Acute kidney injury differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2], Eiman Ghaffarpasand, M.D. [3], Anmol Pitliya, M.B.B.S. M.D.[4]

Overview

AKI typically results in oliguria. AKI should be differentiated on the basis of underlying etiology.

Differentiating AKI from other Diseases

AKI typically results in oliguria. AKI should be differentiated on the basis of underlying etiology.

Abbreviations: ABG = Arterial blood gases, BUN = Blood urea nitrogen, CBC = Complete blood count, CT = Computed tomography, CRP = C - reactive protein, ECG = Electrocardiogram, ESR = Erythrocyte sedimentation rate, IVP = Intravenous pyelography, KFT = Kidney function test, GI = Gastrointestinal, GFR = Glomerular filtration rate, MRI = Magnetic resonance imaging, PT = Prothrombin time

Etiology Clinical manifestations Paraclinical findings Comments
Symptoms and signs Lab findings Imaging
Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other
Prerenal causes Alcohol poisoning[1][2] + - +/- - +/- + +/- - - ↑PT ↑BUN, ↑Cr (isopropyl alcohol) ↓Na NA ↓HCO3 LFT NA NA NA NA - Administer thiamine to prevent Wernicke's encephalopathy
Aspergillosis[3][4] +/- - - - - - - +/- - NA NA NA NA NA Allergy test, ↑IgE (>1000 IU/dl), direct visualization of fungal hyphae NA Pulmonary infiltrates, mucus plug, mass in the upper lobe surrounded by a crescent of air, solitary or multiple cavities Halo sign, wedge-shaped pulmonary infarction, granuloma NA - Polymerase chain reaction (PCR) confirms the diagnosis
Cholera[5][6][6][7] +/- + +/-

Depends on severity

- - +/- + - - Leukocytosis, ↑HCT ↑BUN, ↑Cr ↓Na, ↑Ca, ↑Mg NA ↑Lactate, ↓HCO3 Stool PCR, stool culture, serotyping NA NA NA NA - -
Congestive heart failure (CHF)[8][9] + - - - - - + - + Anemia, leukocytosis ↑BUN, ↑Cr ↓Na, ↑K NA ↑Lactate, ↓HCO3, ↑BNP, ↑troponin Cardiomegaly, pulmonary hypertension, pleural effusion Pulmonary edema NA Valvular heart disease Decreased ejection fraction in echocardiography, decreased heart function and damage in nuclear imaging -
Dehydration[10][11] + + +/-

Depends on the severity

+/- - +/- +/- - - NA ↑BUN, ↑Cr ↓Na, ↑K, ↓Cl ↑ Urine ketones and glucose, ↑urine specific gravity ↑Lactate, ↓HCO3 Hypoglycemia NA NA NA NA - -
Diarrhea and/or vomiting[12][13] +/- +/- - - - + + - - Leukocytosis with predominant neutrophilia, ↑ESR NA NA ↑ Urine ketones, organic acids, porphobilinogen, aminolevulinic acid NA Stool anion gap, stool pH < 5.5, stool culture, serotyping, enzyme immunoassay (rotavirus or adenovirus), abnormal LFT, amylase, lipase Normal NA NA NA - -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments
Drugs/toxins[14][15] +/- +/- +/- +/- +/- +/- +/- +/- +/- NA ↑BUN, ↑Cr, ↑CK ↑K, ↓Mg, ↓Ca, ↓P Ingested drug, glucose, aminoacid, phosphate, ketone, hyaline cast, and RBC ↑Lactate, metabolic acidosis Toxicology, rapid immunoassay Nephropathy Radioopaque substances, ingested drug packets NA NA - -
Esophageal varices bleeding[16][17] +/- - - - +/- - - - - Normocytic normochromic anemia ↑BUN, ↑Cr NA NA NA NA Velocity and direction of portal flow Abnormal opacities outside ofesophageal wall, posterior mediastinal or intraparenchymal mass, dilated azygous vein Entire portal venous system Portrays esophageal varices as flow voids Portal hypertension and esophageal varices in positron emission tomography, flexible endoscope, barium swallow of snake-like filling defects -
Congenital heart disease[18][19] +/- - - - - - - +/- +/- ↑ESR and CRP ↑BUN, ↑Cr NA NA NA Throat culture, rapid streptococcal antigen test, hyperoxia test, pulse oximetry NA Cardiomegaly, dextrocardia NA NA Ventricular dysfunction, left and right ventricular hypertrophy, valvular disease in echocardiography -
Hemorrhage[20][21] - + +/-

Depends on the severity

- - - - +/- - Normocytic normochromic anemia, ↑PT, ↑PTT ↑BUN, ↑Cr ↑Na, ↑Cl, ↓Ca NA Metabolic acidosis NA Peritoneal cavity fluid in FAST Bilateral opacities in the lung field, hemothorax, hemoperitoneum, ruptured abdominal aortic aneurysm Intrathoracic, intra-abdominal, and retroperitoneal bleeding NA Source of bleeding in the upper GI in EGD, angiography -
Hemolysis[22][23] +/- - - - - - - +/- - Thrombocytopenia, microcytic hypochromic anemia, ↑RDW, ↑retic count NA NA NA NA ↑LDH, ↓haptoglobin, ↑unconjugated bilirubin Hepatomegaly, splenomegaly NA NA NA - -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments
Hepatorenal syndrome[24][25] +/- - - - +/- +/- - - +/- Leukocytosis, ↑PT ↓GFR, ↑BUN, ↑Cr ↓Na Proteinuria, Na <10mEq/L, urine osmolality > plasma osmolality NA Alpha feto-protein, cryoglobulinemia Exclude hydronephrosis and intrinsic renal disease NA NA NA Right ventricular preload, ventricular filling pressures, and cardiac function in echocardiography -
Ischemic cardiomyopathy[26][27] +/- - - - - - - +/- +/- Anemia ↑Cr ↓Na, ↓K, ↓Mg NA NA Troponin, creatine kinase, Creatine kinase-MB, BNP NA Abnormal cardiac silhouette Biventricular volume, wall motion abnormality, myocardial perfusion, hypertrophic cardiomyopathy Mid-wall fibrosis in MRI Ejection fraction ≤35%, pulmonary embolism, right ventricular dilation or pericardial effusion with tamponade in echocardiography -
Liver cirrhosis[28][29] +/- - +/- +/- +/- - - - +/- NA NA NA NA NA Abnormal LFT, aspartate aminotransferase to platelet ratio, FibroTest/FibroSure, Hepascore Portal blood flow velocity, hepatic artery enlargement, multifocal lesions or masses, hepatic contour, ascites, splenomegaly Bowel perforation, gynecomastia, azygos vein enlargement, pleural effusion Morphologic changes in the liver, collaterals and shunts, hyperattenuating nodule of hepatocellular carcinoma, portal vein thrombosis Vacular patency, tumor invasion, portal vein thrombosis, steatosis Hepatic function and portal hypertension in nuclear imaging, hepatic perfusion and the development of shunts and tumors in angiography Irreversible and a transplant is usually needed
Malignant hypertension[30][31] +/- - + - - +/- - +/- +/- Microangiopathic hemolytic anemia ↑BUN, ↑Cr ↑Na, ↑K, ↑P Proteinuria, microscopic hematuria Acidosis Cardiac enzymes, urinary catecholamines, TSH, ↑Renin NA Cardiomegaly, pulmonary edema, rib notching, aortic coarctation, mediastinal widening, aortic dissection NA NA Left atrial enlargement and left ventricular hypertrophy in echocardiography -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments
Myocarditis[32] +/- - - - +/- - - +/- - Leukocytosis (eosinophilia),↑ESR and ↑CRP NA NA NA NA Cardiac enzymes, viral antibodies NA NA NA Inflammatory edema, degree of scarring Endomyocardial biopsy, echocardiography, scintigraphy NA
Peritonitis[33][34] +/- - +/- - +/- +/- +/- - - Leukocytosis NA NA NA NA Ascitic fluid neutrophil count > 500 cells/µL NA NA NA NA - -
Polycythemia[35][36] +/- - - - - - - +/- - ↑RBC, ↑HCT, ↑HGB, thrombocytosis, leukocytosis, ↑PT, and ↑aPTT ↓Erythropoietin NA NA NA Hyperuricemia Splenomegaly NA NA NA - Phlebotomy is the usual treatment
Respiratory distress syndrome[37] + - +/- - - - - + - NA NA NA NA Metabolic and respiratory acidosis Pulse oximetry NA Bilateral, diffuse, reticular granular or ground-glass appearance +/- cardiomegaly NA NA Patent ductus arteriosus in echocardiography -
Shock[38] +/- +/- +/- +/- +/- +/- - +/- - ↑HCT, ↑PT and aPTT, Eosinophilia, Leukocytosis ↓GFR, ↑BUN, ↑Cr NA NA ↑Lactate LFT, ↑BNP, ↑troponin, D-dimer, fibrinogen Pulmonary embolism, pericardial effusion, cardiac tamponade, pneumothorax, thoracic or abdominal aortic aneurysm in RUSH (Rapid Ultrasound for Shock and Hypotension) Pneumonia, pneumothorax, pulmonary edema, widened mediastinum, free air under the diaphragm Traumatic brain injury, stroke, spinal injury, pneumonia, pPneumothorax, ruptured aneurysm, aortic dissection, pulmonary embolism NA - -
Toxic megacolon[39] +/- +/- +/- - + + +/- - - Leukocytosis, anemia, ↑ESR and ↑CRP ↑BUN, ↑Cr ↓Na NA NA Loss of haustra, hypoechoic and thick bowel walls, dilated colon > 6cm, dilatation of ileal loops Dilated colon, free intraperitoneal air Bowel perforation, abscess NA NA Endoscopy and colonoscopy -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments
Renal causes Acute interstitial nephritis[40][41] +/- - +/- - +/- +/- +/- +/- +/- Eosinophilia ↑BUN, ↑Cr, ↑FENa NA Eosinophiluria, sterile pyuria, mMicroscopic hematuria, proteinuria NA ↑Total IgG, ↑IgG4 Normal-sized kidneys NA NA NA - History of long term analgesic use
Acute tubular necrosis[42][43] +/- - - - - +/- - - +/- Anemia ↑BUN, ↑Cr, ↑FENa ↓Na, ↑K, ↑Mg, ↑P, ↓Ca Pigmented, muddy brown, granular casts NA NA Obstructive uropathy, cortical thickness, hydronephrosis Nephrolithiasis Nephrolithiasis, area of obstruction Nephrolithiasis, area of obstruction Loss of tubular cells or the denuded tubules, swollen tubular cells, lLoss of the cell brush border in renal biopsy Furosemide stress testing for staging
Cancer[44][45] + - - - +/- +/- - - +/- Normocytic or microcytic anemia, leukocytosis or lymphocytosis, ↑reticulocytes, thrombocytopenia ↓GFR, ↑BUN, ↑Cr, ↓Erythropoietin ↓Na, ↑K, ↓Mg, ↑P, ↓Ca Gross hematuria NA LFT Fluid collection and morphological change, flank mass Calcification and widened mediastinum, filling defects in barium contrast Metastasis and staging, cystic and solid masses, lymph node, renal vein, and inferior vena cava involvement Soft tissue invasion and staging Malignant cystic lesions percutaneous cyst puncture Renal cell carcinoma types: Clear cell (75%), chromophilic (15%), chromophobic (5%), oncocytoma (3%), collecting duct (2%)
Congenital kidney disease[46][47][48]

