History

Fact Explanation
Oliguria Oliguria (urine output less than 500 ml/24 h in older children or urine output less than 1 ml/kg per hour in younger children and infants) is commonly associated with AKI. Some children may present with anuria. Children with contrast nephropathy and AKI due to nephrotoxic drugs may not develop oliguria or anuria. [1,28]
Symptoms of dehydration Excessive thirst, postural dizziness and reduced urine output are symptoms suggestive of volume depletion. [2]
Use of certain drugs Non-steroidal anti-inflammatory drugs inhibit the cyclo-oxygenase enzyme and reduce the Thromboxane A2 (a vasodilator) concentration. Andiotensin converting enzyme inhibitors (ACEIs) cause dilation of the postglomerular efferent arterioles and reduce the glomerular perfusion pressure. Above drugs reduce the renal perfusion and lead to pre-renal renal failure. Other than that penicillin analogs, cimetidine, sulfonamides, rifampin, proton pump inhibitors and NSAIDs can cause interstitial nephritis. Children with interstitial nephtitis present with skin rash, fever and arthralgia. Statins causes rhabdomyolysis and “intrinsic renal” renal failure. [7,828]
Exposure to nephro-toxic substances This is a cause for intrinsic renal renal failure. These substances(ethyl alcohol or ethylene glycol, gentamycin, mercury vapors, lead, cadmium, or other heavy metals ) cause damage to the renal tubular cells. Exposure to radiologic contrast agents is a well-established cause of AKI. [9,10]
Symptoms suggestive of nephritic or nephrotic syndrome Hematuria, generalized edema and history of hypertension are suggestive of nephritic syndrome as the cause of “intrinsic renal” renal failure. Acure glomerular nephritis following streptococcal sore throat is a common cause of AKI in developing countries. Nephrotic syndrome can cause intravascular hypovolemia and pre-renal renal failure. [3,4,5,6]
Symptoms of uremia Uremia is a consequence of renal injury. It can lead to uremic encephalopathy, which can cause altered level of consciousness, and uremic pericarditis which causes retrosternal chest pain which is relieved by bending forwards. [11,12]
Symptoms suggestive of rhabdomyolysis Muscle pain, recent history of vigorous exercise or muscular trauma, ischemic limb tetanus and seizures can cause rhabdomyolysis. [13,14]
Transfusion of incompatible blood Transfusion of incompatible blood can induce intravascular hemolysis and hemoglobinuria resulting intrinsic renal failure. [15]
Symptoms of ureteric stones Bilateral ureteric stones causes obstructive nephropathy and post-renal renal failure. This is relatively rare in children. Affected children will present with flank pain and hematuria. [16,17]
Congenital malformations of the genito urinary system Presence of posterior urethral valves, bilateral ureteropelvic junction obstruction will cause post-renal renal failure due to obstruction of the outflow tract. [17]
History of atrial fibrillation Atrial fibrillation is a known cause for thromboembolic occlusion of renal artery, causing pre-renal renal failure. [18]
History of liver disease Hepato-renal syndrome is a known complication of cirrhosis. [19]
Risk factors for AKI Acute severe hypertension is a cause for both acute kidney injury and acute on chronic renal injury. Chronic heart failure, diabetes, autoimmune diseases (anti-tubular basement membrane disease, Kawasaki’s disease, Sjogren syndrome, systemic lupus erythematosus, Wegener’s granulomatosis and chronic infections (HIV, influenza) are well known causes of AKI. Myeloproliferative disorders (chronic myelogenous leukemia, polycythemia vera, essential thrombocythemia), acute lymphocytic leukemia and B-cell lymphoma can also cause AKI. Severe hapatosplenomegaly can compress the kidneys and essential thrombocythemia can cause renal artery thrombosis or blood clots can lodge in the ureters causing obstructive nephropathy (post-renal renal failure). Connective tissue disorders can lead to accelerated hypertension and as a consequence of that renal failure develops. Excessive vomiting, diarrhea, fever and low fluid intake are common causes for hypovolemia and pre-renal acute kidney injury. Preterm neonates and neonates with very low birth weight (less than 1.500 g) can also develop AKI. Overall neonates with critically ill health are susceptible to develop AKI. [1,2,20,21,22,23,24,25,26,27,28]
