Evaluation of acute kidney injury (acute renal failure) among hospitalized patients
- 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 have a variety of different clinical presentations. Some have symptoms or signs that are directly related to the kidney (such as gross hematuria) or to reduced renal function (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 generally cause acute, subacute, or chronic kidney injury. Acute kidney injury (AKI) develops over hours to days and is usually diagnosed in the emergency department, in hospitalized patients, or following a procedure.
This topic reviews the evaluation of hospitalized patients who present with AKI. Patients who present to the emergency department with a creatinine above the recent baseline value may be acute or subacute. If recent baseline is not known, the kidney disease may be chronic in nature.
The evaluation of patients who present with subacute kidney injury is discussed elsewhere. (See "Diagnostic approach to the patient with subacute kidney injury in an outpatient setting".)
The evaluation of patients with newly identified chronic kidney disease (CKD) is discussed elsewhere . (See "Diagnostic approach to the patient with newly identified chronic kidney disease".)
- Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012; 2:1.
- Balasubramanian G, Al-Aly Z, Moiz A, et al. Early nephrologist involvement in hospital-acquired acute kidney injury: a pilot study. Am J Kidney Dis 2011; 57:228.
- Wilson FP, Shashaty M, Testani J, et al. Automated, electronic alerts for acute kidney injury: a single-blind, parallel-group, randomised controlled trial. Lancet 2015; 385:1966.
- Rose BD. Pathophysiology of Renal Disease, 2nd ed., McGraw-Hill, New York 1987. p.41.
- 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.
- 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.
- 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.
- 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.
- CLINICAL MANIFESTATIONS
- Major causes and classification of AKI
- Relative frequency of AKI etiologies
- Our approach to evaluation
- - Overview
- - Estimation of glomerular filtration rate
- - Urinalysis
- - Urine sodium excretion
- - Urine volume
- - Serologic testing and role of renal biopsy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS