Question 1 of 10

    Acute Kidney Failure (Acute Kidney Injury)

    Kidney – acute cortical necrosis[1]

    Acute kidney failure (acute kidney injury or acute renal failure) is the abrupt loss of the kidney's capacity to remove metabolic wastes from the blood and to maintain fluid and electrolyte balance in the body for optimum health. AKF, if left untreated, is potentially fatal.

    Presentation

    The presentation depends on the etiology and the stage of the acute kidney failure. Mild forms may be asymptomatic and are identified on laboratory examination. More severe cases may present with lethargy, fatigue, confusion, anorexia, nausea, and weight gain. The patient may be anuric, oliguric, pass normal volumes of urine or may even complain of polyuria.

    Skin
    Petechiae
    • Pallor, rash, bruising: petechiae, purpura and nosebleeds may suggest inflammatory or vascular disease, emboli or disseminated intravascular coagulation.[patient.info]
    • Checking the patient for areas of small, purple or red spots (petechiae), hemorrhage beneath the skin (purpura), and bluish discoloration of a fairly large area of the skin (ecchymosis) can lead to a diagnosis of an inflammatory or vascular cause for[encyclopedia.com]
    Pruritus
    • Symptoms may include: Appetite loss General ill feeling and fatigue Headaches Itching ( pruritus) and dry skin Nausea Weight loss without trying to lose weight Symptoms that may occur when kidney function has gotten worse include: Abnormally dark or light[mountsinai.org]
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  • urogenital
    Oliguria
    • A 72-year-old man is brought to the ED from a nursing home for evaluation of oliguria.[foamcast.org]
    • Sudden and sustained deterioration of the kidney function characterized by decreased glomerular filtration rate, increased serum creatinine or oliguria.[icd10data.com]
    • Definition Acute renal failure (ARF) is characterized by azotmeia that progresses over several hours or days, with or without oliguria.[clevelandclinicmeded.com]
    • Symptoms Urine output: AKI is usually accompanied by oliguria or anuria.[patient.info]
    • Oliguria is defined as a daily urine volume of less than 400 mL and has a worse prognosis.[emedicine.medscape.com]
    Anuria
    • Symptoms Urine output: AKI is usually accompanied by oliguria or anuria.[patient.info]
    • KEY TERMS Anuria— When the body ceases to make urine entirely or falls below 100 mL.[encyclopedia.com]
    • […] to threefold from baseline 0.5 mL per kg per hour for more than 12 hours — 3 Increase threefold from baseline or 4.0 mg per dL (353.60 μmol per L) with an acute rise of at least 0.5 mg per dL (44.20 μmol per L) 0.3 mL per kg per hour for 24 hours or anuria[aafp.org]
    • Patients who develop anuria typically have obstruction at the level of the bladder or downstream to it.[emedicine.medscape.com]
    • In RIFLE, failure is defined as a three-fold increase of serum creatinine or decrease in GFR of 75% or a urine output of 24 h or anuria for 12 h.[cjasn.asnjournals.org]
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  • Eyes
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  • hematological
    Easy Bruising
    • bruising, and pale skin (from anemia); ...[emedicinehealth.com]
    • bruising , or blood in the stool Excessive thirst Frequent hiccups Problems with sexual function Menstrual periods stop (amenorrhea) Shortness of breath Sleep problems Vomiting Exams and Tests Most people will have high blood pressure at all stages of[mountsinai.org]
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  • cardiovascular
    Hypertension
    • She is hypertensive and tachycardic.[ems1.com]
    • Hypertension is usually controlled with oral medication, and urinary protein loss may be treated with angiotensin converting enzyme inhibitors.[vet.cornell.edu]
    • Decreased blood flow to the kidney, such as from hypercalcemia (high blood calcium level) or severe heart disease A disease or condition that affects the kidneys, such as hypertension (high blood pressure) or diabetes A blockage in the kidney or ureter[drugs.com]
    • The most common causes are diabetes and high blood pressure ( hypertension ).[labtestsonline.org]
    Hypotension
    • The cause is usually ischemic (from prolonged hypotension) or nephrotoxic (from an agent that is toxic to the tubular cells).[aafp.org]
    • Other signs and symptoms may include orthostatic hypotension and tachycardia.[todaysgeriatricmedicine.com]
    • Dehydration with postural hypotension and no oedema.[patient.info]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    Tachycardia
    • Other signs and symptoms may include orthostatic hypotension and tachycardia.[todaysgeriatricmedicine.com]
    • ., history of vomiting, diarrhea, diuretic overuse, hemorrhage, burns) Weight loss, orthostatic hypotension and tachycardia Thirst and reduced fluid intake Poor skin turgor Cardiac disease Dilated neck veins, S 3 heart sound, pulmonary rales, peripheral[aafp.org]
    • ., tachycardia and hypertension), and approximately five times more likely to be associated with hallucinations ( 8 ).[cdc.gov]
    • Vital signs are assessed frequently, and fever, tachycardia, tachypnea or bradypnea, and hypotension are reported.[medical-dictionary.thefreedictionary.com]
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  • musculoskeletal
    Back Pain
    • C) or chills Muscle aches Night sweats Very little or no urine output Swelling of your hands, legs, or feet Back pain Abdominal pain Extreme tiredness 2000-2016 Krames StayWell, 780 Township Line Road, Yardley, PA 19067.[mountnittany.org]
    • Twelve patients reported abdominal, flank, and/or back pain.[cdc.gov]
    • pain Fever Rash Nosebleed Causes of Acute Kidney Failure There are three main reasons your kidneys fail all of a sudden: Something is stopping blood flow to your kidneys.[webmd.com]
    Muscle Twitch
    • As AKI progresses, you may have any of the following: Decrease in the amount of urine or no urination Swelling in your arms, legs, or feet Weakness, drowsiness, or no appetite Nausea, flank pain, muscle twitching or muscle cramps Itchy skin, or your breath[drugs.com]
    • twitching Seizures or coma (in severe cases) Stomach and back pain Fever Rash Nosebleed Causes of Acute Kidney Failure There are three main reasons your kidneys fail all of a sudden: Something is stopping blood flow to your kidneys.[webmd.com]
    • twitching or cramps Breath odor Easy bruising , or blood in the stool Excessive thirst Frequent hiccups Problems with sexual function Menstrual periods stop (amenorrhea) Shortness of breath Sleep problems Vomiting Exams and Tests Most people will have[mountsinai.org]
    • twitching as a result of increasing potassium levels (hyperkalemia) Changes in the electrocardiogram such as elevated or peaked T waves associated with hyperkalemia Recall that in AKI these signs and symptoms will occur over just a few hours or days.[ems1.com]
    Muscle Weakness
    • Complications of acute kidney injury The most serious complications of acute kidney injury are: high levels of potassium in the blood – in severe cases, this can lead to muscle weakness, paralysis and heart rhythm problems fluid in the lungs (pulmonary[nhs.uk]
    • Potassium intake is restricted because, in renal failure, potassium is not excreted by the kidneys, and hyperkalemia may produce muscle weakness and cardiac rhythm disturbances.[medical-dictionary.thefreedictionary.com]
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  • gastrointestinal
    Nausea
    • Wicked Dreams 7 Oregon 18 Nausea and vomiting, abdominal pain pain 6.6 WBCs, protein 30 Increased cortical echogenicity, no hydronephrosis "Synthetic marijuana" 8 New York 33 Nausea and vomiting 3.3 Not available Not performed Spice Gold 9 Oregon 27[cdc.gov]
    • Symptoms may include anorexia, nausea, and vomiting.[merckmanuals.com]
    • However, someone with AKI can deteriorate quickly and suddenly experience any of the following: nausea and vomiting dehydration confusion high blood pressure abdominal pain slight backache a build-up of fluid in the body ( oedema ) Even if it doesn't[nhs.uk]
    • Symptoms may include swelling, nausea, fatigue, itching, difficulty breathing, and symptoms of the disorder that caused the acute kidney injury.[merckmanuals.com]
    Vomiting
    • […] and vomiting, flank pain 6.3 WBCs, RBCs, epithelial casts, granular casts Not available Blueberry-flavored 4 Wyoming 18 Nausea and vomiting, flank pain 4.1 Hyaline casts, WBCs No increased cortical echogenicity or hydronephrosis Blueberry-flavored or[cdc.gov]