History of congenital heart disease Neonates with congenital heart diseases who undergo cardiopulmonary bypass can develop AKI. [1,28]
History of asphyxia History of postneonatal asphyxia also carries a high risk of AKI in neonates. This is due to multiorgan dysfunction and redistribution of cardiac output after asphyxia. Neonatal resuscitation with high mean airway pressure and use of extracorporeal membrane oxygenation are at increased risk. [1,28]
Maternal ingestion of nephrotoxic drugs Maternal ingestion of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, antibiotics and nonsteroidal anti-inflammatory drugs is associated with development of neonatal AKI. [28]
References
  1. LIBóRIO ALEXANDRE BRAGA, BRANCO KLéBIA MAGALHãES PEREIRA CASTELLO, TORRES DE MELO BEZERRA CANDICE. Acute Kidney Injury in Neonates: From Urine Output to New Biomarkers. BioMed Research International [online] 2014 December, 2014:1-8 [viewed 07 September 2014] Available from: doi:10.1155/2014/601568
  2. NEEDHAM E. Management of acute renal failure. Am Fam Physician [online] 2005 Nov 1, 72(9):1739-46 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16300036
  3. CERDA J., LAMEIRE N., EGGERS P., PANNU N., UCHINO S., WANG H., BAGGA A., LEVIN A.. Epidemiology of Acute Kidney Injury. Clinical Journal of the American Society of Nephrology [online] 2008 February, 3(3):881-886 [viewed 07 September 2014] Available from: doi:10.2215/​CJN.04961107
  4. WELCH THOMAS R.. An Approach to the Child with Acute Glomerulonephritis. International Journal of Pediatrics [online] 2012 December, 2012:1-3 [viewed 07 September 2014] Available from: doi:10.1155/2012/426192
  5. KOOMANS H. A.. Pathophysiology of acute renal failure in idiopatic nephrotic syndrome. [online] 2001 February, 16(2):221-224 [viewed 07 September 2014] Available from: doi:10.1093/ndt/16.2.221
  6. PARK SJ, SHIN JI. Complications of nephrotic syndrome Korean J Pediatr [online] 2011 Aug, 54(8):322-328 [viewed 07 September 2014] Available from: doi:10.3345/kjp.2011.54.8.322
  7. JOHN CM, SHUKLA R, JONES CA. Using NSAID in volume depleted children can precipitate acute renal failure Arch Dis Child [online] 2007 Jun, 92(6):524-526 [viewed 07 September 2014] Available from: doi:10.1136/adc.2006.103564
  8. PANCHANGAM V. Statin-associated acute interstitial nephritis and rhabdomyolysis. Saudi J Kidney Dis Transpl [online] 2014 May, 25(3):659-60 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/24821172
  9. GOLDFARB S, MCCULLOUGH PA, MCDERMOTT J, GAY SB. Contrast-Induced Acute Kidney Injury: Specialty-Specific Protocols for Interventional Radiology, Diagnostic Computed Tomography Radiology, and Interventional Cardiology Mayo Clin Proc [online] 2009 Feb, 84(2):170-179 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664588
  10. REYES JL, MOLINA-JIJóN E, RODRíGUEZ-MUñOZ R, BAUTISTA-GARCíA P, DEBRAY-GARCíA Y, NAMORADO MDEL C. Tight junction proteins and oxidative stress in heavy metals-induced nephrotoxicity. Biomed Res Int [online] 2013:730789 [viewed 07 September 2014] Available from: doi:10.1155/2013/730789
  11. LIU M., LIANG Y., CHIGURUPATI S., LATHIA J. D., PLETNIKOV M., SUN Z., CROW M., ROSS C. A., MATTSON M. P., RABB H.. Acute Kidney Injury Leads to Inflammation and Functional Changes in the Brain. Journal of the American Society of Nephrology [online] 2008 June, 19(7):1360-1370 [viewed 07 September 2014] Available from: doi:10.1681/ASN.2007080901
  12. BALDWIN JJ, EDWARDS JE. Uremic pericarditis as a cause of cardiac tamponade. Circulation [online] 1976 May, 53(5):896-901 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1260996
  13. WEISS MF, BADALAMENTI J, FISH E. Tetanus as a cause of rhabdomyolysis and acute renal failure. Clin Nephrol [online] 2010 Jan, 73(1):64-7 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20040354
  14. EFSTRATIADIS G, VOULGARIDOU A, NIKIFOROU D, KYVENTIDIS A, KOURKOUNI E, VERGOULAS G. Rhabdomyolysis updated Hippokratia [online] 2007, 11(3):129-137 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658796
  15. MAXWELL M. J, WILSON M. J A. Complications of blood transfusion. Continuing Education in Anaesthesia, Critical Care & Pain [online] 2006 December, 6(6):225-229 [viewed 07 September 2014] Available from: doi:10.1093/bjaceaccp/mkl053
  16. ORGAN MICHAEL, NORMAN RICHARD W.. Acute reversible kidney injury secondary to bilateral ureteric Obstruction. cuaj [online] 2011 December, 5(6):392-396 [viewed 07 September 2014] Available from: doi:10.5489/cuaj.11058
  17. CASELLA DANIEL P., TOMASZEWSKI JEFFREY J., OST MICHAEL C.. Posterior Urethral Valves: Renal Failure and Prenatal Treatment. International Journal of Nephrology [online] 2012 December, 2012:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2012/351067
  18. KLEJNA K, HRYSZKO T, MYśLIWIEC M. [Acute renal failure as atypical complication of atrial fibrillation]. Kardiol Pol [online] 2009 Mar, 67(3):283-6 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19378234
  19. NG CK, CHAN MH, TAI MH, LAM CW. Hepatorenal Syndrome Clin Biochem Rev [online] 2007 Feb, 28(1):11-17 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904420
  20. SZCZECH L. A., GRANGER C. B., DASTA J. F., AMIN A., PEACOCK W. F., MCCULLOUGH P. A., DEVLIN J. W., WEIR M. R., KATZ J. N., ANDERSON F. A., WYMAN A., VARON J.. Acute Kidney Injury and Cardiovascular Outcomes in Acute Severe Hypertension. Circulation [online] December, 121(20):2183-2191 [viewed 07 September 2014] Available from: doi:10.1161/CIRCULATIONAHA.109.896597
  21. LINDNER GREGOR, DOBERER EDITH, VYCHYTIL ANDREAS, SENGöLGE GüRKAN, WAKOUNIG SAMO, MOERTL DEDDO, HöRL WALTER H., DRUML WILFRED. . Wien Klin Wochenschr [online] 2009 June, 121(11-12):391-397 [viewed 07 September 2014] Available from: doi:10.1007/s00508-009-1158-y
  22. GIRMAN CJ, KOU TD, BRODOVICZ K, ALEXANDER CM, O'NEILL EA, ENGEL S, WILLIAMS-HERMAN DE, KATZ L. Risk of acute renal failure in patients with Type 2 diabetes mellitus. Diabet Med [online] 2012 May, 29(5):614-21 [viewed 07 September 2014] Available from: doi:10.1111/j.1464-5491.2011.03498.x
  23. KUO VC, FENVES AZ, MEHTA AN. Multiple myeloma presenting as acute renal failure Proc (Bayl Univ Med Cent) [online] 2011 Oct, 24(4):302-305 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3205153
  24. AGRAWAL V, CRISI GM, D'AGATI VD, FREDA BJ. Renal sarcoidosis presenting as acute kidney injury with granulomatous interstitial nephritis and vasculitis. Am J Kidney Dis [online] 2012 Feb, 59(2):303-8 [viewed 07 September 2014] Available from: doi:10.1053/j.ajkd.2011.09.025
  25. VALLEJOS A, ARIAS M, CUSUMANO A, COSTE E, SIMON M, MARTINEZ R, MENDEZ S, RAñO M, SINTADO L, LOCOCO B, BLANCO C, CESTARI J. Dialysis for acute kidney injury associated with influenza a (H1N1) infection. Saudi J Kidney Dis Transpl [online] 2013 May, 24(3):527-33 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23640625
  26. SAID SAMAR M, LEUNG NELSON, SETHI SANJEEV, CORNELL LYNN D, FIDLER MARY E, GRANDE JOSEPH P, HERRMANN SANDRA, TEFFERI AYALEW, D'AGATI VIVETTE D, NASR SAMIH H. Myeloproliferative neoplasms cause glomerulopathy. Kidney Int [online] December, 80(7):753-759 [viewed 07 September 2014] Available from: doi:10.1038/ki.2011.147
  27. STRONGWATER SL, GALVANEK EG, STOFF JS. Control of hypertension and reversal of renal failure in undifferentiated connective tissue disease by enalapril. Arch Intern Med [online] 1989 Mar, 149(3):582-5 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2537611
  28. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9
  29. VAN BIESEN W., VANHOLDER R., LAMEIRE N.. Defining Acute Renal Failure: RIFLE and Beyond. Clinical Journal of the American Society of Nephrology [online] 2006 October, 1(6):1314-1319 [viewed 08 September 2014] Available from: doi:10.2215/​CJN.02070606
  30. KRISHNAMURTHY S, MONDAL N, NARAYANAN P, BISWAL N, SRINIVASAN S, SOUNDRAVALLY R. Incidence and etiology of acute kidney injury in southern India. Indian J Pediatr [online] 2013 Mar, 80(3):183-9 [viewed 08 September 2014] Available from: doi:10.1007/s12098-012-0791-z
  31. MARTIN SM, BALESTRACCI A, APREA V, BOLASELL C, WAINSZTEIN R, DEBAISI G, ROSóN G. Acute kidney injury in critically ill children: incidence and risk factors for mortality. Arch Argent Pediatr [online] 2013 Oct, 111(5):411-6 [viewed 08 September 2014] Available from: doi:10.1590/S0325-00752013000500009

Examination

Fact Explanation
Signs of dehydration [1] These include tachycardia, low pulse volume, postural hypotension, reduced skin turgor, dry mucous membranes and altered mental status.
Signs suggestive of connective tissue disorders Livido reticularis, digital ischemia and palpable purpura are suggestive of systemic vasculitis. Malar rash favors the diagnosis of systemic lupus erythematosis. Keratitis, uveitis, iritis and dry eyes are ophthalmological findings suggestive of autoimmune disorders. Inflammatory ulcerations in the nasal mucosa and pulmonary crepitations are seen in Wegener granulomatosis. [2,3,4]
Signs of posterior urethral valves Due to outflow obstruction, distended bladder can be palpated. Hydronephrosis causes enlarged ballotable kidneys. [14]
Signs suggestive of interstitial nephritis When due to infection, fever and generalized skin rash can be detected in interstitial nephritis. [17]
Signs suggestive of hypertension High blood pressure, evidence of hypertensive retinopathy (arteriovenous nicking, silver wiring pattern, papilledema) are helpful signs in detecting acute severe hypertension as the possible cause of AKI. [5,6]
Hearing assessment Alport syndrome is an autosomal recessive disorder affecting kidneys, eyes and cochlea. Cochlear involvement can cause neurogenic hearing loss. Aminoglycoside toxicity is also another cause for hearing loss and AKI. [7,8]
Examination of the cardiovascular system Low volume pulse is indicative of intravascular volume depletion. Irregularly irregular pulse is indicative of atrial fibrillation, which causes thromboembolism and pre-renal renal failure. Newly detected murmurs aid in the diagnosis of infective endocarditis which is another causes for thromboembolic occlusion of renal artery and pre-renal AKI. Signs of heart failure (pulmonary crackles due to pulmonary edema, peripheral edema) are also suggestive of pre-renal renal failure due to renal hypo-perfusion. Measurement of blood pressure will not only favor the diagnosis of severe hypertension but also it has diagnostic value in diagnosing nephritic syndrome. [9,10,11]
Renal angle tenderness Renal angle tenderness can be elicited in nephrolithiasis, papillary necrosis (due to diabetes or non-steroidal anti-inflammatory drug use), renal artery thrombosis and renal vein thrombosis. [12,13]
Clinical signs of cirrhosis Jaundice, finger clubbing, palmar erythema, spider naevi, gynecomastia, splenomegaly and ascites are suggestive of cirrhosis. [15]
Evidence of acute ischemic limb Paralysis and anesthesia of the affected limb and pain on squeezing the calf muscles all are suggestive of rhabdomyolysis due to acute limb ischemia. [16]
References
  1. EDDIE NEEDHAM. Management of Acute Renal Failure. Am Fam Physician. [online] 2005 Nov 1;72(9):1739-1746. [viewed 07 September 2014] Available from: http://www.aafp.org/afp/2005/1101/p1739.html
  2. KOLE AK, GHOSH A. CUTANEOUS MANIFESTATIONS OF SYSTEMIC LUPUS ERYTHEMATOSUS IN A TERTIARY REFERRAL CENTER Indian J Dermatol [online] 2009, 54(2):132-136 [viewed 07 September 2014] Available from: doi:10.4103/0019-5154.53189
  3. PATEL SJ, LUNDY DC. Ocular manifestations of autoimmune disease. Am Fam Physician [online] 2002 Sep 15, 66(6):991-8 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12358224
  4. GRAVES N. Wegener granulomatosis Proc (Bayl Univ Med Cent) [online] 2006 Oct, 19(4):342-344 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1618758
  5. VARON J, MARIK PE. The diagnosis and management of hypertensive crises. Chest [online] 2000 Jul, 118(1):214-27 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10893382
  6. GROSSO A, VEGLIO F, PORTA M, GRIGNOLO FM, WONG TY. Hypertensive retinopathy revisited: some answers, more questions Br J Ophthalmol [online] 2005 Dec, 89(12):1646-1654 [viewed 07 September 2014] Available from: doi:10.1136/bjo.2005.072546
  7. RATNER NA, VIKHERT AM, ABUGOVA SP, ARABIDZE GG, MATVEEVA LS. Problems of the pathogenesis, clinics, and therapy of panarteritis of the aorta and its branches. Cor Vasa [online] 1975, 17(3):177-87 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1207
  8. OLIVEIRA JF, SILVA CA, BARBIERI CD, OLIVEIRA GM, ZANETTA DM, BURDMANN EA. Prevalence and Risk Factors for Aminoglycoside Nephrotoxicity in Intensive Care Units Antimicrob Agents Chemother [online] 2009 Jul, 53(7):2887-2891 [viewed 07 September 2014] Available from: doi:10.1128/AAC.01430-08
  9. KLEJNA K, HRYSZKO T, MYśLIWIEC M. [Acute renal failure as atypical complication of atrial fibrillation]. Kardiol Pol [online] 2009 Mar, 67(3):283-6 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19378234
  10. SEVINC A, DAVUTOGLU V, BARUTCU I, KOCOGLU ME. Unusual course of infective endocarditis: acute renal failure progressing to chronic renal failure. J Natl Med Assoc [online] 2006 Apr, 98(4):651-654 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2569218
  11. HAN SW, RYU KH. Renal Dysfunction in Acute Heart Failure Korean Circ J [online] 2011 Oct, 41(10):565-574 [viewed 07 September 2014] Available from: doi:10.4070/kcj.2011.41.10.565
  12. SUBRAHMANIAN PS, ABRAHAM G, THIRUMURTHI K, MATHEW M, REDDY YN, REDDY YN. Reversible acute kidney injury due to bilateral papillary necrosis in a patient with leptospirosis and diabetes mellitus Indian J Nephrol [online] 2012, 22(5):392-394 [viewed 07 September 2014] Available from: doi:10.4103/0971-4065.103927
  13. LESSMAN RK, JOHNSON SF, COBURN JW, KAUFMAN JJ. Renal artery embolism: clinical features and long-term follow-up of 17 cases. Ann Intern Med [online] 1978 Oct, 89(4):477-82 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/697226
  14. ODETUNDE ODUTOLA ISRAEL, ODETUNDE OLUWATOYIN ARINOLA, ADEMUYIWA ADESOJI OLUDOTUN, OKAFOR HENRIETTA UCHE, EKWOCHI UCHENNA, AZUBUIKE JONATHAN CHUKWUEMEKA, OBIANYO NENE ELSIE. Outcome of Late Presentation of Posterior Urethral Valves in a Resource-Limited Economy: Challenges in Management. International Journal of Nephrology [online] 2012 December, 2012:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2012/345298
  15. NG CK, CHAN MH, TAI MH, LAM CW. Hepatorenal Syndrome Clin Biochem Rev [online] 2007 Feb, 28(1):11-17 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904420
  16. CALLUM K, BRADBURY A. Acute limb ischaemia BMJ [online] 2000 Mar 18, 320(7237):764-767 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1117769
  17. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9

