Acute Kidney Injury

Definition
Abrupt (<48 h) absolute increase in the serum
creatinine concentration of ≥ 0.3 mg/dL from baseline
Increase in the serum creatinine ≥50%
Oliguria < 0.5 mL/kg per hour for > 6 hours

Mehta R, Kellum J, Shah S, et al. Acute Kidney Injury Network : Report of an initiative
to improve outcomes in acute kidney injury. Critical Care. 2007, 11(2):R31
RIFLE Criteria

Kellum, Bellomo, Ronco. The Concept of Acute Kidney Injury and the RIFLE
Criteria. In Contributions to Nephrology. Vol 156. 2007
Initial Diagnostic Tools
History
General
 PO intake, urine output, and baseline creatinine measurement (to assess
how far from baseline the current creatinine is)
Prerenal
 Thirst, orthostatic dizziness
Intrarenal
 Nephrotoxic medications, radiocontrast material, other toxins;
 Fever, arthralgias, and pruritic rash suggest allergic interstitial nephritis,
although systemic effects are not always seen in this pathology.
 Edema, hypertension, and oliguria with nephritic urine sediment points
to glomerulonephritis or vasculitis.
 Livedo reticularis, subcutaneous nodules, and ischemic toes and fingers
despite good pulses suggest atheroembolization.
 Flank pain suggests occlusion of the renal artery or vein.
Initial Diagnostic Tools
Postrenal
 Colicky flank pain that radiates to the groin suggests a ureteric
obstruction such as a stone
 Nocturia, frequency, and hesitancy suggest prostatic disease
 Suprapubic and flank pain are usually secondary to distension of
the bladder and collecting system
 Ask about anticholinergic drugs that could lead to neurogenic
bladder
Initial Diagnostic Tools
 Physical examination
Prerenal signs: Tachycardia, decreased jugular venous
pressure (JVP), orthostatic hypotension, dry mucous
membranes, decreased skin turgor; look for stigmata of
associated comorbidities such as liver and heart failure, as well
as sepsis.
Intrinsic renal signs: Pruritic rash, livedo reticularis,
subcutaneous nodules, ischemic digits despite good pulses
Postrenal signs: Suprapubic distension, flank pain, and
enlarged prostate
General uremic signs: Lethargy, seizures, asterixis,
myoclonus, pericardial friction rub, peripheral neuropathies
Initial Diagnostic Tools
 Blood urea nitrogen and serum creatinine
 Arterial blood gases
 CBC, peripheral smear, and serology
 Serum electrolytes
 Serology: ANA,ANCA, Anti DNA, HBV, HCV, Anti GBM,
cryoglobulin, CK, urinary myoglobulin
 Urinalysis : protein, blood, infection
 Urine microscopy : casts, cells (eosinophils), crystals
 Urine electrolytes
 Renal imaging : Ultrasound
Management
Optimization of hemodynamic and volume status
Avoid excessive fluid overload
Avoid hypotension and maintain euvolemia
Treat acute complications
Hyperkalemia, acidosis, pulmonary edema
Avoidance of further renal insults
Protein restriction
Review patient’s medication – necessary doses adjustment
Optimization of nutrition
Adequate calories, minimal nitrogenous waste production, water
and sodium restriction, potassium restriction
If necessary, institution of renal replacement therapy

Esson ML. Annals of Intern Med. 2002; 137:744-754

Indication for Renal Replacement Therapy
Metabolic
Azotemia : BUN > 36 mmol/L
Uremic complications : encephalopathy, pericarditis, bleeding
Hyperkalemia : K+ > 6 mEq/L and/or ECG abnormalities
Hypermagnesemia : Mg2+ > 4 mEq/L and/or anuria / absent
deep tendon reflexes
Acidosis : serum pH ≤ 7.15
Anuria / oligouria : urine output < 200 mL/24 h or anuria
Volume overload : diuretic – resistant organ edema (that is,
pulmonary edema) in the presence of acute kidney injury

Gibney et al. Clin J Am Soc Nephrol. 2008;3:876-880

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