    • The clinical signs of ARF may include sudden anorexia, listlessness, vomiting (the vomited material may have blood in it), diarrhea that also may contain blood, a strange breath odor, and/or seizures.[vcahospitals.com]
    • Felines may present with a sudden onset of vomiting, weakness and dehydration.[petfinder.com]
    • Any warning signs of AKI, such as vomiting or producing little urine, require immediate investigation for AKI and treatment.[nhs.uk]
    • Symptoms may include anorexia, nausea, and vomiting.[merckmanuals.com]
    Loss of Appetite
    • […] of appetite, nausea and vomiting; itching, easy bruising, and pale skin (from anemia); ...[emedicinehealth.com]
    • You may experience the following: Peeing less than normal Swelling in your legs, ankles , and feet (caused by your body holding on to fluid) Drowsiness or feeling very tired Shortness of breath Itching Loss of appetite Confusion Throwing up or feeling[webmd.com]
    • The loss of important proteins and vitamins in their urine may contribute to abnormal metabolism and loss of appetite.[vet.cornell.edu]
    • Accumulation of urea and other nitrogen-containing substances in the bloodstream lead to a number of symptoms, such as fatigue , loss of appetite , headache , nausea and vomiting . [4] Marked increases in the potassium level can lead to abnormal heart[en.wikipedia.org]
    Hiccup
    • Decreased appetite Decreased sensation , especially in the hands or feet Fatigue or slow sluggish movements Flank pain (between the ribs and hips) Hand tremor Heart murmur High blood pressure Nausea or vomiting, may last for days Nosebleeds Persistent hiccups[nlm.nih.gov]
    • […] worse include: Abnormally dark or light skin Bone pain Drowsiness or problems concentrating or thinking Numbness or swelling in the hands and feet Muscle twitching or cramps Breath odor Easy bruising , or blood in the stool Excessive thirst Frequent hiccups[mountsinai.org]
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  • respiratoric
    Tachypnea
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  • neurologic
    Confusion
    • Many different and sometimes confusing terms are used to describe renal function and its deterioration.[veterinarycalendar.dvm360.com]
    • Feeling confused, anxious and restless, or sleepy.[worldkidneyday.org]
    • If you are confused about the difference between acute renal (also called kidney) failure and chronic kidney failure, you came to the right place.[davita.com]
    • […] following: Decrease in the amount of urine or no urination Swelling in your arms, legs, or feet Weakness, drowsiness, or no appetite Nausea, flank pain, muscle twitching or muscle cramps Itchy skin, or your breath or body smells like urine Behavior changes, confusion[drugs.com]
    Seizure
    • Seizures and coma may occur if the condition is untreated.[merckmanuals.com]
    • ., alcohol, cocaine) Seizure Traumatic crush injury Hypercalcemia (high level of calcium in the blood) caused by the following: Deposition of calcium in tissue Vasoconstriction (reduced diameter of blood vessels) Both ischemic and nephrotoxic ARF cause[healthcommunities.com]
    • The clinical signs of ARF may include sudden anorexia, listlessness, vomiting (the vomited material may have blood in it), diarrhea that also may contain blood, a strange breath odor, and/or seizures.[vcahospitals.com]
    • EMS providers will likely consider more common causes of respiratory distress, chest pain or seizures.[ems1.com]
    • […] sensation , especially in the hands or feet Fatigue or slow sluggish movements Flank pain (between the ribs and hips) Hand tremor Heart murmur High blood pressure Nausea or vomiting, may last for days Nosebleeds Persistent hiccups Prolonged bleeding Seizures[nlm.nih.gov]
    Headache
    • ., heart, liver) Overuse of pain medicines called “ NSAIDs ”, which are used to reduce swelling or relieve pain from headaches, colds, flu, and other ailments.[kidney.org]
    • Symptoms may include: Appetite loss General ill feeling and fatigue Headaches Itching ( pruritus) and dry skin Nausea Weight loss without trying to lose weight Symptoms that may occur when kidney function has gotten worse include: Abnormally dark or light[mountsinai.org]
    • High blood pressure may trigger headaches.[encyclopedia.com]
    • High blood pressure may trigger headaches. hypertension, or high blood pressure.[medical-dictionary.thefreedictionary.com]
    • Accumulation of urea and other nitrogen-containing substances in the bloodstream lead to a number of symptoms, such as fatigue , loss of appetite , headache , nausea and vomiting . [4] Marked increases in the potassium level can lead to abnormal heart[en.wikipedia.org]
    Lethargy
    • Hughson, MD, of Shorsh General Hospital in Kurdistan, said the patients complained of weakness and lethargy.[renalandurologynews.com]
    • Signs It’s crucial to notice the signs of acute kidney injury, which include: Lethargy Disorientation Problems with coordination Weakness Increased or decreased thirst Increased or decreased urination Lack of appetite Straining when urinating Vomiting[pethealthnetwork.com]
    • Clinical features and diagnosis Clinical signs of renal failure are often nonspecific and include lethargy, depression, anorexia, vomiting, diarrhea, and dehydration; occasionally uremic breath and/or oral ulcers may be present.[veterinarycalendar.dvm360.com]
    • Another cause of lethargy in cats with CKD is the buildup of acids in their blood.[vet.cornell.edu]
    • Alterations in mental status (lethargy or coma) and bleeding caused by coagulopathy may develop.[medical-dictionary.thefreedictionary.com]
    Altered Mental Status
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  • Entire body system
    Fatigue
    • Symptoms may include swelling, nausea, fatigue, itching, difficulty breathing, and symptoms of the disorder that caused the acute kidney injury.[merckmanuals.com]
    • Kidney Failure: Chronic Kidney Disease Symptoms Effects and symptoms of chronic kidney disease include: need to urinate frequently, especially at night (nocturia); swelling of the legs and puffiness around the eyes (fluid retention); high blood pressure; fatigue[emedicinehealth.com]
    • By LISA FOGARTY Photo Credit Patient Voices: Hepatitis Fatigue, liver disease and the stigma of a contagious disease: six men and women speak about living with hepatitis.[nytimes.com]
    • This makes blood pressure rise. increased fatigue.[medical-dictionary.thefreedictionary.com]
    • […] drugs Symptoms of acute kidney failure may include any of the following: Bloody stools Breath odor and metallic taste in the mouth Bruising easily Changes in mental status or mood Decreased appetite Decreased sensation , especially in the hands or feet Fatigue[nlm.nih.gov]
    Congestive Heart Failure
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    • Hypovolemia – volume depleted, hemorrhage, intravascular volume depletion from congestive heart failure or cirrhosis.[foamcast.org]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • Clinical findings • Cardiovascular Congestive heart failure, myocardial infarction, arrhythmias, cardiac arrest occur in up to 35% of patients with ARF.[medical-dictionary.thefreedictionary.com]
    • NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics.[todaysgeriatricmedicine.com]
    Weight Gain
    • gain of 3 to 5 lb (1.4 to 2.3 kg) in 1 week.[medical-dictionary.thefreedictionary.com]
    • Patients with severe cases, however, may be symptomatic and present with listlessness, confusion, fatigue, anorexia, nausea, vomiting, weight gain, or edema. 15 Patients can also present with oliguria (urine output less than 400 mL per day), anuria (urine[aafp.org]
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  • Liver, Gall & Pancreas
    Asterixis
    • Other presentations of acute kidney injury may include development of uremic encephalopathy (manifested by a decline in mental status, asterixis, or other neurologic symptoms), anemia, or bleeding caused by uremic platelet dysfunction.[aafp.org]
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  • Jaw & Teeth
    Metallic Taste
    • taste in the mouth Bruising easily Changes in mental status or mood Decreased appetite Decreased sensation , especially in the hands or feet Fatigue or slow sluggish movements Flank pain (between the ribs and hips) Hand tremor Heart murmur High blood[nlm.nih.gov]
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  • Workup