Differential Diagnoses

Fact Explanation
Chronic renal failure Some patients with chronic renal failure may remain undiagnosed and a minor insult to the kidneys can manifest symptoms and signs due to acute on chronic renal failure. [1]
Dehydration Dehydration is one contributory cause for AKI. Other causes of dehydration like excessive vomiting, diarrhea, and iatrogenic causes (inadequate fluid replacement in unconscious patients or patients undergoing surgery) should be considered of. [2]
Heart failure AKI may not be an isolated event but a manifestation of heart failure. Chest X-ray will demonstrate the signs of heart failure like pulmonary edema, Kerley B lines, cardiomegaly, upper lobe diversion and pleural effusions. [3]
Diabetic ketoacidosis (DKA) Like some patients with pre-renal AKI, DKA patients can present with polydipsia, altered mental status and fatigue. Other than those symptoms DKA patients tend to have abdominal pain, polyuria, nausea and vomiting. Estimation of random blood sugar value will aid in making the diagnosis. [4]
Hypertension As for the heart failure AKI can be the presenting complain of severe hypertension. [5]
Hemolytic uremic syndrome This is a combination of microangiopathic haemolytic anaemia, thrombocytopenia and AKI. Commonly seen in children. Full blood count and blood picture will be helpful in diagnosis. [6,9]
Henoch-Schonlein Purpura This is an IgA-mediated, autoimmune, hypersensitivity vasculitis associated with group A streptococci and Mycoplasma infection cand commonly seen in children. Usual presenting complains are purpuric rash over the lower extremities, abdominal pain, hematuria and arthritis. [7,9]
Hyperkalemia AKI can also cause hyperkalemia. However other possible causes of hyperkalemia like dehydration, syndrome of hyporeninemic hypoaldosteronism and diabetic nephropathy should also be considered. [8]
References
  1. CHAWLA LAKHMIR S., EGGERS PAUL W., STAR ROBERT A., KIMMEL PAUL L.. Acute Kidney Injury and Chronic Kidney Disease as Interconnected Syndromes. N Engl J Med [online] 2014 July, 371(1):58-66 [viewed 07 September 2014] Available from: doi:10.1056/NEJMra1214243
  2. EDDIE NEEDHAM. Management of Acute Renal Failure. Am Fam Physician. [online] 2005 Nov 1;72(9):1739-1746. [viewed 07 September 2014] Available from: http://www.aafp.org/afp/2005/1101/p1739.html
  3. JESSUP M, BROZENA S. Heart failure. N Engl J Med [online] 2003 May 15, 348(20):2007-18 [viewed 07 September 2014] Available from: doi:10.1056/NEJMra021498
  4. TRACHTENBARG DE. Diabetic ketoacidosis. Am Fam Physician [online] 2005 May 1, 71(9):1705-14 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15887449
  5. VARON J, MARIK PE. The diagnosis and management of hypertensive crises. Chest [online] 2000 Jul, 118(1):214-27 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10893382
  6. AMIRLAK I, AMIRLAK B. Haemolytic uraemic syndrome: an overview. Nephrology (Carlton) [online] 2006 Jun, 11(3):213-8 [viewed 07 September 2014] Available from: doi:10.1111/j.1440-1797.2006.00556.x
  7. KRAFT DM, MCKEE D, SCOTT C. Henoch-Schönlein purpura: a review. Am Fam Physician [online] 1998 Aug, 58(2):405-8, 411 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9713395
  8. HOLLANDER-RODRIGUEZ JC, CALVERT JF JR. Hyperkalemia. Am Fam Physician [online] 2006 Jan 15, 73(2):283-90 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16445274
  9. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9

