Acute kidney injury

(Redirected from Nephrotoxicity)


  • Majority of cases of community-acquired ARF is secondary to volume depletion although consideration of pre-renal, post renal, and renal causes are important.

AKI Staging

1 Cr 1.5-1.9x baseline over 7d or ≥0.3 mg/dL increase over 48hrs <0.5 mL/kg/hr for 6-12hrs
2 Cr 2.0-2.9x baseline <0.5 mL/kg/hr for >12hrs
3 Cr ≥3.0x baseline or ≥4.0 mg/dL increase or initiation of RRT <0.3 mL/kg/hr for >24hrs or anuria for >12hrs

Chronic Kidney Disease Stages

  • Useful if patient's baseline creatinine is unknown
    • Stage 1: Kidney damage (e.g. proteinuria) and normal GFR; GFR >90
    • Stage 2: Kidney damage (e.g. proteinuria) and mild decrease in GFR; GFR 60-89
    • Stage 3: Moderate decrease in GFR; GFR >30-59
    • Stage 4: Severe decrease in GFR; GFR 15-29
    • Stage 5: Kidney failure (dialysis or kidney transplant needed); GFR <15

Risk Factors

Clinical Features


Differential Diagnosis of Acute Kidney Injury.png






  • Urine
  • Prostate exam
  • Urinalysis, urine sodium, urine creatinine, urine urea
  • ECG (hyperkalemia)
  • Chronic renal failure features
    • Anemia, thrombocytopenia
    • Iron studies with low Fe, low TIBC, low iron saturation, normal ferritin
    • Secondary rise in PTH, high phos, low calcium


  • CXR
    • Evidence of volume overload, pneumonia
  • US: renal/bladder
    • Test of choice in setting of acute renal failure
    • Bladder size (post-void)
    • Hydronephrosis
    • IVC collapsibility (prerenal)
  • CT
    • Useful to determine cause of post renal failure (identification of abdominal masses etc.)
    • Should generally not be used with IV contrast due to potential risk for CIN
    • Indicated if hydronephrosis found on ultrasound in order to define the location of obstruction


Finding Prerenal Intrinsic Postrenal
BUN/creatinine ratio >20 < 12 12-20 (normal range)
  • <1%
  • < 2% for neonates
  • >1%
  • > 2.5% for neonates
  • >1%
Urine osm >500 <350
Urine sodium < 20 mEq/L > 40 mEq/L
Specific gravity > 1.020 < 1.020
Fractional excretion of urea < 35% > 50%
Microscopic analysis
  • Hyaline casts
  • Acute glomerulonephritis: RBCs, casts
  • Acute tubular necrosis: protein, tubular epithelial cells
  • Interstitial nephritis: eosinophils

^ (urine sodium/plasma sodium) / (urine creatinine / serum creatinine)


Treat underlying cause

  • Prerenal: IVF (or pRBCs if bleeding)
  • Intrinsic: Depends on cause
  • Obstruction:
    • Note: Postobstructive diuresis can result in significant volume loss and death
      • Typically occurs when obstruction has been prolonged / has resulted in renal failure
      • Admit patients with persistent diuresis of >250 mL/h for >2hr
    • Foley Catheter, consider Coude Catheter
    • Suprapubic (if Coude fails)


Phlebotomy to Treat Pulmonary Edema

  • Possible last ditch effort to tide patient over to formal dialysis if hours away
  • If traditional pulmonary edema treatments are not working for SCAPE patient, one may attempt to remove 200-300 cc of blood as a bridge to dialysis[2]
  • If Hb too low, may consider temporary venous tourniquets on each leg proximally q30 min to reduce preload volume to the heart, alternating legs


  • Admit

See Also

External Links


  1. Moore PK, et. al. Management of acute kidney injury: core curriculum 2018. Am J Kidney Dis. 2018; 72: 136-148.
  2. Eiser AR et al. Phlebotomy for pulmonary edema in dialysis patients. Clin Nephrol. 1997 Jan;47(1):47-9.