Acute Renal Failure

First Things First (assess & treat for the following)

  • Is there an acute increase in BUN or serum creatinine?
  • Is pt oliguric (100-500 mL/d), anuric (< 100 mL/d) or polyuric (>500 mL/d)?
    • If anuric, think complete urinary tract obstruction, bilateral renal arterial or venous occlusion, bilateral cortical necrosis, overwhelming acute tubular necrosis (ATN) or glomerular nephritis (GN).
    • If polyuric, think recovery phase ATN, interstitial nephritis, partial intermittent obstruction, postobstructive renal failure (RF).
  • Place bladder catheter to rule out or relieve lower urinary tract obstruction.
  • Collect urine sample for analysis, lytes & creatinine prior to interventions (eg, diuretics).
  • Assess & correct volume status & electrolyte abnormalities.
  • Avoid further renal insult such as hypovolemia, hypotension, nephrotoxins.
  • Adjust dosages of all renally excreted drugs.
  • Identify & aggressively treat potentially reversible causes of RF.
  • Is it prerenal, renal or postrenal?
    • Prerenal
      • Hypovolemia (GI, renal, skin losses, hemorrhage, third-spacing)
      • Decreased effective intravascular volume (hypoalbuminemia, cirrhosis, nephrotic syndrome, left ventricular cardiac failure, vasodilator therapy, anesthetics, anaphylaxis, sepsis)
      • Renal artery occlusion
      • Autoregulatory failure in states of renal hypoperfusion, due to NSAIDs, ACE inhibitors
    • Renal
      • Glomerular/vascular
        • Acute GN (Goodpasture’s, SLE, Henoch-Schonlein, poststreptococcal)
        • Vasculitis/immune complex disorders: hemolytic uremic syndrome (HUS), thrombotic thrombocytopenic purpura (TTP), polyarteritis nodosa (PAN), Wegener’s granulomatosis
        • Malignant HTN
        • Bilateral renal vein thrombosis
      • Acute interstitial nephritis (AIN)
        • Ischemia
        • Toxins (eg, aminoglycosides, cyclosporine, myoglobin)
      • AIN
        • Drug hypersensitivity
        • Infections
        • Immunologic disorders
    • Postrenal
      • Extrarenal
        • Ureteral obstruction (bilateral or solitary kidney)
        • Lower tract obstruction (bladder neck or urethra)
      • Intrarenal: tubular occlusion (eg, crystals, protein, pyogenic debris, stones, blood clots, papillary necrosis)

There's more to see -- the rest of this topic is available only to subscribers.

Last updated: April 16, 2010