Investigations - for Diagnosis

Fact Explanation
Full blood count Hemoglobin may be low in hemolysis. [3]
Blood picture This is an important investigation in diagnosing hemolytic anemia. Blood picture will show schistocytes in hemolytic uremic syndrome. [4]
Serum creatinine Serum creatinine is elevated in AKI due to reduced or absent excretion of creatinine from kidneys. [1]
Urine full report Macroscopically brown or cola-colored urine indicates either myoglobinuria or hemoglobinuria. Urine protein dipstick will be positive in the presence of above two conditions. [3]
Urine micorscopy Granular, muddy brown casts, oxalate crystals, and presence of tubular cells are seen in tubular necrosis. Calcium oxalate crystal are seen in ethylene glycol poisoning. Dysmorphic red blood cells are suggestive of glomerulonephritis. In pyelonephritis and acute interstitial nephritis white blood cell casts are seen in phase contrast microscopic examination. Presence of eosinophil suggests allergic nephritis or interstitial nephritis.[3]
Serum electrolytes AKI causes hyperkalemia due to poor renal excretion of potassium. [3]
Urine electrolytes In pre-renal AKI urinary sodium is less than 20–30 mEq/l. Urinary sodium is high (more than 30–40 mEq/l) and potassium is less in intrinsic AKI. Since renal tubules can not reabsorb sodium urine osmolality is less than 350 mosmol/l in intrinsic AKI. In the presence of oliguria fractional excretion of sodium (FENa = (Urinary sodium/Plasma sodium) / (Urinary creatinine /Plasma creatininte) X 100%) will narrow down the possible cause of etiology. FENa is less than 2.5% in pre-renal causes and more than 2% in acute tubular necrosis. [3,5,16]
Urine osmolality Urine osmolality is usually greater than 350 mosmol/l in pre-renal AKI. [16]
GFR is reduced in AKI. [15] Glomerular Filtration Rate (GFR)
Serum creatinine Plasma levels are elevated due to diminished renal excretion of creatinine. However it takes some time to develop (serum creatinine begins to rise when the renal function is 25–50% lesser than the normal). In neonates estimation of serum creatinine is less useful during the first 48–72 h of life, because it depends on maternal serum creatinine levels. [1]
Blood urea nitrogen (BUN) BUN is elevated in AKI. BUN to creatinine ratio is increased if the urea reabsorption is high, like in hypovolemia and pre-renal renal failure. (More than 20:1 in pre-renal and 10 to 20:1 in intrinsic renal failure.) Fractional excretion of urea ((Urinary urea/Plasma urea) / (Urinary creatinine /Plasma creatininte) X 100%) is also another important calculation. A value less than 35% is in favor of pre-renal cause. The use of estimation of fractional excretion of urea is helpful in patients who are treated with diuretics. [6,7]
Ultrasound scan Ultrasound scan of the kidney, ureters and bladder is helpful in detecting the etiology of AKI. In the presence of posterior urethral valves the bladder is distended and hypertrophied. Bilateral hydronephrosis, hydroureter and dilated posterior urethra are other radiological signs of posterior urethral valves. Ultrasound scan combined with Doppler flow can detect renal hypo-perfusion. [2,8]
Voiding cystourethrography This is the gold standard in diagnosing posterior urethral valves. [2]
Autoantibodies Elevated levels of complement and antinuclear antibody (ANA) favors but not diagnostic of systemic lupus erythematosis. Positive antineutrophil cytoplasmic antibody (ANCA) aids the diagnosis of Wagner’s granulomatosis and other vasculitic disorders. Anti-glomerular basement membrane (anti-GBM) antibody are present in most autoimmune glomerular pathologies. [8,10]
Radionuclide imaging These tests can detect renal hypo-perfusion and function of tubular cells. [11]
Aortorenal angiography Angiography can detect renal artery stenosis (a possible cause of severe hypertension) and thrombo-embolic occlusion of the renal arteries. However this also carries a potential risk of contrast induced nephropathy. [12]
Renal biopsy Although not routinely done a biopsy will enable definitive diagnosis of the possible etiology of intrinsic renal failure. [13]
Biomarkers Urinary neutrophil gelatinase-associated lipocalin (NGAL) levels and cystatin C can be checked to detect AKI early. However this is not widely practiced. plasma B-type natriuretic peptide (BNP) is another biomarker. Kidney injury molecule-1 (KIM-1) is a transmembrane protein found in proximal tubular cells and urinary KIM-1 levels are found in increased amounts in tubular necrosis. [14,16]
References
  1. LIBóRIO ALEXANDRE BRAGA, BRANCO KLéBIA MAGALHãES PEREIRA CASTELLO, TORRES DE MELO BEZERRA CANDICE. Acute Kidney Injury in Neonates: From Urine Output to New Biomarkers. BioMed Research International [online] 2014 December, 2014:1-8 [viewed 07 September 2014] Available from: doi:10.1155/2014/601568
  2. CASELLA DANIEL P., TOMASZEWSKI JEFFREY J., OST MICHAEL C.. Posterior Urethral Valves: Renal Failure and Prenatal Treatment. International Journal of Nephrology [online] 2012 December, 2012:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2012/351067
  3. MAXWELL M. J, WILSON M. J A. Complications of blood transfusion. Continuing Education in Anaesthesia, Critical Care & Pain [online] 2006 December, 6(6):225-229 [viewed 07 September 2014] Available from: doi:10.1093/bjaceaccp/mkl053
  4. AMIRLAK I, AMIRLAK B. Haemolytic uraemic syndrome: an overview. Nephrology (Carlton) [online] 2006 Jun, 11(3):213-8 [viewed 07 September 2014] Available from: doi:10.1111/j.1440-1797.2006.00556.x
  5. DIAMOND JR, YOBURN DC. Nonoliguric acute renal failure associated with a low fractional excretion of sodium. Ann Intern Med [online] 1982 May, 96(5):597-600 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7073153
  6. CARVOUNIS CP, NISAR S, GURO-RAZUMAN S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int [online] 2002 Dec, 62(6):2223-9 [viewed 07 September 2014] Available from: doi:10.1046/j.1523-1755.2002.00683.x
  7. GOTFRIED J, WIESEN J, RAINA R, NALLY JV JR. Finding the cause of acute kidney injury: which index of fractional excretion is better? Cleve Clin J Med [online] 2012 Feb, 79(2):121-6 [viewed 07 September 2014] Available from: doi:10.3949/ccjm.79a.11030
  8. HABASH-BSEISO DE, YALE SH, GLURICH I, GOLDBERG JW. Serologic Testing in Connective Tissue Diseases Clin Med Res [online] 2005 Aug, 3(3):190-193 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1237162
  9. MERKEL PA, POLISSON RP, CHANG Y, SKATES SJ, NILES JL. Prevalence of antineutrophil cytoplasmic antibodies in a large inception cohort of patients with connective tissue disease. Ann Intern Med [online] 1997 Jun 1, 126(11):866-73 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9163287
  10. PODOLL AMBER, WALTHER CARL, FINKEL KEVIN. Clinical utility of gray scale renal ultrasound in acute kidney injury. Array [online] 2013 December [viewed 07 September 2014] Available from: doi:10.1186/1471-2369-14-188
  11. KALANTARINIA K. Novel imaging techniques in acute kidney injury. Curr Drug Targets [online] 2009 Dec, 10(12):1184-9 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/19715540
  12. COCHRAN ST, WONG WS, ROE DJ. Predicting angiography-induced acute renal function impairment: clinical risk model. AJR Am J Roentgenol [online] 1983 Nov, 141(5):1027-33 [viewed 07 September 2014] Available from: doi:10.2214/ajr.141.5.1027
  13. LóPEZ-GóMEZ JM, RIVERA F, ON BEHALF OF SPANISH REGISTRY OF GLOMERULONEPHRITIS. Renal Biopsy Findings in Acute Renal Failure in the Cohort of Patients in the Spanish Registry of Glomerulonephritis Clin J Am Soc Nephrol [online] 2008 May, 3(3):674-681 [viewed 07 September 2014] Available from: doi:10.2215/CJN.04441007
  14. HAN SW, RYU KH. Renal Dysfunction in Acute Heart Failure Korean Circ J [online] 2011 Oct, 41(10):565-574 [viewed 07 September 2014] Available from: doi:10.4070/kcj.2011.41.10.565
  15. WAIKAR S. S., LIU K. D., CHERTOW G. M.. Diagnosis, Epidemiology and Outcomes of Acute Kidney Injury. Clinical Journal of the American Society of Nephrology [online] 2008 February, 3(3):844-861 [viewed 07 September 2014] Available from: doi:10.2215/​CJN.05191107
  16. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9

