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I HAVE A PATIENT WITH ACUTE KIDNEY INJURY

How do I determine the cause?

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 broad clinical syndrome defined by an abrupt decrease in kidney function over a period of hours to days, characterized by a rise in serum creatinine or a decrease in urinary output. The time frame of development and persistence of kidney damage defines a spectrum that extends to acute kidney disease (AKD) and chronic kidney disease (CKD). Table 28-1 summarizes the current diagnostic criteria and staging for AKI, AKD, and CKD, which may be relevant in the evaluation and prognostication of disease.

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, typically divided into prerenal, intrarenal, and postrenal causes:

  1. Prerenal (due to renal hypoperfusion)

    1. Intravascular volume depletion

      1. Gastrointestinal loss

      2. Renal loss: drug-induced or osmotic diuresis (such as from hyperglycemia), diabetes insipidus

      3. Skin and mucous membrane losses

      4. Hemorrhage

      5. Third spacing, such as nephrotic syndrome, pancreatitis, etc.

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

      1. Heart failure (HF), with or without cardiogenic shock

        ...

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