Acute kidney injury: Difference between revisions

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'''Acute kidney injury''', previously called '''acute renal failure''', is defined as as "An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours)."<ref name="pmid17331245">{{cite journal |author=Mehta RL, Kellum JA, Shah SV, ''et al'' |title=Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury |journal= |volume=11 |issue=2 |pages=R31 |year=2007 |pmid=17331245 |doi=10.1186/cc5713}}</ref>
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'''Acute kidney injury''', previously called '''acute renal failure''', is defined as "An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours)."<ref name="pmid17331245">{{cite journal |author=Mehta RL, Kellum JA, Shah SV, ''et al'' |title=Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury |journal= |volume=11 |issue=2 |pages=R31 |year=2007 |pmid=17331245 |doi=10.1186/cc5713}}</ref>


==Classification==
==Classification==
===Prerenal===
===Prerenal===
This is characterized by fractional excretion of sodium in the urine of < 1%.<ref name="pmid666184">{{cite journal |author=Miller TR, Anderson RJ, Linas SL, ''et al'' |title=Urinary diagnostic indices in acute renal failure: a prospective study |journal=Ann. Intern. Med. |volume=89 |issue=1 |pages=47–50 |year=1978 |pmid=666184 |doi=}}</ref>
{| class="wikitable" align="right"
|+ Fractional excretion of sodium and urea for diagnosing transient AKI<ref name="pmid17900456">{{cite journal |author=Pépin MN, Bouchard J, Legault L, Ethier J |title=Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment |journal=Am. J. Kidney Dis. |volume=50 |issue=4 |pages=566–73 |year=2007 |month=October |pmid=17900456 |doi=10.1053/j.ajkd.2007.07.001 |url=http://linkinghub.elsevier.com/retrieve/pii/S0272-6386(07)01029-3 |issn=}}</ref>
! Patients!! [[Sensitivity and specificity|Sensitivity]]!! [[Sensitivity and specificity|Specificity]]
|-
!colspan="3"|Fractional excretion of sodium ≤ 1%
|-
| Receiving [[diuretic]]s||58%||81%
|-
| No [[diuretic]]s||78%||75%
|-
!colspan="3"|Fractional excretion of urea ≤ 35%
|-
| Receiving [[diuretic]]s||79%||33%
|-
| No [[diuretic]]s||48%||75%
|}
 
This is characterized by:
* Urinary sodium < 15 mmol/liter<ref name="pmid18753652">{{cite journal |author=Steinman TI, Samir AE, Cornell LD |title=Case records of the Massachusetts General Hospital. Case 27-2008. A 64-year-old man with abdominal pain, nausea, and an elevated level of serum creatinine |journal=N. Engl. J. Med. |volume=359 |issue=9 |pages=951–60 |year=2008 |month=August |pmid=18753652 |doi=10.1056/NEJMcpc0804600 |url=http://content.nejm.org/cgi/content/full/359/9/951 |issn=}}</ref>
* [[Fractional excretion of sodium]] in the urine of < 1% <ref name="pmid17900456">{{cite journal |author=Pépin MN, Bouchard J, Legault L, Ethier J |title=Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment |journal=Am. J. Kidney Dis. |volume=50 |issue=4 |pages=566–73 |year=2007 |month=October |pmid=17900456 |doi=10.1053/j.ajkd.2007.07.001 |url=http://linkinghub.elsevier.com/retrieve/pii/S0272-6386(07)01029-3 |issn=}}</ref><ref name="pmid18753652"/><ref name="pmid666184">{{cite journal |author=Miller TR, Anderson RJ, Linas SL, ''et al'' |title=Urinary diagnostic indices in acute renal failure: a prospective study |journal=Ann. Intern. Med. |volume=89 |issue=1 |pages=47–50 |year=1978 |pmid=666184 |doi=}}</ref>
* Fractional excretion of urea nitrogen < 35%. <ref name="pmid17900456">{{cite journal |author=Pépin MN, Bouchard J, Legault L, Ethier J |title=Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment |journal=Am. J. Kidney Dis. |volume=50 |issue=4 |pages=566–73 |year=2007 |month=October |pmid=17900456 |doi=10.1053/j.ajkd.2007.07.001 |url=http://linkinghub.elsevier.com/retrieve/pii/S0272-6386(07)01029-3 |issn=}}</ref><ref name="pmid18753652"/>
* Ratio of urinary to plasma creatinine of > 20.<ref name="pmid18753652"/>
 
Causes include:
Causes include:
* Hypovolemia
* Hypovolemia
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===Intrarenal===
===Intrarenal===
Also simply called 'renal', this is characterized by fractional excretion of sodium in the urine of > 1%.<ref name="pmid666184"/>
Also simply called 'renal', this is characterized by [[fractional excretion of sodium]] in the urine of > 1%.<ref name="pmid666184"/>
Causes include:
Causes include:
* Glomerulonephritis (GN). This is characterized by significant proteinuria, red cells in the urine (possibly dysmorphic in appearance), and red-cell casts.<ref name="pmid17928602">{{cite journal |author=Rabb H, Colvin RB |title=Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine |journal=N. Engl. J. Med. |volume=357 |issue=15 |pages=1531–41 |year=2007 |pmid=17928602 |doi=10.1056/NEJMcpc079024}}</ref> GN may be caused by [[vasculitis]].
* [[Glomerulonephritis]] (GN). This is characterized by significant [[proteinuria]], red cells in the urine (possibly dysmorphic in appearance), and red-cell casts.<ref name="pmid17928602">{{cite journal |author=Rabb H, Colvin RB |title=Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine |journal=N. Engl. J. Med. |volume=357 |issue=15 |pages=1531–41 |year=2007 |pmid=17928602 |doi=10.1056/NEJMcpc079024}}</ref> GN may be caused by [[vasculitis]].
* Acute tubular necrosis (ATN). ATN is characterized by pigmented granular casts in the urine sediment.<ref name="pmid17928602">{{cite journal |author=Rabb H, Colvin RB |title=Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine |journal=N. Engl. J. Med. |volume=357 |issue=15 |pages=1531–41 |year=2007 |pmid=17928602 |doi=10.1056/NEJMcpc079024}}</ref> Causes of ATN include [[radiocontrast]] media and [[non-steroidal anti-inflammatory agents]].
* [[Acute tubular necrosis]] (ATN). ATN is characterized by pigmented granular casts in the urine sediment.<ref name="pmid17928602">{{cite journal |author=Rabb H, Colvin RB |title=Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine |journal=N. Engl. J. Med. |volume=357 |issue=15 |pages=1531–41 |year=2007 |pmid=17928602 |doi=10.1056/NEJMcpc079024}}</ref> Causes of ATN include [[radiocontrast]] media and [[non-steroidal anti-inflammatory agents]].
* Interstitial nephritis.
* [[Interstitial nephritis]].
* Drug induced. Many drugs can cause acute kidney injury as a form of [[drug toxicity]]. [[Vancomycin]] is associated with acute kidney injury if trough levels are above 15 microg/mL.<ref name="pmid17060545">{{cite journal |author=Hidayat LK, Hsu DI, Quist R, Shriner KA, Wong-Beringer A |title=High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity |journal=Arch. Intern. Med. |volume=166 |issue=19 |pages=2138–44 |year=2006 |pmid=17060545 |doi=10.1001/archinte.166.19.2138}}</ref>


===Post-renal===
===Post-renal===
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The underlying cause of the kidney injury should be treated. Diuresis has been investigated as a nonspecific treatment, but no benefit was found.<ref name="pmid16861256">{{cite journal |author=Ho KM, Sheridan DJ |title=Meta-analysis of frusemide to prevent or treat acute renal failure |journal=BMJ |volume=333 |issue=7565 |pages=420 |year=2006 |pmid=16861256 |doi=10.1136/bmj.38902.605347.7C}}</ref>
The underlying cause of the kidney injury should be treated. Diuresis has been investigated as a nonspecific treatment, but no benefit was found.<ref name="pmid16861256">{{cite journal |author=Ho KM, Sheridan DJ |title=Meta-analysis of frusemide to prevent or treat acute renal failure |journal=BMJ |volume=333 |issue=7565 |pages=420 |year=2006 |pmid=16861256 |doi=10.1136/bmj.38902.605347.7C}}</ref>


If fluid resuscitation is used, the type of fluid probably does not matter according to a [meta-analysis]] of [[randomized controlled trial]]s by the [[Cochrane Collaboration]].<ref name="pmid17943746">{{cite journal |author=Perel P, Roberts I |title=Colloids versus crystalloids for fluid resuscitation in critically ill patients |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD000567 |year=2007 |pmid=17943746 |doi=10.1002/14651858.CD000567.pub3}}</ref>
If fluid resuscitation is used, the type of fluid probably does not matter according to a [[meta-analysis]] of [[randomized controlled trial]]s by the [[Cochrane Collaboration]].<ref name="pmid17943746">{{cite journal |author=Perel P, Roberts I |title=Colloids versus crystalloids for fluid resuscitation in critically ill patients |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD000567 |year=2007 |pmid=17943746 |doi=10.1002/14651858.CD000567.pub3}}</ref>
 
===Renal replacement therapy===
{{main|Renal replacement therapy}}
 
Renal replacement therapy may be used as treatment for acute kidney injury although the optimal intensitivy is unclear.<ref>VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, O'Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P. [http://content.nejm.org/cgi/content/full/359/1/7 Intensity of renal support in critically ill patients with acute kidney injury]. N Engl J Med. 2008 Jul 3;359(1):7-20. Epub 2008 May 20.
PMID 18492867</ref>
 
==Prevention==
Administration of atrial natriuretic peptide prior to major surgery may reduce acute kidney injury.<ref name="pmid19073785">{{cite journal |author=Nigwekar SU, Navaneethan SD, Parikh CR, Hix JK |title=Atrial natriuretic peptide for management of acute kidney injury: a systematic review and meta-analysis |journal=Clin J Am Soc Nephrol |volume=4 |issue=2 |pages=261–72 |year=2009 |month=February |pmid=19073785 |doi=10.2215/CJN.03780808 |url=http://cjasn.asnjournals.org/cgi/pmidlookup?view=long&pmid=19073785 |issn=}}</ref>
 
Various treatments may reduce [[contrast-induced nephropathy]].
 
==Prognosis==
Neutrophil gelatinase-associated lipocalin (NGAL), an acute-phase protein that is also called LCN2 protein, may help predict the need for [[renal replacement therapy]].<ref name="pmid19850388">{{cite journal| author=Haase M, Bellomo R, Devarajan P, Schlattmann P, Haase-Fielitz A, NGAL Meta-analysis Investigator Group| title=Accuracy of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis and prognosis in acute kidney injury: a systematic review and meta-analysis. | journal=Am J Kidney Dis | year= 2009 | volume= 54 | issue= 6 | pages= 1012-24 | pmid=19850388
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19850388 | doi=10.1053/j.ajkd.2009.07.020 }} <!--Formatted by http://sumsearch.uthscsa.edu/cite/--></ref>
 
==See also==
* [[Chronic kidney disease]]


==References==
==References==
<references/>
{{reflist|2}}[[Category:Suggestion Bot Tag]]
 
[[Category:CZ Live]] [[Category:Health Sciences Workgroup]]

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Acute kidney injury, previously called acute renal failure, is defined as "An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours)."[1]

Classification

Prerenal

Fractional excretion of sodium and urea for diagnosing transient AKI[2]
Patients Sensitivity Specificity
Fractional excretion of sodium ≤ 1%
Receiving diuretics 58% 81%
No diuretics 78% 75%
Fractional excretion of urea ≤ 35%
Receiving diuretics 79% 33%
No diuretics 48% 75%

This is characterized by:

Causes include:

Intrarenal

Also simply called 'renal', this is characterized by fractional excretion of sodium in the urine of > 1%.[4] Causes include:

Post-renal

This is characterized by symptoms of obstruction and sometimes by anuria.

Treatment

The underlying cause of the kidney injury should be treated. Diuresis has been investigated as a nonspecific treatment, but no benefit was found.[7]

If fluid resuscitation is used, the type of fluid probably does not matter according to a meta-analysis of randomized controlled trials by the Cochrane Collaboration.[8]

Renal replacement therapy

For more information, see: Renal replacement therapy.


Renal replacement therapy may be used as treatment for acute kidney injury although the optimal intensitivy is unclear.[9]

Prevention

Administration of atrial natriuretic peptide prior to major surgery may reduce acute kidney injury.[10]

Various treatments may reduce contrast-induced nephropathy.

Prognosis

Neutrophil gelatinase-associated lipocalin (NGAL), an acute-phase protein that is also called LCN2 protein, may help predict the need for renal replacement therapy.[11]

See also

References

  1. ↑ Mehta RL, Kellum JA, Shah SV, et al (2007). "Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury" 11 (2): R31. DOI:10.1186/cc5713. PMID 17331245. Research Blogging.
  2. ↑ 2.0 2.1 2.2 Pépin MN, Bouchard J, Legault L, Ethier J (October 2007). "Diagnostic performance of fractional excretion of urea and fractional excretion of sodium in the evaluations of patients with acute kidney injury with or without diuretic treatment". Am. J. Kidney Dis. 50 (4): 566–73. DOI:10.1053/j.ajkd.2007.07.001. PMID 17900456. Research Blogging.
  3. ↑ 3.0 3.1 3.2 3.3 Steinman TI, Samir AE, Cornell LD (August 2008). "Case records of the Massachusetts General Hospital. Case 27-2008. A 64-year-old man with abdominal pain, nausea, and an elevated level of serum creatinine". N. Engl. J. Med. 359 (9): 951–60. DOI:10.1056/NEJMcpc0804600. PMID 18753652. Research Blogging.
  4. ↑ 4.0 4.1 Miller TR, Anderson RJ, Linas SL, et al (1978). "Urinary diagnostic indices in acute renal failure: a prospective study". Ann. Intern. Med. 89 (1): 47–50. PMID 666184. [e]
  5. ↑ 5.0 5.1 Rabb H, Colvin RB (2007). "Case records of the Massachusetts General Hospital. Case 31-2007. A 41-year-old man with abdominal pain and elevated serum creatinine". N. Engl. J. Med. 357 (15): 1531–41. DOI:10.1056/NEJMcpc079024. PMID 17928602. Research Blogging.
  6. ↑ Hidayat LK, Hsu DI, Quist R, Shriner KA, Wong-Beringer A (2006). "High-dose vancomycin therapy for methicillin-resistant Staphylococcus aureus infections: efficacy and toxicity". Arch. Intern. Med. 166 (19): 2138–44. DOI:10.1001/archinte.166.19.2138. PMID 17060545. Research Blogging.
  7. ↑ Ho KM, Sheridan DJ (2006). "Meta-analysis of frusemide to prevent or treat acute renal failure". BMJ 333 (7565): 420. DOI:10.1136/bmj.38902.605347.7C. PMID 16861256. Research Blogging.
  8. ↑ Perel P, Roberts I (2007). "Colloids versus crystalloids for fluid resuscitation in critically ill patients". Cochrane Database Syst Rev (4): CD000567. DOI:10.1002/14651858.CD000567.pub3. PMID 17943746. Research Blogging.
  9. ↑ VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, O'Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008 Jul 3;359(1):7-20. Epub 2008 May 20. PMID 18492867
  10. ↑ Nigwekar SU, Navaneethan SD, Parikh CR, Hix JK (February 2009). "Atrial natriuretic peptide for management of acute kidney injury: a systematic review and meta-analysis". Clin J Am Soc Nephrol 4 (2): 261–72. DOI:10.2215/CJN.03780808. PMID 19073785. Research Blogging.
  11. ↑ Haase M, Bellomo R, Devarajan P, Schlattmann P, Haase-Fielitz A, NGAL Meta-analysis Investigator Group (2009). "Accuracy of neutrophil gelatinase-associated lipocalin (NGAL) in diagnosis and prognosis in acute kidney injury: a systematic review and meta-analysis.". Am J Kidney Dis 54 (6): 1012-24. DOI:10.1053/j.ajkd.2009.07.020. PMID 19850388. Research Blogging.
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