Investigations - Followup

Fact Explanation
Arterial blood gas analysis Kidneys are main organs involved in acid base homeostasis. Renal failure may lead to acidosis. [2]
Serum electrolytes Recovery of renal function is indicated by normalizing serum electrolyte concentrations. [3]
Serum creatinine Serum creatinine should be monitored to detect recovery of worsening of renal functions. [1,3]
Blood urea Return of the elevated values to normal indicates recovery from the acute insult to the kidneys. [3]
ECG Detects cardiac arrhythmia which may occur due to hyperkalemia. [3]
Chest X-ray Diagnose heart failure (alveolar edema, Kerley B lines, pleural effusions) and fluid overload.
References
  1. LIBóRIO ALEXANDRE BRAGA, BRANCO KLéBIA MAGALHãES PEREIRA CASTELLO, TORRES DE MELO BEZERRA CANDICE. Acute Kidney Injury in Neonates: From Urine Output to New Biomarkers. BioMed Research International [online] 2014 December, 2014:1-8 [viewed 07 September 2014] Available from: doi:10.1155/2014/601568
  2. MACIEL AT, PARK M, MACEDO E. Physicochemical analysis of blood and urine in the course of acute kidney injury in critically ill patients: a prospective, observational study BMC Anesthesiol [online] :31 [viewed 07 September 2014] Available from: doi:10.1186/1471-2253-13-31
  3. EDDIE NEEDHAM. Management of Acute Renal Failure. Am Fam Physician. [online] 2005 Nov 1;72(9):1739-1746. [viewed 07 September 2014] Available from: http://www.aafp.org/afp/2005/1101/p1739.html

Investigations - Screening/Staging

Fact Explanation
Fetal ultrasound scan Presence of oligohydramnios, bilateral renal dysplasia, thickened bladder wall, bilateral hydronephrosis and or hydroureter, and Keyhole sign (dilated bladder and posterior urethra) are suggestive of posterior urethral valves. Screening is best done during the second trimester of the pregnancy. [1,2]
References
  1. DOMMERGUES MARC, BENACHI ALEXANDRA, BENIFLA JEAN-LOUIS, NOETTES RICHARD, DUMEZ YYVES. The reasons for termination of pregnancy in the third trimester. BJOG:An international journal of O&G [online] 1999 April, 106(4):297-303 [viewed 07 September 2014] Available from: doi:10.1111/j.1471-0528.1999.tb08265.x
  2. CASELLA DANIEL P., TOMASZEWSKI JEFFREY J., OST MICHAEL C.. Posterior Urethral Valves: Renal Failure and Prenatal Treatment. International Journal of Nephrology [online] 2012 December, 2012:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2012/351067

