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{{Acute renal failure}}
{{Acute renal failure}}
{{CMG}} {{AE}} {{AN}}
{{CMG}}; {{AE}} {{AN}}; [[User:Sergekorjian| Serge Korjian]]; [[User:YazanDaaboul| Yazan Daaboul]]; [[User:Rim Halaby| Rim Halaby]]


==Overview==
==Overview==
Acute renal failure can complicate a wide spectrum of disorders, and for the purpose of diagnosis and management is divided according to the mechanism that lead to renal compromise. The three categories are pre-renal [[azotemia]] (diseases that cause renal [[hypoperfusion]]), renal azotemia (diseases directly affecting the renal parenchyma), and post-renal azotemia (diseases affecting the [[urinary tract]] causing [[urinary tract obstruction|obstruction]]).
Acute renal failure can complicate a wide spectrum of disorders, and for the purpose of diagnosis and management is divided according to the mechanism that lead to renal compromise. The three categories are pre-renal [[azotemia]] (diseases that cause renal [[hypoperfusion]]), renal azotemia (diseases directly affecting the renal parenchyma), and post-renal azotemia (diseases affecting the [[urinary tract]] causing [[urinary tract obstruction|obstruction]]). However, the first consensus definition described and the most used definition is known as the RIFLE criteria. The acronym combines a classification of 3 levels of renal dysfunction (Risk, Injury, Failure) with 2 clinical outcomes (Loss, ESRD) to give the RIFLE stages of AKI.


==Classification==
==Classification==
 
===The Levels of Renal Dysfunction===
Acute renal failure is usually categorised (as in the flowchart below) according to ''pre-renal, renal'' and ''post-renal'' causes.
Acute renal failure is usually categorized (as in the flowchart below) according to ''pre-renal, renal'' and ''post-renal'' causes.
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===Pre-renal (compromise in the renal blood flow)===
1. Pre-renal
* [[Hypovolemia]] (decreased blood volume) -
* Compromise in the renal blood flow
** [[Shock (medical)|Shock]], [[hemorrhage]], [[burns]], [[dehydration]]
2. Renal
** Fluid loss from [[diuretic]]s use, [[diabetes mellitus]], [[hypoadrenalism]]
* Damage to the kidney itself
** Gastrointestinal fluid loss: [[vomiting]], surgical drainage, [[diarrhea]]
3.  Post-renal
** Extra-vascular space sequestration: [[pancreatitis]], [[hypoalbuminemia]], [[peritonitis]], [[trauma]], [[burns]]
* Obstructive causes in the urinary tract
*Low cardiac output -
 
** [[Cardiac arrhthymia]]'s
===RIFLE Criteria===
** [[Congestive heart failure]]: [[left ventricular failure]], [[right ventricular failure]]
The RIFLE (''R''isk of renal dysfunction, ''I''njury to the kidney, ''F''ailure or ''L''oss of kidney function, and ''E''nd-stage kidney disease) criteria classifies acute renal failure according to the probable clinical outcomes<ref name="pmid15312219">{{cite journal |author=Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P |title=Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group |journal=[[Critical Care (London, England)]] |volume=8 |issue=4 |pages=R204–12 |year=2004 |month=August |pmid=15312219 |pmc=522841 |doi=10.1186/cc2872 |url=}}</ref><ref>{{cite journal |author=Lameire N, Van Biesen W, Vanholder R |title=Acute renal failure |journal=[[The Lancet|Lancet]] |volume=365 |issue=9457 |pages=417–30 |year=2005 |pmid=15680458 |doi=10.1016/S0140-6736(05)17831-3}}</ref>. The acronym combines a classification of 3 levels of renal dysfunction (Risk, Injury, Failure) with 2 clinical outcomes (Loss, ESRD). This unified classification was proposed to enable a viable comparison in trials of prevention and therapy and to observe clinical outcomes of the defined stages of AKI.
** Valvular disorders: severe [[aortic stenosis]]
 
