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CHIEF COMPLAINT

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PATIENT Image not available.

Mr. T is 77-year-old man with acute kidney injury (AKI).

Image not available. What is the differential diagnosis of AKI? How would you frame the differential?

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CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

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AKI is a syndrome defined as a reduction in kidney function that has occurred within the last 7 days. AKI can occur in patients with no known kidney disease but is more likely to develop in patients with preexisting kidney disease. Table 28-1 summarizes the current diagnostic criteria and staging for AKI, and acute and chronic kidney disease (CKD).

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Table Graphic Jump Location
Table 28-1.Diagnostic criteria and staging for kidney disease.
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The framework for the differential diagnosis of AKI is a combination of anatomic and pathophysiologic:

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  1. Prerenal (due to renal hypoperfusion)

    1. Hypovolemia

      1. Gastrointestinal fluid loss

      2. Renal loss

      3. Hemorrhage

      4. Third spacing

    2. Decreased effective circulating volume (with or without hypotension)

      1. Heart failure (HF)

      2. Cirrhosis

    3. Hypotension

      1. Sepsis

      2. Cardiogenic shock

      3. Anaphylaxis

      4. Anesthesia- and medication-induced

      5. Relative hypotension below patient’s autoregulatory level

    4. Changes in renal hemodynamics

      1. Nonsteroidal antiinflammatory drugs (NSAIDs) (including cyclooxygenase (COX)-2 inhibitors)

      2. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers

      3. Renal artery thrombosis or embolism

      4. Abdominal aortic aneurysm

  2. Intrarenal

    1. Vascular

      1. Vasculitis

      2. Malignant hypertension

      3. Cholesterol emboli

      4. Thrombotic microangiopathies

        • (1) Thrombotic thrombocytopenic purpura

        • (2) Hemolytic uremic syndrome

        • (3) Disseminated intravascular coagulopathy

    2. Glomerular

      1. Inflammatory

        • (1) Postinfectious glomerulonephritis (GN)

        • (2) Cryoglobulinemia

        • (3) Henoch-Schönlein purpura

        • (4) Systemic lupus erythematosus

        • (5) Antineutrophil cytoplasmic antibody associated GN

        • (6) Anti-glomerular basement membrane disease

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