    Most persons with AKF are asymptomatic; if at all, the symptoms are generalized and physical examination is not conclusive. Oftentimes, the disorder is detected incidentally from the results of blood and urine tests during consultation for some other medical condition or purpose.

    Laboratory predictors of AKF:

    • Azotemia: Elevated blood urea nitrogen (BUN]) and creatinine.
    • Fluctuating electrolyte levels in the blood (may be abnormally high or low): Impaired perfusion.
    • Anemia: Severe kidney failure is severe. The red blood cell count is low.

    Urine output per unit time or metabolic waste excreted should be measured. Proteins and useful substances are excreted when kidney tissue is damaged. In case of renal retention, urine remaining in the bladder after micturation is measured by inserting a catheter into the bladder. This is done in postrenal failure due to enlarged prostate.

    Dark-colored urine is due to the presence of creatinine and other substances in concentrated form. Microscopy will reveal blood, pus cells and casts as indicators of disease. Measurement of electrolyte levels can help identify the cause of AKF.

    Ultrasonography of the kidneys and bladder can confirm specific causes of kidney failure [10]. Biopsy can be done for histological assessment, if needed.

    Laboratory

    Urine
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  • Serum
    Hyponatremia
    • ., hyperkalemia, hyperphosphatemia, hypermagnesemia, hyponatremia, hypernatremia, metabolic acidosis) is important.[aafp.org]
    Creatinine Increased
    • Stage II, acute kidney injury, is when the creatinine increases by over 200 percent.[ucsfhealth.org]
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  • Imaging

    X-ray
    Congestive Heart Failure
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    • Hypovolemia – volume depleted, hemorrhage, intravascular volume depletion from congestive heart failure or cirrhosis.[foamcast.org]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • Clinical findings • Cardiovascular Congestive heart failure, myocardial infarction, arrhythmias, cardiac arrest occur in up to 35% of patients with ARF.[medical-dictionary.thefreedictionary.com]
    • NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics.[todaysgeriatricmedicine.com]
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  • ECG

    QT, RR, ST Intervals
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  • Treatment

    Complicated and advanced cases of AKF are confined in the intensive care unit of the hospital and treated as a medical emergency. Catheterization, endoscopy or surgery are indicated in cases of postrenal AKF or obstruction of the renal outflow.

    Uncomplicated cases of less than 5 days duration, without infection or malignancy may heal spontaneously with palliative procedures alone. Restoring normal kidney function can be attained by:

    • Regulating or restricting the use of certain medications
    • Maintaining proper nutrition.
    • Restricting fluids, dietary sodium, phosphorus and potassium.
    • Regulating blood levels of potassium and phosphate.
    • Initiating dialysis.

    For anemia, infusion of crystalloid (normal saline or lactated Ringers) or colloid (in cases of significant hypoalbuminemia) fluids with packed RBCs is recommended [2]. Use of semisynthetic hydroxyethyl starch has been linked to higher mortality rates [11]. Blood transfusion is optional if only 1 unit is required. Fluid resuscitation should be managed by an expert in this procedure.

    Proper diet, with protein equivalent to 0.8 to 1 grams per kilogram of body weight (0.4 to 0.5 grams per pound) may be prescribed. No foods that are high in phosphorus (e.g., liver, nuts, dairy products, legumes, and soft drinks) to lower the phosphorus concentration in the blood. Calcium salts (calcium carbonate or calcium acetate) or sevelamer may be taken orally to lower phosphate levels in the blood. To reduce potassium level in the blood, sodium polystyrene sulfonate may be given per orem or via the rectum.

    Prolonged AKF leads to the accumulation of metabolic wastes and excess fluids in the blood, necessitating removal of these by hemodialysis. Dialysis is initiated as per need or in some cases repeated for several weeks until the kidneys normal function is restored.

    Prognosis

    Recovery from acute kidney failure is determined by the nature and location of the underlying cause of the disease. Prognosis is good and full recovery may be expected when the disease process does not involve direct damage to the kidney parenchyma itself. Partial recovery is possible in cases where there is residual pathology. Prognosis is poor when the patient is in the advanced stage of disease at the onset of renal failure. Mortality is high in severe cases of acute renal injury [9].

    In a longitudinal study of 1-10 years period, about 12.5% of survivors of acute renal failure had to undergo dialysis; 19-31% of these patients had chronic kidney disease. The mortality rate in hospitalized AKF patients is 40- 50%. The mortality rate among ICU patients with acute kidney failure requiring dialysis is 70-to 80%.

    Complications

    Proteinuria
    • , acute kidney injury in older patients Multiple myeloma Positive antinuclear antibody, double-stranded DNA antibody Proteinuria, skin rash, arthritis Autoimmune diseases, systemic lupus erythematosus Positive blood cultures Intravenous drug use, recent[aafp.org]
    • Immunology: Serum immunoglobulins, serum protein electrophoresis, Bence Jones' proteinuria: immune paresis, monoclonal band on serum protein electrophoresis, and Bence Jones' proteinuria suggest myeloma.[patient.info]
    • Urinalysis for 15 patients showed variable results: proteinuria (eight patients), casts (five), white blood cells (nine), and red blood cells (eight).[cdc.gov]
    • Then you can look for albuminuria and proteinuria and work it up as appropriate.”[todayshospitalist.com]
    • Proteinuria A large cohort study demonstrated that proteinuria coupled with low baseline GFR is associated with a higher incidence of AKI and should be considered as an identifying factor for individuals at risk.[emedicine.medscape.com]
    Coma
    • Seizures and coma may occur if the condition is untreated.[merckmanuals.com]
    • Signs and symptoms of acute kidney injury differ depending on the cause and may include: Too little urine leaving the body Swelling in legs, ankles, and around the eyes Fatigue or tiredness Shortness of breath Confusion Nausea Seizures or coma in severe[kidney.org]
    • […] legs, ankles , and feet (caused by your body holding on to fluid) Drowsiness or feeling very tired Shortness of breath Itching Loss of appetite Confusion Throwing up or feeling like you’re going to Chest pain or pressure Muscle twitching Seizures or coma[webmd.com]
    • […] all of the following problems: Not enough urine Swelling in your legs, ankles or feet Feeling tired Trouble catching your breath Feeling confused Nausea Pain or pressure in your chest If you have very severe AKI, you may have seizures or fall into a coma[kidneyfund.org]
    Congestive Heart Failure
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    • Hypovolemia – volume depleted, hemorrhage, intravascular volume depletion from congestive heart failure or cirrhosis.[foamcast.org]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • Clinical findings • Cardiovascular Congestive heart failure, myocardial infarction, arrhythmias, cardiac arrest occur in up to 35% of patients with ARF.[medical-dictionary.thefreedictionary.com]
    • NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics.[todaysgeriatricmedicine.com]
    Hypertension
    • She is hypertensive and tachycardic.[ems1.com]
    • Hypertension is usually controlled with oral medication, and urinary protein loss may be treated with angiotensin converting enzyme inhibitors.[vet.cornell.edu]
    • Decreased blood flow to the kidney, such as from hypercalcemia (high blood calcium level) or severe heart disease A disease or condition that affects the kidneys, such as hypertension (high blood pressure) or diabetes A blockage in the kidney or ureter[drugs.com]
    • The most common causes are diabetes and high blood pressure ( hypertension ).[labtestsonline.org]
    Interstitial Nephritis
    • Allergic interstitial nephritis can be triggered by several different types of drugs .[healthcommunities.com]
    • Acute interstitial nephritis due to drugs (eg, NSAIDs), infection or autoimmune diseases.[patient.info]
    • Acute interstitial nephritis: clinical features and response to corticosteroid therapy.[aafp.org]
    • ., acute interstitial nephritis, pyelonephritis).[foamcast.org]
    • nephritis”) A group of diseases (called “scleroderma”) that affect the connective tissue that supports your internal organs Conditions that cause inflammation or damage to the kidney tubules, to the small blood vessels in the kidneys, or to the filtering[kidney.org]
    Acidosis
    • Indications for emergent dialysis – AEIOU A- Acidosis E- Electrolyte emergencies (hyperkalemia!)[foamcast.org]
    • Acidosis develops because hydrogen ions cannot be excreted.[merckmanuals.com]
    • The uremic syndrome is a constellation of clinical signs, including anemia, gastroenteritis, acidosis, pneumonitis, osteodystrophy, and encephalopathy, which occur secondary to uremia.[veterinarycalendar.dvm360.com]
    • Arterial blood gas and blood chemistries may show metabolic acidosis .[lutheranhealthcare.org]
    • AKI may lead to a number of complications, including metabolic acidosis , high potassium levels , uremia , changes in body fluid balance , and effects on other organ systems , including death.[en.wikipedia.org]
    Metabolic Acidosis
    • Suggested renoresuscitation measures: (1) Avoid renal failure – avoid nephrotoxins (many antibiotics, NSAIDs, ace-inhibitors), avoid hyperchloremic metabolic acidosis. (2) Avoid volume overload – treating decreased urine output by flooding a patient with[foamcast.org]
    • Arterial blood gas and blood chemistries may show metabolic acidosis .[lutheranhealthcare.org]
    • AKI may lead to a number of complications, including metabolic acidosis , high potassium levels , uremia , changes in body fluid balance , and effects on other organ systems , including death.[en.wikipedia.org]
    • ., granular casts and renal epithelial cells), and relatively severe hyperkalemia and metabolic acidosis (especially in the face of oliguria).[veterinarycalendar.dvm360.com]
    • acidosis) – which can cause nausea, vomiting, drowsiness and breathlessness[nhs.uk]
    Hypotension
    • The cause is usually ischemic (from prolonged hypotension) or nephrotoxic (from an agent that is toxic to the tubular cells).[aafp.org]
    • Other signs and symptoms may include orthostatic hypotension and tachycardia.[todaysgeriatricmedicine.com]
    • Dehydration with postural hypotension and no oedema.[patient.info]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    Hyperkalemia
    • Indications for emergent dialysis – AEIOU A- Acidosis E- Electrolyte emergencies (hyperkalemia!)[foamcast.org]
    • The most serious of these disorders are hyperkalemia and fluid overload (possibly causing pulmonary edema).[merckmanuals.com]
    • Severe hyperkalemia is defined as potassium levels of 6.5 mEq per L (6.5 mmol per L) or greater, or less than 6.5 mEq per L with electrocardiographic changes typical of hyperkalemia (e.g., tall, peaked T waves).[aafp.org]
    • Leading indications for dialysis are volume overload and hyperkalemia.[clevelandclinicmeded.com]
    • ) Changes in the electrocardiogram such as elevated or peaked T waves associated with hyperkalemia Recall that in AKI these signs and symptoms will occur over just a few hours or days.[ems1.com]
    Hyperphosphatemia
    • Phosphate retention leads to hyperphosphatemia.[merckmanuals.com]
    • Renal failure can also cause significant problems for the patient such as electrolyte abnormalities (hyperkalemia the most worriesome, but also hyperphosphatemia) and pulmonary edema.[foamcast.org]
    • Oral intake of phosphorus must also be limited as prescribed; alternately, phosphorus-binding medications are taken with meals to prevent hyperphosphatemia.[medical-dictionary.thefreedictionary.com]
    • ., hyperkalemia, hyperphosphatemia, hypermagnesemia, hyponatremia, hypernatremia, metabolic acidosis) is important.[aafp.org]
    Hypernatremia
    • ., hyperkalemia, hyperphosphatemia, hypermagnesemia, hyponatremia, hypernatremia, metabolic acidosis) is important.[aafp.org]
    Hyponatremia
    • ., hyperkalemia, hyperphosphatemia, hypermagnesemia, hyponatremia, hypernatremia, metabolic acidosis) is important.[aafp.org]
    Hypermagnesemia
    • ., hyperkalemia, hyperphosphatemia, hypermagnesemia, hyponatremia, hypernatremia, metabolic acidosis) is important.[aafp.org]
    Hypocalcemia
    • Hypocalcemia is thought to occur because the impaired kidney no longer produces calcitriol and because hyperphosphatemia causes calcium phosphate precipitation in the tissues.[merckmanuals.com]
    Retinopathy
    • […] examination may reveal the following: Keratitis, iritis, uveitis, dry conjunctivae: Autoimmune vasculitis Jaundice: Liver diseases Band keratopathy (ie, hypercalcemia): Multiple myeloma Signs of diabetes mellitus Signs of hypertension Atheroemboli: Retinopathy[emedicine.medscape.com]
    Polyarteritis Nodosa
    • Vascular disease: vasculitis (usually associated with antineutrophil cytoplasmic antibody), cryoglobulinaemia, polyarteritis nodosa, thrombotic microangiopathy, cholesterol emboli, renal artery stenosis, renal vein thrombosis, malignant hypertension.[patient.info]
    • In addition, diseases exist that commonly present with simultaneous pulmonary and renal involvement, including the following: Goodpasture syndrome Granulomatosis with polyangiitis (Wegener granulomatosis) Polyarteritis nodosa Cryoglobulinemia Sarcoidosis[emedicine.medscape.com]
    • ., Goodpasture syndrome, Wegener granulomatosis, polyarteritis nodosa, cryoglobulinemia, sarcoidosis.[medical-dictionary.thefreedictionary.com]
    Diabetic Ketoacidosis
    • ., diabetic ketoacidosis*) Extrarenal loss from vomiting, diarrhea,* burns, sweating, blood loss Intrinsic renal Glomerular (e.g., postinfectious and other glomerulonephritis) Interstitial Medications: penicillin analogues,* cephalosporins,* sulfonamides[aafp.org]
    • ketoacidosis can interfere with the alkaline picrate method), causing a false elevation in SCr [ 32 ]; Cr is a marker of renal function, and not of renal lesion.[oxfordjournals.org]

    Etiology

    The underlying causes of acute kidney failure by location of injury [3]:

    Causes

    Congestive Heart Failure
    • These comorbidities include diabetes mellitus, congestive heart failure, acute hypotension (requiring pressors or intra-aortic balloon pump), ST-elevation myocardial infarction, and volume depletion.[circ.ahajournals.org]
    • Hypovolemia – volume depleted, hemorrhage, intravascular volume depletion from congestive heart failure or cirrhosis.[foamcast.org]
    • According to Mehran, et al. 5 , the incidence of CIN increases with these patient-related characteristics: Renal Insufficiency Hypotension Congestive Heart Failure Hypotension Age 75 years Anemia Diabetes Mellitus The risk of CIN is directly proportional[renalguard.com]
    • Clinical findings • Cardiovascular Congestive heart failure, myocardial infarction, arrhythmias, cardiac arrest occur in up to 35% of patients with ARF.[medical-dictionary.thefreedictionary.com]
    • NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics.[todaysgeriatricmedicine.com]
    Hypertension
    • She is hypertensive and tachycardic.[ems1.com]
    • Hypertension is usually controlled with oral medication, and urinary protein loss may be treated with angiotensin converting enzyme inhibitors.[vet.cornell.edu]
    • Decreased blood flow to the kidney, such as from hypercalcemia (high blood calcium level) or severe heart disease A disease or condition that affects the kidneys, such as hypertension (high blood pressure) or diabetes A blockage in the kidney or ureter[drugs.com]
    • The most common causes are diabetes and high blood pressure ( hypertension ).[labtestsonline.org]
    Metabolic Acidosis
    • Suggested renoresuscitation measures: (1) Avoid renal failure – avoid nephrotoxins (many antibiotics, NSAIDs, ace-inhibitors), avoid hyperchloremic metabolic acidosis. (2) Avoid volume overload – treating decreased urine output by flooding a patient with[foamcast.org]
    • Arterial blood gas and blood chemistries may show metabolic acidosis .[lutheranhealthcare.org]
    • AKI may lead to a number of complications, including metabolic acidosis , high potassium levels , uremia , changes in body fluid balance , and effects on other organ systems , including death.[en.wikipedia.org]
    • ., granular casts and renal epithelial cells), and relatively severe hyperkalemia and metabolic acidosis (especially in the face of oliguria).[veterinarycalendar.dvm360.com]
    • acidosis) – which can cause nausea, vomiting, drowsiness and breathlessness[nhs.uk]
    Diabetic Ketoacidosis
    • ., diabetic ketoacidosis*) Extrarenal loss from vomiting, diarrhea,* burns, sweating, blood loss Intrinsic renal Glomerular (e.g., postinfectious and other glomerulonephritis) Interstitial Medications: penicillin analogues,* cephalosporins,* sulfonamides[aafp.org]
    • ketoacidosis can interfere with the alkaline picrate method), causing a false elevation in SCr [ 32 ]; Cr is a marker of renal function, and not of renal lesion.[oxfordjournals.org]

    Epidemiology

    Acute kidney injury is an escalating problem of clinical and public health importance. Two to three cases per 1,000 persons are diagnosed each year [4]. Seven percent of in-patients and 75% of severely ill patients develop the disease in conjunction with multiple organ disorders.

    Sex distribution
    Age distribution

    Pathophysiology

    Low blood pressure or slow blood flow to the kidneys diminishes the kidney's filtration function, causing the accumulation of nitrogenous waste products in the blood (prerenal azotemia). Consequently, the kidneys respond to the decrease in glomerular filtration rate by reabsorbing sodium and water back into the blood stream to maintain electrolyte and fluid balance. Baroreceptors in the carotid artery and aortic arch likewise respond by causing vasoconstriction of the glomerular efferent arteriole and dilatation of the afferent arteriole to limit glomerular filtration. The renin/angiotensin/aldosterone system is activated, whereby, angiotensin II, another vasoconstrictor, causes aldosterone to be released and resulting in reabsorption of sodium and water at the renal tubules. Hypovolemia (low blood volume) likewise stimulates the hypothalamus to signal the release of ADH (anitdiurectic hormone or vasopressin), leading to further resorption of water in the tubules thus, concentrating the urine.

    After glomerular dysfunction, direct damage to the kidneys is brought about by pathophysiological processes involving the inner wall of small blood vessels and death of epithelial cells in the renal tubules or acute tubular necrosis (ATN), secondary to ischemia (lack of oxygen) of the kidneys. Damage is most severe in the proximal part of the tubule and outer layers of the medulla. Incremental reactive oxygen species, decreased ATP, and death of cells are the results of hypoxemia [5]. Immune-mediated reactions such as, activation of complement, participation of cytokines, chemokines, neutrophils, complement-mediated attack on membranes, and vasoactive hormones all contribute to disrupting the integrity of the renal parenchyma. Exposure to poisons, medications, and contrast dye used for x-ray studies may also cause ATN. Toxicity to cells from the dye  and constriction of blood vessels were observed in animal models. These resulted in increased viscosity, low oxygen tension in the blood and poor circulation in the renal medulla [6].

    Renal injury at the level of the ureters is associated with blocked tubules resulting from increased internal pressure causing ischemia and degeneration. Presence of monocytes and macrophages, cytokines, free radicals, proteases, and TNF-beta are linked to direct damage on the tubules and fibrosis [7].

    The possible involvement of a genetic component in the etiology of AKI is being considered with apolipoprotein E (APO-E) genes [8]. More genes may be anticipated in future studies.

    Prevention

    The National Institute for Health and Care Excellence (NICE/UK) recommends eliminating the causes of acute kidney failure as the best strategy for prevention [12]. NICE guidance of 2013 emphasizes the importance of early detection of patients at risk by monitoring their urinary output and creatinine levels. Risk factors such as nephrotoxic drugs and iodinated contrast agents should be avoided. These guidelines apply to all acutely ill patients in hospital. An alternative to the use of contrast dye is intravenous volume expansion with isotonic sodium bicarbonate or 0.9% sodium chloride [13].

    Summary

    Acute kidney failure (AKF), also referred to as acute kidney injury or acute renal failure, is the sudden disruption of renal filtration function, resulting in the accumulation of metabolic wastes and electrolytes in the blood, which is life-threatening. AKF is known to occur in hospitalized patients, especially those who are in an advanced stage of illness and who are, therefore, the most vulnerable among high risk groups. AKF may develop within hours or, at most, a few days, and as such, it is treated as a medical emergency. Presumably, except in the case of a patient with severe disease or multiorgan dysfunction, it is possible to reverse the damage to the kidneys and to recover from AKF.

    The organization Kidney Disease: Improving Global Outcomes (KDIGO) considers a case as acute kidney failure when [1]:

    • The urine output is <0.5 mL/kg/hour for 6 hours or
    • Serum creatinine level increase by ≥0.3 mg/dL within 48 hours; or
    • Serum creatinine is ≥1.5 times of baseline, for 7 days prior to consultation.

    The pathophysiology of AKF [2] can be classified into three subgroups:

    • Prerenal AKF due to decline in filtration function
    • Intrinsic AKF due to direct damage to the kidneys
    • Postrenal AKF due to impairment of excretory function

    The cause of AKF is multifactorial based on the aforementioned classification. It ranges from impairment of blood flow to the kidneys, to infections and malignancies, and obstruction of the ureters. Symptoms are oftentimes generalized or mimic other diseases. Diagnosis is based on laboratory examinations and confirmatory imaging studies of the underlying causes of AKF. The rationale of treatment is to eliminate the causes and to restore the normal functioning of the kidneys. Prevention depends on a large extent on primary health care and avoidance of the predisposing conditions.

    Patient Information

    Acute kidney failure (AKF) is the sudden inability of the kidneys to filter off excess salts, fluids, and waste materials from the blood, which, if left untreated, can lead to fatal consequences. In-patients who are severely ill, are most likely to develop AKF. Sudden onset and rapid progression of the disease characterize AKF in contrast to chronic kidney disease in which the loss of kidney function is gradual and lasts over a long period of time. The cause of AKF is diverse which ranges from infection, trauma, pathophysiological processes, autoimmunity, systemic diseases, to malignancy. AKF occurs in three stages:

    • Prerenal - impairment of the filtering function.
    • Intrinsic - direct damage to the kidney tissue.
    • Postrenal - obstruction with excretion of urine via the ureters.

    Causes

    Conditions that predispose to acute kidney failure are: autoimmune diseases (e.g., acute nephritic syndrome and interstitial nephritis); acute tubular necrosis (ATN); severe or sudden dehydrationurinary tract obstruction; and toxicity from poisons or certain medications.

    Reduced blood flow that are associated with the following conditions can impair kidney functions. These are: hemorrhageseptic shock, dehydration, low blood pressure, burns, trauma, serious illness, and surgery.

    Conditions that are associated with clotting of blood, leading to AKF include: transfusion reactionhemolytic uremic syndromescleroderma; idiopathic thrombocytopenic thrombotic purpura (ITTP); and malignant hypertension.

    Other conditions that can cause complications and damage the kidneys are: infections, such as septicemia and acute pyelonephritisplacenta previa and placenta abruption in pregnancy.

    Symptoms

    Symptoms that can occur abruptly and progress rapidly in AKF are edema and crackling sound in the lungs (due to fluid retention), nausea and vomitingconfusion, low back pain, dehydration, abdominal pain, and high blood pressure.

    Diagnosis

    Routine laboratory tests for AKF include serum creatinine, creatinine clearance time, blood urea nitrogen (BUN), serum potassium, serum sodium, urinalysis (microscopy), estimated glomerular filtration rate (eGFR) and certain blood tests (optional). Preferred imaging procedure is ultrasound, others that can be helpful in detecting postrenal dysfunction are X-ray, MRI, and CT scan.

    Treatment

    Treatment is based on mitigating and if possible, eliminating the conditions which lead to the development of AKF. Complete recovery is not always possible, but repair of the damage to the kidneys should at least restore part of the filtration function and normal physiologic responses. Early detection and prompt intervention can reverse the threat to human life.

    Dietary restriction must be observed in terms of kinds and amount of fluids, protein (low), salt (low), carbohydrates (high) and potassium (low) to prevent the accumulation of toxic substances in the kidneys.

    Prescriptions of antibiotics, for infection; diuretics, to facilitate excretion of urine; calcium and insulin, to regulate blood potassium levels must be complied with.

    Dialysis may be needed to facilitate removal of accumulated nitrogenous waste in the blood. It is mandatory in cases of cessation of micturation, dementia, pericarditis, and high potassium blood level.

