Nephrology Book

Acute Renal Failure

Aka: Acute Renal Failure, Renal Failure, Azotemia, Uremia, Acute Tubular Necrosis, Acute Intrinsic Renal Failure
  1. See Also
    1. Prerenal Failure
    2. Postrenal Failure
    3. Chronic Renal Failure
  2. Epidemiology
    1. Acute Tubular Necrosis accounts for 20-30% of ARF
  3. Causes
    1. See Acute Renal Failure Causes
  4. Pathogenesis
    1. Types: Extrarenal Conditions
      1. Prerenal Failure
        1. Decreased renal perfusion
        2. Examples: Dehydration, CHF, Liver failure
      2. Postrenal Failure
        1. Renal outflow obstruction
        2. Examples: BPH, Genitourinary tumors
    2. Types: Intrarenal Conditions
      1. Vascular Injury
        1. Afferent arteriolar Vasoconstriction
          1. Results in decreased driving force
          2. Decreased Glomerular filtration
        2. Types
          1. Microvascular (Small vessel thrombosis)
          2. Macrovascular (e.g. Renal Artery Stenosis)
      2. Glomerulonephritis
        1. Associated with Hematuria and Proteinuria
      3. Acute Interstitial Nephritis
        1. Due to allergic or autoimmune diseases
      4. Tubular Injury and Acute Tubular Necrosis
        1. Mechanism
          1. Tubules injured in most but not all acute failure
          2. Obstruction
            1. Abnormal material inspissates and plugs flow
          3. Back-leak
            1. Tubular cells loose integrity
            2. Back-leaks ultrafiltrate
            3. Results in poor waste clearance
        2. Course (3 phases)
          1. Initiation phase (minutes to hours)
            1. Starts with well functioning Kidney
            2. Kidney bombarded by potential toxins
          2. Maintenance phase
            1. Established loss of Renal Function
            2. Kidney unresponsive to simple interventions
          3. Recovery phase (weeks to months)
            1. Complete recovery in Acute Tubular Necrosis
    3. Specific Examples
      1. Intravenous Contrast Related Acute Renal Failure
      2. Renal Ischemia
        1. Tubular obstruction and back-leak
      3. Aminoglycoside Antibiotics
        1. Decreased Glomerular Filtration Rate
        2. Tubular cell injury
      4. Rhabdomyolysis
        1. Decreased afferent blood flow
        2. Renal tubular obstruction
  5. Risk Factors
    1. See Acute Renal Failure Risk
  6. Signs
    1. Aortic aneurysm
    2. Skin
      1. Rash (Drug-induced Interstitial Nephritis)
      2. Palpable Purpura (Vasculitis)
      3. Non-palpable Purpura
        1. Thrombotic Thrombocytopenic Purpura (TTP)
        2. Hemolytic Uremic Syndrome (HUS)
      4. Livido reticularis
  7. Labs
    1. Renal Function: Criteria for Acute Renal Failure
      1. Serum Creatinine rises >0.3 on 2 contiguous days or
      2. Serum Creatinine rises >0.5 mg/dl or
      3. Serum Creatinine rises >50% above baseline or
      4. Calculated GFR falls >50% below baseline
    2. Fractional Excretion of Sodium (FENa)
      1. Requires urine sample prior to IV fluids, Diuretics
      2. FENa >1%: Acute Tubular Necrosis
      3. FENa <1%: Prerenal Failure
        1. Kidney still able to concentrate urine
    3. Complete Blood Count (CBC)
      1. Platelets decreased in Purpura (see above)
      2. Eosinophils increased in interstitial disease
    4. Urinalysis with Urine sediment examination
      1. Urine Specific Gravity
        1. Prerenal Failure: Specific Gravity >1.020
        2. Intrarenal Failure: Specific Gravity 1.010 - 1.020
      2. Vascular disease
        1. Urine RBCs often present
      3. Glomerulonephritis
        1. Urine RBCs
        2. Granular casts
        3. Proteinuria
      4. Interstitial Nephritis
        1. Pyuria
        2. Eosinophils
        3. White Blood Cell and Eosinophil casts
      5. Drug hypersensitivity nephritis
        1. Eosinophils
      6. Tubular Necrosis
        1. Pigmented granular casts
        2. Tubular epithelial cells
        3. Granular casts
      7. Prerenal Failure
        1. Hyaline Casts
    5. Autoimmune Testing for Glomerular Disease
      1. Antinuclear Antibody (ANA)
      2. Antineutrophil Cytoplasmic Antibody
      3. Antiglomerular basement membrane Antibody
    6. Percutaneous Renal Biopsy
      1. Indicated for Glomerular or Interstitial disease
  8. Radiology: Renal Ultrasound
    1. Intrarenal Failure: May show parenchymal abnormality
    2. Postrenal Failure: Hydronephrosis
  9. Management
    1. See Acute Renal Failure Management
  10. Prevention
    1. See Intravenous Contrast Related Acute Renal Failure
  11. Reference:
    1. Needham (2005) Am Fam Physician 72:1739-46
    2. Singri (2003) Acute Renal Failure 289:747-51
    3. Wilkes (1986) Am J Med 80:1129-36
    4. Anderson (8/15/1993) Hospital Practice, p. 61-75

