidney disease on the basis of echogenicity. AJR Am J Roentgenol 1988; 151:317.
- Wilson FP, Reese PP, Shashaty MG, et al. A trial of in-hospital, electronic alerts for acute kidney injury: design and rationale. Clin Trials 2014; 11:521.
- Genovese G, Friedman DJ, Ross MD, et al. Association of trypanolytic ApoL1 variants with kidney disease in African Americans. Science 2010; 329:841.
- Tzur S, Rosset S, Shemer R, et al. Missense mutations in the APOL1 gene are highly associated with end stage kidney disease risk previously attributed to the MYH9 gene. Hum Genet 2010; 128:345.
- Textor SC. Ischemic nephropathy: where are we now? J Am Soc Nephrol 2004; 15:1974.
- Kitamoto Y, Tomita M, Akamine M, et al. Differentiation of hematuria using a uniquely shaped red cell. Nephron 1993; 64:32.
- Köhler H, Wandel E, Brunck B. Acanthocyturia--a characteristic marker for glomerular bleeding. Kidney Int 1991; 40:115.
- Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis. Ann Intern Med 2002; 137:744.
- Liaño F, Pascual J. Epidemiology of acute renal failure: a prospective, multicenter, community-based study. Madrid Acute Renal Failure Study Group. Kidney Int 1996; 50:811.
- Mehta RL, Pascual MT, Soroko S, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004; 66:1613.
- http://www.usrds.org/atlas.aspx (Accessed on June 21, 2013).
- Liu KD, Thompson BT, Ancukiewicz M, et al. Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes. Crit Care Med 2011; 39:2665.
- Holding S, Spradbery D, Hoole R, et al. Use of serum free light chain analysis and urine protein electrophoresis for detection of monoclonal gammopathies. Clin Chem Lab Med 2011; 49:83.
- Katzmann JA. Screening panels for monoclonal gammopathies: time to change. Clin Biochem Rev 2009; 30:105.
- Moran SM, Myers BD. Course of acute renal failure studied by a model of creatinine kinetics. Kidney Int 1985; 27:928.
- Chen S. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. J Am Soc Nephrol 2013; 24:877.
- Lye WC, Leong SO, Lee EJ. Rhabdomyolysis with acute tubular necrosis--a nonglomerular cause of dysmorphic hematuria. N Engl J Med 1992; 327:570.
- Dinda AK, Saxena S, Guleria S, et al. Diagnosis of glomerular haematuria: role of dysmorphic red cell, G1 cell and bright-field microscopy. Scand J Clin Lab Invest 1997; 57:203.
- Anderson RJ, Linas SL, Berns AS, et al. Nonoliguric acute renal failure. N Engl J Med 1977; 296:1134.
- Parker RA, Himmelfarb J, Tolkoff-Rubin N, et al. Prognosis of patients with acute renal failure requiring dialysis: results of a multicenter study. Am J Kidney Dis 1998; 32:432.
- Morgan DJ, Ho KM. A comparison of nonoliguric and oliguric severe acute kidney injury according to the risk injury failure loss end-stage (RIFLE) criteria. Nephron Clin Pract 2010; 115:c59.
- Oh HJ, Shin DH, Lee MJ, et al. Urine output is associated with prognosis in patients with acute kidney injury requiring continuous renal replacement therapy. J Crit Care 2013; 28:379.
- Madaio MP. Renal biopsy. Kidney Int 1990; 38:529.
- Appel GB. Renal biopsy: How effective, what technique, and how safe. J Nephrol 1993; 6:4.
- Mak SK, Gwi E, Chan KW, et al. Clinical predictors of non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus. Nephrol Dial Transplant 1997; 12:2588.
- Soni SS, Gowrishankar S, Kishan AG, Raman A. Non diabetic renal disease in type 2 diabetes mellitus. Nephrology (Carlton) 2006; 11:533.
- Disease duration
- MAJOR CAUSES AND CLASSIFICATION OF KIDNEY DISEASE
- Prerenal disease
- Intrinsic renal vascular disease
- Intrinsic glomerular disease
- Intrinsic tubular and interstitial disease
- Obstructive nephropathy
- Relative frequency of acute kidney injury etiologies
- Relative frequency of chronic kidney disease etiologies
- Relationship between acute kidney inury and chronic kidney disease
- PRESENTING MANIFESTATIONS
- In-hospital acute kidney injury
- Diagnosis of underlying cause
- Estimation of glomerular filtration rate
- URINARY FINDINGS
- Urine sodium excretion
- - Acute kidney injury
- - Chronic kidney disease
- Urine volume
- RADIOLOGIC STUDIES
- SEROLOGIC TESTING AND ROLE OF RENAL BIOPSY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS