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CHIEF COMPLAINT

PATIENT image

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

image What is the differential diagnosis of AKI? How would you frame the differential?

CONSTRUCTING A DIFFERENTIAL DIAGNOSIS

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).

Table 28-1.Diagnostic criteria and staging for kidney disease.

The framework for the differential diagnosis of AKI is a combination of anatomic and pathophysiologic:

  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

        ...

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