Snapshot A 54-year-old man is admitted to the cardiac care unit after coronary angiography and revascularization secondary to unstable agina. Approximately 1 week after the procedure he is found to have a "bluish" discoloration of the first and second digits of the foot. Laboratory testing is significant for an elevated serum creatinine. A urinalysis is benign. (Renal atheroemboli) summary Clinical definition acute reduction in glomerular filtration rate (GFR) recall that GFR represents the sum of the filtration rates of nephrons therefore, GFR reflects functioning renal mass Pathogenesis based upcome etiology (look at etiology) Epidemiology risk factors hypertension chronic kidney disease dehydration and volume depletion diabetes chronic liver or lung disease Etiology prerenal causes decreased renal perfusion (e.g., hemorrhage, congestive heart failure, and diuretic use) intrarenal causes acute tubular necrosis ischemia and toxic causes interstitial nephritis glomerulonephritis vasculitis hemolytic uremic syndrome cholesterol emboli postrenal causes urinary flow obstruction (e.g., benign prostatic hyperplasia and nephrolithiasis) post-operative secondary to bladder manipulation and anesthesia bladder scans should be performed followed by urinary catheterization Presentation Symptoms may be asymptomatic oliguria anuria polyuria confusion Physical exam hypertension edema decreased urine output Differential Acute gastrointestinal bleeding Rhabdomyolysis Medication-induced impairment of creatinine secretion cimetidine trimethoprim pyrimethamine Imaging Renal ultrasound indication initial imaging study for assessing acute kidney injury can assess for renal size and hydronephrosis to assess for postrenal obstruction Studies Labs increase in serum creatinine by ≥ 0.3 mg/dL within 48 hours blood urea nitrogen (BUN):creatinine ratio urinalysis dipstick to assess for protein, glucose, leukocyte esterase, hemoglobin and myoglobin, and specific gravity microscopy for example red dysmorphic cells suggests a glomerular etiology (e.g., glomerulonephritis) muddy brown casts suggests tubular necrosis white blood cell casts suggest pyelonephritis or acute interstitial nephritis fractional excretion of Na+ (FeNa+) if patient is on diuretics use FeUrea urine osmolality and Na+ Studies To Assess For Prerenal, Intrarenal, and Postrenal Acute Kidney Injury (AKI)StudiesPrerenal AKIIntrarenal AKIPostrenal AKIUrine osmolality (mOsm/kg)> 500< 350< 350FeNa+< 1%> 2%< 1% in mild cases> 2% in severe casesUrine Na+(mEq/L)< 20> 40> 40Serum BUN/Cr> 20:1< 15:1Variable Treatment Treatment is dependent on the etiology of AKI and its consequences for example a patient who is hyperkalemic and not responding to medical treatment should be dialyzed a patient with a history of excessive fluid loss (e.g., diarrhea and vomiting) should be given intravenous fluid Complications Hyperkalemia Metabolic acidosis Uremic encephalopathy and platelet dysfunction Anemia Chronic kidney disease Elevated troponin due to decreased renal clearance of the troponin Prognosis lower rates of recovery in patients > 65 years of age increased risk of end-stage renal disease, chronic kidney disease, and mortality