    Other symptoms

    Cisplatin
    • ., cisplatin, ifosfamide) Cyclosporine Radiocontrast dyes (used in imaging procedures) Some toxins are released by tissues as a result of injury or are created by electrolyte imbalance.[healthcommunities.com]
    • Apoptosis induced by cisplatin nephrotoxic injury.[comprehensivephysiology.com]
    • Patients can also be put at risk by angiotensin-converting enzyme (ACE) inhibitors, cisplatin, ifosfamide, and even Chinese herbal remedies.[clevelandclinicmeded.com]
    • Drug-Induced Kidney Failure Antihypertensives ACE inhibitors ARBs (“sartans”) Diuretics Antimicrobials Aminogycosides Cephlosporins Fluroquinolones Penicillins Pentamadine Sulfonamides Tetracyclines Vancomycin Anti-inflammatories NSAIDs Antineoplastics Cisplatin[todaysgeriatricmedicine.com]
    • ., radiographic contrast agents,* aminoglycosides,* cisplatin, methotrexate, ethylene glycol, amphotericin B) and endogenous toxins (e.g., hemolysis and rhabdomyolysis [pigment nephropathy], tumor lysis syndrome, myeloma) Vascular Renal vein thrombosis[aafp.org]
    Angiotensin-Converting Enzyme Inhibitor
    • Hypertension is usually controlled with oral medication, and urinary protein loss may be treated with angiotensin converting enzyme inhibitors.[vet.cornell.edu]
    • Notably, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can impair renal perfusion by causing dilation of the efferent arteriole and reduce intraglomerular pressure.[aafp.org]
    • Box 1: Drugs and Other Exogenous Causes of Acute Renal Failure Analgesics Nonsteroidal anti-inflammatory drugs (NSAIDs) Anesthetics Enflurane Methoxyflurane Angiotensin-Converting Enzyme Inhibitors Antimicrobials Acyclovir Aminoglycosides Amphotericin[clevelandclinicmeded.com]
    • And in particular, for example, many people, chronic disease are on diuretics, many of them are on a class of drug called angiotensin converting enzyme inhibitors, so ACE inhibitors, or angiotensin receptor blockers.[ucsfhealth.org]
    • Treatment Diuretics (including furosemide and bumetanide), neurohormonal agents (such as angiotensin-converting enzyme inhibitors or angiotension receptor blockers), beta blockers (such as carvedilol or bisoprolol) are often combined in the acute and[medical-dictionary.thefreedictionary.com]
    Cyclophosphamide
    • ., cyclophosphamide, prednisone) in patients with rapidly progressive glomerulonephritis.[aafp.org]
    • AKI due to crescentic glomerulonephritis may respond to treatment with prednisolone and cyclophosphamide, together with the addition of plasma exchange.[patient.info]
    • For example, intrinsic AKI due to vasculitis or glomerulonephritis may respond to steroid medication, cyclophosphamide , and (in some cases) plasma exchange .[en.wikipedia.org]
    Microscopic Polyangiitis
    • […] tubulointerstitial nephritis, tumors damaging the kidneys, or injury to blood vessels as occurs with hemolytic-uremic syndrome, systemic lupus erythematosus [lupus], atheroembolic kidney disease, Goodpasture syndrome, granulomatosis with polyangiitis, or microscopic[merckmanuals.com]
    • polyangiitis), anti-PR3 antibodies, anti-MPO antibodies.[patient.info]
    • polyangiitis Immune complex glomerulonephritis - Lupus, postinfectious glomerulonephritis, cryoglobulinemia, primary membranoproliferative glomerulonephritis Tubular etiologies may include ischemia or cytotoxicity.[emedicine.medscape.com]

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    References

    1. Kidney disease: improving global outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Inter Suppl. 2012; 2:1-138.
    2. Sharfuddin AA, Weisbord SD, Palevsky PM, et al. Acute kidney injury. In: Taal MW, Chertow GM, Marsden PA, et al, eds. Brenner and Rector's The Kidney. 9th ed. Philadelphia, PA: Saunders; 2012.
    3. Lameire N, Van Biesen W, Vanholder R. Acute renal failure. Lancet. 2005; 365:417-430.
    4. Hoste EA, Schurgers M. Epidemiology of acute kidney injury: how big is the problem? Crit Care Med. 2008; 36(4 suppl):S146–S151.
    5. Kaushal GP, Basnakian AG, Shah SV. Apoptotic pathways in ischemic acute renal failure. Kidney Int. 2004; 66:500-506.
    6. Weisberg LS, Kurnik PB, Kurnik BR, et al. Radiocontrast induced nephropathy in humans. Role of renal vasoconstriction. Kidney Int. 1992; 41:1408-1415.
    7. Schreiner GF, Kohan DE. Regulation of renal transport processes and hemodynamics by macrophages and lymphocytes. Am J Kidney Dis. 1990; 258:F761-F767.
    8. Lu JC, Coca SG, Patel UD, et al. Searching for genes that matter in acute kidney injury: a systematic review. Clin J Am Soc Nephrol. 2009; 4:1020-1031.
    9. Goldberg R, Dennen P. Long-term outcomes of acute kidney injury. Adv Chronic Kidney Dis. 2008; 15(3):297–307.
    10. Davis PC, Wippold FJ II, Cornelius RS, et al. ACR Appropriateness Criteria® renal failure. National Guideline Clearinghouse. Accessed: March 24, 2011. 8 p.
    11. Zarychanski R, Abou-Setta AM, Turgeon AF, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis. JAMA. 2013; 7:678-688.
    12. Fliser D, Laville M, Covic A, et al; A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant. 2012 Dec; 27(12):4263-72.
    13. Acute kidney injury - Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy; NICE Guidelines (Aug 2013).

    • Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention - J Kay, WH Chow, TM Chan, SK Lo - JAMA: the journal of , 2003 - Am Med Assoc
    • Acute renal failure in kidney transplant patients treated with interferon alpha 2b for chronic hepatitis C - L Rostaing, A Modesto, E Baron, J Cisterne - Nephron, 1996 - content.karger.com
    • For the diagnosis and treatment of acute and chronic heart failure 2008 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the - K Dickstein, A Cohen-Solal, G Filippatos - European heart , 2008 - Eur Soc Cardiology
    • Acute renal failure in infancy and childhood: Clinical course and treatment of 41 patients - CA Gianantonio, M Vitacco, J Mendilaharzu - The Journal of , 1962 - Elsevier
    • A comparison of enalapril with hydralazine–isosorbide dinitrate in the treatment of chronic congestive heart failure - JN Cohn, G Johnson, S Ziesche, F Cobb - England Journal of , 1991 - Mass Medical Soc
    • 3–5 year longitudinal follow-up of pediatric patients after acute renal failure - DJ Askenazi, DI Feig, NM Graham, S Hui-Stickle - Kidney , 2006 - nature.com
    • A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease - D Fouque, K Kalantar-Zadeh, J Kopple, N Cano - Kidney , 2007 - nature.com
    • A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease - D Fouque, K Kalantar-Zadeh, J Kopple, N Cano - Kidney , 2007 - nature.com
    • Acute renal failure in patients with rhabdomyolysis. - W Sułowicz, B Walatek, A Sydor - medical journal of , 2002 - ncbi.nlm.nih.gov
    • Acute renal failure due to accelerated hypertension following ingestion of 3, 4-methylenedioxymethamphetamine ('ecstasy') - G Woodrow, P Harnden, JH Turney - Nephrology Dialysis , 1995 - ERA-EDTA
    • Effect of pharmacological modulation of the GABAA‐benzodiazepine receptor on hepatic encephalopathy in the rat: Comparison with uremic encephalopathy - P Steindl, A Püspök, W Druml, P Ferenci - Hepatology, 2005 - Wiley Online Library
    • A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients - SM Bagshaw, C George, R Bellomo - Nephrology Dialysis , 2008 - ERA-EDTA
    • Acute increase in plasma osmolality as a cause of hyperkalemia in patients with renal failure - G Conte, A Dal Canton, P Imperatore, L De Nicola - Kidney Int, 1990 - nature.com
    • Acute kidney injury in children - SP Andreoli - Pediatric Nephrology, 2009 - Springer
    • A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure - RL Mehta, B Mcdonald, FB Gabbai, M Pahl - Kidney , 2001 - nature.com
    • Acute hypermagnesemia after laxative use - TI Qureshi, TK Melonakos - Annals of emergency medicine, 1996 - Elsevier
    • A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients - SM Bagshaw, C George, I Dinu - Nephrology dialysis , 2008 - ERA-EDTA
    • 4A randomized trial of prolonged prone positioning in children with acute respiratory failure - A Kornecki, H Frndova, AL Coates - CHEST , 2001 - journal.publications.chestnet.org
    • Acute phosphate nephropathy following oral sodium phosphate bowel purgative: an underrecognized cause of chronic renal failure - GS Markowitz, MB Stokes - Journal of the , 2005 - Am Soc Nephrol
    • Acute renal failure associated with immunoglobulin therapy - TG Cantú, EW Hoehn-Saric, KM Burgess - journal of kidney , 1995 - Elsevier
    • Acute kidney failure: a pediatric experience over 20 years - DM Williams, SS Sreedhar, JJ Mickell - Archives of pediatrics & , 2002 - Am Med Assoc
    • Acute digitalis intoxication-is pacing still appropriate? - P Taboulet, FJ Baud, C Bismuth - Clinical Toxicology, 1993 - informahealthcare.com
    • Halitosis: an etiologic classification, a treatment approach, and prevention - DP Lu - Oral Surgery, Oral Medicine, Oral Pathology, 1982 - Elsevier
    • Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention - J Kay, WH Chow, TM Chan, SK Lo - JAMA: the journal of , 2003 - Am Med Assoc
    • A proposed nomenclature and diagnostic criteria for protein–energy wasting in acute and chronic kidney disease - D Fouque, K Kalantar-Zadeh, J Kopple, N Cano - Kidney , 2007 - nature.com
    • A trial of thyroxine in acute renal failure - CG Acker, AR Singh, RP Flick, J Bernardini - Kidney , 2000 - nature.com
    • OF ACUTE RENAL FAILURE TREATED WITH CONTINUOUS RENAL REPLACEMENT THERAPYOLIGURIC ACUTE RENAL FAILURE SECONDARY TO SEVERE - H Hayashi, W Sato, S Maruyama, D Sugiyama - NDT , 2009 - ckj.oxfordjournals.org
    • 3–5 year longitudinal follow-up of pediatric patients after acute renal failure - DJ Askenazi, DI Feig, NM Graham, S Hui-Stickle - Kidney , 2006 - nature.com
    • A novel clinical scoring system for outcome prediction in dogs with acute kidney injury managed by hemodialysis - G Segev, PH Kass, T Francey - Journal of Veterinary , 2008 - Wiley Online Library
    • For the diagnosis and treatment of acute and chronic heart failure 2008 The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the - K Dickstein, A Cohen-Solal, G Filippatos - European heart , 2008 - Eur Soc Cardiology
    • AASLD position paper: the management of acute liver failure - J Polson, WM Lee - Hepatology, 2005 - Wiley Online Library
    • Acute multiorgan failure syndrome: a potentially catastrophic complication of severe sickle cell pain episodes - KL Hassell, JR Eckman, PA Lane - The American journal of medicine, 1994 - Elsevier
    • Acetylcysteine for prevention of acute deterioration of renal function following elective coronary angiography and intervention - J Kay, WH Chow, TM Chan, SK Lo - JAMA: the journal of , 2003 - Am Med Assoc
    • A disorder of muscle lipid metabolism and myoglobinuria. Absence of carnitine palmityl transferase. - WJ Bank, S DiMauro, E Bonilla, DM Capuzzi - The New England , 1975 - ukpmc.ac.uk
    • Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission* - G Marenzi, E Assanelli, J Campodonico - Critical care , 2010 - journals.lww.com
    • Acute Kidney Injury in Cancer Patients - M Darmon, L Camous, C Devanlay, E Canet - Involvement in Patients , 2011 - Springer
    • Acute renal failure following intravenous immunoglobulin therapy - SMA Shah, CW Graeber - Hospital Physician, 2005 - tebwjec.turner-white.com
    • Acute renal failure among Blacks and Indians in South Africa - YK Seedat - S Afr Med J, 1978 - archive.samj.org.za
    • Acute kidney injury - JA Kellum - Critical care medicine, 2008 - journals.lww.com
    • Acute kidney failure: a pediatric experience over 20 years - DM Williams, SS Sreedhar, JJ Mickell - Archives of pediatrics & , 2002 - Am Med Assoc
    • Acute renal failure in HIV-infected patients: a brief review of common causes - MA Perazella - The American journal of the medical sciences, 2000 - journals.lww.com
    • Acquired Bartter-like syndrome associated with gentamicin administration - CL Chou, YH Chen, T Chau, SH Lin - The American journal of the , 2005 - journals.lww.com
    • Acute hypercapnic respiratory failure due to thyrotoxic periodic paralysis - YC Liu, WS Tsai, T Chau, SH Lin - The American journal of the , 2004 - journals.lww.com
    • A retrospective 5‐year study in Moldova of acute renal failure due to leptospirosis: 58 cases and a review of the literature - A Covic, DJA Goldsmith, P Gusbeth‐Tatomir - Nephrology Dialysis , 2003 - ERA-EDTA
    • A Clinical Study Of Nail Changes In Geriatric Age Group - NS Haneef - 2006 - 119.82.96.198
    • 3–5 year longitudinal follow-up of pediatric patients after acute renal failure - DJ Askenazi, DI Feig, NM Graham, S Hui-Stickle - Kidney , 2006 - nature.com
    • Acute reactions to urographic contrast media. - P Davies, MB Roberts, J Roylance - British medical journal, 1975 - ncbi.nlm.nih.gov
    • Of freeze-dried Lactobacillus acidophilus on small bowel bacterial overgrowth in patients with end stage kidney disease: reducing uremic toxins and improving - SR Dunn, ML Simenhoff, KE Ahmed - International dairy , 1998 - Elsevier
    • Amyloidosis in familial Mediterranean fever: an independent genetically determined character - H HELLER, E SOHAR, J GAFNI - Archives of internal , 1961 - Am Med Assoc

    Media References

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