Etiology and diagnosis of prerenal disease and acute tubular necrosis in acute kidney injury in adults
- Uta Erdbruegger, MD
Uta Erdbruegger, MD
- Assistant Professor of Medicine
- University of Virginia
- Mark D Okusa, MD
Mark D Okusa, MD
- Professor of Medicine
- University of Virginia Health System
INTRODUCTION AND DEFINITION
Acute kidney injury (AKI), previously called acute renal failure (ARF), is a common clinical problem [1-7]. The 2012 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Acute Kidney Injury defined AKI as one or more of three criteria . The first two were a rise in serum creatinine of at least 0.3 mg/dL (26.5 micromol/L) over a 48-hour period and/or ≥1.5 times the baseline value within the seven previous days .
The third criterion was a urine volume ≤0.5 mL/kg per hour for six hours. However, in a 70 kg adult male, this would represent a urine volume as high as 210 mL in six hours, which, if maintained, would be 840 mL/day. Many healthy individuals could meet this criterion if they had limited fluid intake. Thus, the authors and reviewers of this topic do not agree with making a diagnosis of AKI based solely upon the urine volume.
Other definitions and severity staging of AKI have also been proposed. These issues are discussed in detail elsewhere. (See "Definition and staging criteria of acute kidney injury in adults".)
The two major causes of AKI that occur in the hospital are prerenal disease and acute tubular necrosis (ATN). Together, they account for approximately 65 to 75 percent of cases of AKI. (See 'Frequency of prerenal disease and acute tubular necrosis as a cause of AKI' below.)
This topic will review the pathophysiology, etiology, clinical presentation, and evaluation and diagnosis of prerenal disease and ATN as a cause of AKI. The diagnostic approach to patients with acute or chronic kidney disease (CKD), the possible prevention and management of ATN, and renal and patient outcomes after ATN are discussed elsewhere. (See "Diagnostic approach to adult patients with subacute kidney injury in an outpatient setting" and "Possible prevention and therapy of ischemic acute tubular necrosis" and "Renal and patient outcomes after acute tubular necrosis".)
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- INTRODUCTION AND DEFINITION
- Prerenal disease
- Acute tubular necrosis
- Causes of prerenal disease
- Causes of acute tubular necrosis
- - Renal ischemia
- - Sepsis
- - Nephrotoxins
- FREQUENCY OF PRERENAL DISEASE AND ACUTE TUBULAR NECROSIS AS A CAUSE OF AKI
- EVALUATION AND DIAGNOSIS
- History and physical examination
- Distinction of prerenal disease from acute tubular necrosis
- - Urinalysis
- - Fractional excretion of sodium and urine sodium concentration
- Limitations of the fractional excretion of sodium
- - Response to fluid repletion
- - Other tests that may be helpful
- Blood urea nitrogen/serum creatinine ratio
- Rate of rise of serum creatinine concentration
- Urine osmolality
- Urine volume
- Investigational biomarkers
- - Limitations with underlying renal disease
- SUMMARY AND RECOMMENDATIONS