Uremia (C0041948)

Definition (CSP) excess in the blood of urea, creatinine and other nitrogenous end products of protein and aminoacid metabolism; also, the constellation of signs and symptoms of chronic renal failure.
Definition (MSH) A clinical syndrome associated with the retention of renal waste products or uremic toxins in the blood. It is usually the result of RENAL INSUFFICIENCY. Most uremic toxins are end products of protein or nitrogen CATABOLISM, such as UREA or CREATININE. Severe uremia can lead to multiple organ dysfunctions with a constellation of symptoms.
Concepts Disease or Syndrome (T047)
MSH D014511
ICD10 N19
SnomedCT 44730006, 197656003, 266616000
English Uremias, URAEMIA, URAEMIA OF RENAL ORIGIN, UREMIA, UREMIA OF RENAL ORIGIN, Uremia, NOS, Uraemia, NOS, Uraemia NOS, Uremia NOS, uremia, uremia (diagnosis), Uraemia of renal origin, Uremia of renal origin, Uremia [Disease/Finding], Uraemia, Uremia (disorder), urea in blood; high, Uremia, uraemia
French UREMIE, Urémie d'origine rénale, UREMIE D'ORIGINE RENALE, Urémie
Portuguese UREMIA, Uremia de origem renal, UREMIA DE ORIGEM RENAL, Uremia
Spanish UREMIA, Azotemia, Uremia de origen renal, UREMIA DE ORIGEN RENAL, uremia (trastorno), uremia, Uremia
German URAEMIE, Uraemie, Uraemie renalen Ursprungs, URAEMIE RENALER GENESE, Harnvergiftung, Urämie
Dutch uremie, uremie van renale oorsprong, ureum in bloed; hoog, Uremie
Italian Uremia di origine renale, Uremia
Japanese 尿毒症, 腎性尿毒症, ジンセイニョウドクショウ, ニョウドクショウ
Swedish Uremi
Czech urémie, Uremie, Uremie z renálních příčin
Finnish Uremia
Croatian UREMIJA
Polish Mocznica
Hungarian Vese eredetű uraemia, uraemia, Uraemia
Derived from the NIH UMLS (Unified Medical Language System)

Kidney Failure, Acute (C0022660)

Definition (NCI) Sudden and sustained deterioration of the kidney function characterized by decreased glomerular filtration rate, increased serum creatinine or oliguria.
Definition (NCI) A disorder characterized by the acute loss of renal function and is traditionally classified as pre-renal (low blood flow into kidney), renal (kidney damage) and post-renal causes (ureteral or bladder outflow obstruction).
Definition (CSP) clinical syndrome characterized by a sudden decrease in glomerular filtration rate, usually associated with oliguria and always associated with biochemical consequences of the reduction in glomerular filtration rate such as a rise in blood urea nitrogen (BUN) and serum creatinine concentrations.
Concepts Disease or Syndrome (T047)
MSH D007675, D058186
ICD9 584, 584.9
ICD10 N17, N17.9
SnomedCT 155855008, 197653006, 14669001
English Kidney Failure, Acute, Acute renal failure, KIDNEY, FAILURE, ACUTE, ACUTE KIDNEY FAILURE, FAILURE KIDNEY ACUTE, KIDNEY FAILURE ACUTE, RENAL FAILURE ACUTE, ACUTE RENAL FAILURE, RENAL FAILURE, ACUTE, RENAL SHUTDOWN ACUTE, Acute renal failure syndrome, NOS, Acute renal failure NOS, Acute renal failure, unspecified, ARF, acute renal failure, acute renal failure (diagnosis), arf, Acute renal failure (disorder), ARF (acute renal failure), Acute kidney failure, Failure kidney acute, Kidney failure acute, Renal failure acute, Renal shutdown acute, Acute kidney failure NOS, Acute renal failure NOS (disorder), Acute and unspecified renal failure, Acute kidney injury, Acute kidney failure, unspecified, Kidney Failure, Acute [Disease/Finding], Acute Kidney Failure, Kidney Failures, Acute, Acute Renal Failure, Renal Failure, Acute, Acute Kidney Failures, Acute Renal Failures, Renal Failures, Acute, kidney failure acute, Failure;renal;acute, syndrome acute renal failure, acute renal failures, renal failure acute, acute renal shutdown, acute failure kidney, acute kidney failure, failure acute renal, acute failure renal, acute renal insufficiency, Acute renal failure syndrome, ARF - Acute renal failure, Acute renal failure syndrome (disorder)
French INSUFFISANCE RENALE AIGUE, Insuffisance rénale aiguë, Ligo-anurie aiguë, Insuffisance rénale aiguë, non précisée, SIDERATION RENALE, Défaillance rénale aigüe, Défaillance rénale aiguë
Portuguese INSUFICIENCIA RENAL AGUDA, Insuficiência renal aguda NE, Falência renal aguda, PARALIZACAO RENAL, Insuficiência renal aguda
Spanish INSUFICIENCIA RENAL AGUDA, Fallo renal agudo, Insuficiencia renal aguda no especificada, Acute renal failure, FALLO RENAL AGUDO, Insuficiencia renal aguda
Dutch niet-gespecificeerd acuut nierfalen, acuut falen nier, Acute nierinsufficiëntie, niet gespecificeerd, acuut nierfalen, Nierfalen, acuut, Acute nierinsufficiëntie, Insufficiëntie, acute nier-, Nierinsufficiëntie, acute, Renale insufficiëntie, acute
German akutes Nierenversagen, akutes Nierenversagen, unspezifisch, Versagen der Niere akut, Nierenausfall akut, Akutes Nierenversagen, nicht naeher bezeichnet, NIERENEMBOLIE, NIERENVERSAGEN AKUT, Renales Versagen, akutes, Akutes Nierenversagen, Nierenversagen, akutes, Nierenversagen akut
Italian Insufficienza renale acuta, non specificata, Insufficienza renale acuta
Japanese 急性腎不全、詳細不明, 急性腎不全, 急性腎機能停止, キュウセイジンフゼンショウサイフメイ, キュウセイジンキノウテイシ, キュウセイジンフゼン
Swedish Njursvikt, akut
Finnish Munuaisten äkillinen vajaatoiminta
Czech Akutní selhání ledvin, Renální selhání akutní, Akutní renální selhání, Akutní renální selhání blíže neurčené, akutní selhání ledvin, ledviny - selhání akutní
Korean 상세불명의 급성 콩팥(신장)기능상실, 급성 콩팥(신장)기능상실
Hungarian acut veseelégtelenség, Acut veseelégtelenség, Acut veseelégtelenség, k.m.n., Acut veseleállás
Derived from the NIH UMLS (Unified Medical Language System)

Kidney Tubular Necrosis, Acute (C0022672)

Definition (MSH) Acute kidney failure resulting from destruction of EPITHELIAL CELLS of the KIDNEY TUBULES. It is commonly attributed to exposure to toxic agents or renal ISCHEMIA following severe TRAUMA.
Concepts Disease or Syndrome (T047)
MSH D007683
ICD10 N17.0, N10
SnomedCT 197649009, 23697004, 35455006
English Acute ischemic nephropathy, Acute Kidney Tubular Necrosis, Kidney Tubular Necrosis, Acute, Lower Nephron Nephroses, Lower Nephron Nephrosis, Nephron Nephroses, Lower, Nephron Nephrosis, Lower, Nephroses, Lower Nephron, Nephrosis, Lower Nephron, ACUTE TUBULAR NECROSIS, LOWER NEPHRON NEPHROSIS, NEPHROSIS LOWER NEPHRON, Acute tubular necrosis, NOS, ATN - Acute tubular necrosis, Acute renal failure with tubular necrosis, TUBULAR NECROSIS ACUTE, lower nephron nephrosis, acute tubular necrosis, Renal tubular necrosis acute, Lower nephron nephrosis, Nephrosis lower nephron, RENAL TUBULAR NECROSIS ACUTE, Kidney Tubular Necrosis, Acute [Disease/Finding], acute renal tubular necrosis, acute necrosis tubular, Acute tubular necrosis, Tubulorrhexis, Acute renal tubular necrosis, Acute tubular necrosis (disorder), Acute tubule necrosis, insufficiency; renal, acute, with necrosis, tubular, insufficiency; renal, with tubular necrosis (acute), kidney; insufficiency, acute, with necrosis, tubular, kidney; insufficiency, with tubular necrosis (acute), Acute Renal Failure with Tubular Necrosis
Dutch nefrose in het onderste nefron, acute tubulusnecrose, acute tubulaire nefrose in het onderste nefron, acute niertubulusnecrose, insufficiëntie; nier, acuut, met necrose, tubulus, insufficiëntie; nier, met tubulusnecrose (acuut), nier; insufficiëntie, acuut, met necrose, tubulus, nier; insufficiëntie, met tubulusnecrose (acuut), Acute nierinsufficiëntie met tubulusnecrose, ATN, Acute tubulusnecrose, Lower-nephron necrosis, Necrose, acute tubulus-, Niertubulusnecrose, acute, Tubulusnecrose, acute
French Néphrose du néphron inférieur, Nécrose tubulaire rénale aiguë, Nécrose tubulaire aiguë, Néphrite tubulaire aigüe, Néphropathie tubulo-interstitielle aiguë, Néphropathie tubulo-interstitielle aigüe, Tubulo-néphrite aigüe, NEPHROSE LOCALISEE AU TUBE DISTAL, Néphrite tubulaire aiguë, Tubulo-néphrite aiguë
German akute Nierentubulusnekrose, Nephrose Tubulus, Nierentubulusnekrose akut, Tubulusnephrose, Akutes Nierenversagen mit Tubulusnekrose, NEPHROSE TUBULAER BEDINGT, Akute Tubulusnekrose, Nierentubulusnekrose, akute
Italian Nefrosi tubulare, Necrosi tubulare renale acuta, Necrosi tubulare acuta, Necrosi tubulorenale acuta
Portuguese Nefrose do nefrónio inferior, Necrose tubular aguda, Necrose renal tubular aguda, NEFROSE DA ALCA DE HENLE, Necrose Tubular Aguda, Nefrose do Néfron Inferior
Spanish Necrosis tubular aguda, Nefrosis de la nefrona inferior, Necrosis tubular renal aguda, Acute tubular necrosis, Nefrosis de la Nefrona Distal, NEFROSIS NEFRONA INFERIOR, necrosis tubular aguda (trastorno), necrosis tubular aguda, necrosis tubular renal aguda, tubulorrexis, Necrosis Tubular Aguda
Swedish Njurkanalnekros, akut
Japanese キュウセイジンニョウサイカンエシ, カブネフロンネフローゼ, 尿細管壊死-急性, 下部ネフロンネフローゼ, 急性尿細管え死, 急性尿細管壊死, 急性腎尿細管壊死, 腎尿細管壊死-急性
Czech ledviny - tubulární nekróza akutní, Nefróza dolního nefronu, Akutní tubulární nekróza, Akutní renální tubulární nekróza
Finnish Äkillinen munuaistiehyeiden kuolio
Korean 세뇨관 괴사를 동반한 급성 콩팥(신장)기능상실
Polish Zespół dolnego nefronu, Ostra nekroza kanalików nerkowych, Ostra martwica kanalikowa, Martwica kanalikowa ostra
Hungarian Acut renalis tubularis necrosis, Alsó nephron nephrosis, Acut tubularis necrosis
Derived from the NIH UMLS (Unified Medical Language System)

Azotemia (C0242528)

Definition (MSH) A biochemical abnormality referring to an elevation of BLOOD UREA NITROGEN and CREATININE. Azotemia can be produced by KIDNEY DISEASES or other extrarenal disorders. When azotemia becomes associated with a constellation of clinical signs, it is termed UREMIA.
Concepts Disease or Syndrome (T047)
MSH D053099
SnomedCT 445009001
English AZOTEMIA, Azotemia (disorder), Azotaemia, Azotemia [Disease/Finding], azotaemia, Azotemia, azotemia
Portuguese AZOTEMIA, Azotemia
Italian Azotemia, Presenza di urea nel sangue, Azotemia prerenale
Spanish Azotemia, Azoemia, AZOEMIA, azoemia, azoemia (trastorno), Uremia
German Azotämie, AZOTAEMIE, Azotaemie
French Azotémie, HYPERAZOTEMIE
Japanese 高窒素血症, コウチッソケッショウ
Czech azotémie, Azotemie
Finnish Atsotemia
Swedish Azotemi
Polish Azotemia
Hungarian azotaemia, azotémia
Dutch azotemie
Derived from the NIH UMLS (Unified Medical Language System)

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