- Agenesis

- Dysplasia

- Hypoplasia

- Polycystic

+/- - - - +/- +/- - - +/- ↑HCT ↓GFR ↓P, ↓Ca Microalbuminuria, uricosuria NA Genetic testing forADPKD2 Visualization of kidney cysts Small kidney cysts (0.5 cm) Kidney size, intracranial aneurysms NA - -
End stage renal disease[49][50] + - - - +/- - - - + Anemia ↓GFR, ↑BUN, ↑Cr ↑K Hypoalbuminuria ↓HCO3 Phosphate, 25-hydroxy vitamin D, alkaline phosphatase, parathyroid hormone Hydronephrosis, retroperitoneal fibrosis, enlarged or shrunken kidneys Obstruction in retrograde pyelogram Renal masses, stones, and cysts Renal vein thrombosis, renal artery stenosis in magnetic resonance angiography Percutaneous renal biopsy -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments
Endogenous toxins[51][52][53][54][55]

- Hemoglobin

- Myoglobin

- Uric acid

+/- - +/- + - +/- - - +/- Anemia, thrombocytopenia ↓GFR, ↑BUN, ↑Cr ↑K, ↑urate, ↓Ca Uricosuria, hematuria, myoglobinuria, casts NA Creatine kinase > 1000 U/L Malignant or cystic lesions, hydronephrosis, nephrocalcinosis, urolithiasis NA Urolithiasis, wilms tumor, polycystic kidney disease NA Ureter or bladder abnormality in voiding cystourethrography -
Glomerulonephritis[56][57][58] +/- - - - - - - - + Pleocytosis, anemia, leukocytosis, ↑ESR ↑BUN, ↑Cr NA Specific gravity > 1.020, proteinuria, hematuria, red blood cell casts, white blood cell casts, cellular casts, oval fat bodies NA NA ↑C3, ↑C4, ↑CH50, blood and tissue culture, antinuclear antibodies, cryoglobulins, hepatitis B and C serologies, antineutrophil cytoplasmic antibody (ANCA) Kidney size, echogenicity of the renal cortex, obstruction, degree of fibrosis Pulmonary congestion Visceral abscesses - Renal biopsy, light and electron microscopy, immunofluorescence aid diagnosis
Goodpasture syndrome[59][60][61] +/- - - - - - - +/- +/- Anemia, leukocytosis, ↑ESR ↑BUN, ↑Cr NA Low-grade proteinuria, gross or microscopic hematuria, RBC casts NA Anti– glomerular basement membrane antibody, antineutrophilic cytoplasmic antibody NA Bilateral, basal, patchy parenchymal consolidations NA NA Diffuse alveolar hemorrhage in pulmonary biopsy -
Hemolytic uremic syndrome[62][63][64] +/- - +/- +/- +/- + + - +/- Severe anemia, thrombocytopenia, ↑aPTT ↑BUN, ↑Cr NA Mild proteinuria, Red blood cells, Red blood cell casts NA Schistocytes, ↑FDP and D-dimer, ↑bilirubin, ↑LDH, ↓haptoglobin, stool culture (for E coli 0157:H7 or shigella), ↓ADAMTS-13 activity Ruling out obstruction NA NA NA Diffuse thickening of the glomerular capillary wall, swelling of endothelial cells, fibrin thrombi in renal biopsy -
Nephrolithiasis[65][66][67] - - - - +/- +/- - - - Mild leukocytosis, ↑CRP ↑BUN, ↑Cr ↑Na, ↑K, ↑P, ↑Ca, ↑urate Gross or microscopic hematuria, Red blood cells, urinary crystals of calcium oxalate, uric acid, or cystine, hypercalciuria, urinary pH > 7 in struvite stones (Proteus, Pseudomonas, Klebsiella), urinary pH < 5 in uric acid stones ↓HCO3, renal tubular acidosis - All types of stones are visible, hydronephrosis, abdominal aortic aneurysm, cholelithiasis Calcium - containing stones, uric acid or cystine stones, stone movement Stone density, size and composition, hydronephrosis, nephromegaly, perinephric fat streaking NA Intravenous pyelography (IVP), renal tomography, nuclear renal scan -
Etiology Fatigue/

Lethargy

Thirst Dizziness/

Confusion

Muscle weakness/

cramp

Somatic/

visceral pain

Vomiting Diarrhea Tachypnea Edema Blood indices Renal Funtion test Electrolytes Urine analysis ABG Other Ultrasound X-ray CT MRI Other Comments


References

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