Management - General Measures

Fact Explanation
Health education Patients can be advised to prevent the recurrence of AKI due to potentially reversible causes (dehydration, ingestion of nephrotoxic drugs). [6]
Withhold nephrotoxic drugs If the patient is on any nephrotoxic drugs it should be stopped or changed to once daily regime. [1]
Salt restriction In oliguric renal failure salt restriction will minimize the risk of fluid retention.
Protein restriction Dietary protein intake of 0.6 g per kg per day is usually adequate and rest of the energy requirement should be met with carbohydrates. [1]
Maintenance of electrolyte homeostasis During the oliguric phase serum levels of sodium and potassium tend to be high which decreases rapidly during the polyuric phase at the recovery. Restriction is necessary during the oliguric phase and replacement might be necessary during the polyuric phase. If serum potassium levels fall below 6 mEq/L (6 mmol/L) dietary restriction of potassium and potassium binding resins can be used for treatment. Severe hyperkalemia refractory to medical management may need renal replacement therapy (hemodialysis or peritoneal dialysis). [1]
Maintenance of acid-base homeostasis Severe metabolic acidosis (pH below 7.2) is treated with sodium bicarbonate. If refractory, renal replacement therapy is indicated. [1]
Prevention of contrast-induced nephropathy Adequate hydration (intravenous saline 1 mL/kg/h is administered from 12 hours before the procedure which is continued till 12 hours after the procedure), administration of isotonic NaHCO3 solution before and after the procedure for at risk patients and oral N –acetylcysteine (1200 mg every 12 hours) will be useful in prevention of contrast-induced nephropathy. [3]
Treatment of hypertension Uncontrolled hypertension lead to hypertensive nephropathy and chronic renal failure. Pharmacological treatment will control blood pressure and delay or minimize the progression to hypertensive nephropathy. [4]
Treatment of heart failure Diuretics and angiotensin converting enzyme inhibitors are used as the baseline treatment. In acute heart failure dopamine and other inotropics are used. [4]
Management of hepato-renal syndrome Vasoconstrictors are the mainstay of treatment. Intravenous terlipressin (0.5 2 mg/4–6h) is used in treatment. [5]
Allopurinol Allopurinol is used for the prevention of AKI due to tumor lysis syndrome. Children with acute lymphocytic leukemia and B-cell lymphoma can be prescribed allopurinol. [6]
Theophylline Intravenous infusion of theophylline imporves renal prefusion in infants with severe asphyxia. [6]
References
  1. EDDIE NEEDHAM. Management of Acute Renal Failure. Am Fam Physician. [online] 2005 Nov 1;72(9):1739-1746. [viewed 07 September 2014] Available from: http://www.aafp.org/afp/2005/1101/p1739.html
  2. RITZ E, MEHLS O. Salt restriction in kidney disease--a missed therapeutic opportunity? Pediatr Nephrol [online] 2009 Jan, 24(1):9-17 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-0856-4
  3. GOLDFARB S, MCCULLOUGH PA, MCDERMOTT J, GAY SB. Contrast-Induced Acute Kidney Injury: Specialty-Specific Protocols for Interventional Radiology, Diagnostic Computed Tomography Radiology, and Interventional Cardiology Mayo Clin Proc [online] 2009 Feb, 84(2):170-179 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664588
  4. STRONGWATER SL, GALVANEK EG, STOFF JS. Control of hypertension and reversal of renal failure in undifferentiated connective tissue disease by enalapril. Arch Intern Med [online] 1989 Mar, 149(3):582-5 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2537611
  5. NG CK, CHAN MH, TAI MH, LAM CW. Hepatorenal Syndrome Clin Biochem Rev [online] 2007 Feb, 28(1):11-17 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1904420
  6. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9

Management - Specific Treatments

Fact Explanation
Fluid management If renal hypoperfusion is found to be the possible etiology of AKI fluid replacement will restore the normal renal perfusion and reverse AKI. However fluid restriction is important in oliguric renal failure to prevent fluid overload. [3]
Renal vasodilators Dopamine (0.5 μg/kg per minute to 3-5 μg/kg per minute) will improve the renal perfusion. This is useful in the treatment of pre-renal renal failure. [4,5]
Renal replacement therapy Patient may require renal replacement therapy in the form of peritoneal dialysis or preferably hemodialysis. Common indications for the renal replacement therapy are severe pulmonary edema, hyperkalemia refractory to medical management, uremic pericarditis, uremic encephalopathy, bleeding diathesis and severe acid base disturbances. [1,6]
Treatment of posterior urethral valves If antenatally detected termination of pregnancy is indicated. Otherwise open fetal ureterostomies and cutaneous vesicostomies can be used to decompress the bladder during intrauterine life. Endoscopic ablation of the posterior urethral valves is indicated if the diagnosis is made during the post-natal life. [2,7]
References
  1. NEEDHAM E. Management of acute renal failure. Am Fam Physician [online] 2005 Nov 1, 72(9):1739-46 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/16300036
  2. CASELLA DANIEL P., TOMASZEWSKI JEFFREY J., OST MICHAEL C.. Posterior Urethral Valves: Renal Failure and Prenatal Treatment. International Journal of Nephrology [online] 2012 December, 2012:1-4 [viewed 07 September 2014] Available from: doi:10.1155/2012/351067
  3. MURUGAN R, KELLUM JA. Fluid balance and outcome in acute kidney injury: is fluid really the best medicine? Crit Care Med [online] 2012 Jun, 40(6):1970-1972 [viewed 07 September 2014] Available from: doi:10.1097/CCM.0b013e31824e1a1f
  4. EDDIE NEEDHAM. Management of Acute Renal Failure. Am Fam Physician. [online] 2005 Nov 1;72(9):1739-1746. [viewed07 September 2014] Available from: http://www.aafp.org/afp/2005/1101/p1739.html
  5. ANDREOLI SP. Acute kidney injury in children Pediatr Nephrol [online] 2009 Feb, 24(2):253-263 [viewed 07 September 2014] Available from: doi:10.1007/s00467-008-1074-9
  6. ESEZOBOR CHRISTOPHER IMOKHUEDE, LADAPO TAIWO AUGUSTINA, OSINAIKE BABAYEMI, LESI FOLUSO EBUN AFOLABI, SEGURO ANTONIO CARLOS. Paediatric Acute Kidney Injury in a Tertiary Hospital in Nigeria: Prevalence, Causes and Mortality Rate. PLoS ONE [online] 2012 December [viewed 07 September 2014] Available from: doi:10.1371/journal.pone.0051229
  7. MIRSHEMIRANI A, KHALEGHNEJAD A, ROUZROKH M, SADEGHI A, MOHAJERZADEH L, SHARIFIAN M. Posterior Urethral Valves; A single Center Experience Iran J Pediatr [online] 2013 Oct, 23(5):531-535 [viewed 08 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006501