** Severe [[pulmonary hypertension]], massive [[pulmonary emobolism]]
{| class="wikitable" border="1" style="margin: 1em auto 1em auto; width: 70%;"
* Systemic vasodilatation -
|+ Proposed classification scheme for acute kidney injury (RIFLE) according to the Acute Dialysis Quality Initiative.
** [[Anaphylaxis]]
| align="center" style="background:#d3ffb0;"|'''CLASSIFICATION'''
** [[Sepsis]]
| align="center" style="background:#d3ffb0;"|'''GFR CRITERIA'''
** [[Antihypertensives]]
| align="center" style="background:#d3ffb0;"|'''URINE OUTPUT CRITERIA'''
* [[Hepatorenal syndrome]] in which renal [[perfusion]] is compromised in [[liver failure]] ([[cirrhosis]] with [[ascites]])
|-
* Vascular problems -
| Risk||style="text-align:center;"|1.5x increase in SCr or GFR decrease >25%||style="text-align:center;"|<0.5 mL/kg/h for 6 hours
** [[Atheroembolic disease]]
|-
** [[Renal vein thrombosis]] (which can occur as a complication of the [[nephrotic syndrome]])
| Injury||style="text-align:center;"|2x increase in SCr or GFR decrease >50%||style="text-align:center;"|<0.5 mL/kg/h for 12 hours
** Renal [[hypoperfusion]] from [[cyclooxygenase inhibitors]], [[ACE inhibitors]]
|-
** Renal [[vasoconstriction]] from [[hypercalcemia]], [[cyclosporine]], [[tacrolimus]] and [[amphotericin B]]
| Failure||style="text-align:center;"|3x increase in SCr or GFR decrease >75%||style="text-align:center;"|<0.3 mL/kg/h for 24 hours or anuria for 12 hours
* [[Hyperviscosity syndrome]] -
|-
** [[Multiple myeloma]]
| Loss|| colspan=2 style="text-align:center;"| Complete loss of renal function >4 weeks
** [[Polycythemia]]
|-
** [[Waldenstrom's macroglobulinemia]]
| End Stage Renal Disease|| colspan=2 style="text-align:center;"| Complete loss of renal function >3 months
===Renal (damage to the kidney itself)===
|}
* Diseases affecting the renal vasculature -
** Renal arterial obstruction: [[atherosclerosis]], [[dissecting aneurysm]], [[thrombosis]], [[embolism]]
** Renal venous obstruction: [[thrombosis]] of the [[veins]]
* Diseases affecting the [[renal glomeruli]] -
** [[Glomerulonephritis]], which may be due to a variety of causes, such as [[anti glomerular basement membrane disease]]/ [[Goodpasture's syndrome]], [[Wegener's granulomatosis]] or acute [[lupus nephritis]] with [[systemic lupus erythematosus]]
** [[Vasculitis]]
** [[Accelerated hypertension]]
** [[Hemolytic uremic syndrome]]
* [[Acute tubular necrosis]] from
** [[Ischemia]] - Same causes as for pre-renal failure
** Toxins - [[Radiocontrast agents]], [[aminoglycosides]], [[cisplatin]], [[acetaminophen]], [[myoglobin]] from [[rhabdomyolysis]], [[hemosiderin]] from [[hemolysis]], [[light chain immunolobulins]] in [[multiple myeloma]], [[uric acid]] crystals, etc.
* [[Interstitial nephritis]]
** Infections: [[Acute pyelonephritis]], [[cytomegalovirus]] infection, etc.
** Allergic: [[Penicillin]]'s, [[sulphonamides]], [[rifampin]], [[diuretic agents]], [[ACE inhibitors]]
** Infiltration: Malignancies ([[leukemia]]s and [[lymphoma]]'s)
* [[Graft rejection]]


===Post-renal (obstructive causes in the urinary tract)===
===Modified RIFLE Criteria===
Due to:
In 2007, the Acute Kidney Injury Network (AKIN) proposed  modified diagnostic criteria based on the RIFLE criteria. AKI was defined as an acute increase in the serum creatinine of ≥ 0.3 mg/dL from baseline within 48 hours, a 50% increase in the serum creatinine concentration, or oliguria <0.5 mL/kg/h for 6 hours (following volume status optimization). The staging criteria retained the Risk, Injury, & Failure stages from the RIFLE criteria, with modifications related to serum creatinine increase.<ref name="pmid17331245">{{cite journal| author=Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG et al.| title=Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. | journal=Crit Care | year= 2007 | volume= 11 | issue= 2 | pages= R31 | pmid=17331245 | doi=10.1186/cc5713 | pmc=PMC2206446 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17331245  }} </ref>
* Ureteric:
 
** [[Ureteric calculi]]
{| class="wikitable" border="1" style="margin: 1em auto 1em auto; width: 70%;"
** [[Blood clot]]
|+ Modified RIFLE classification scheme for acute kidney injury according to the Acute Kidney Injury Network (AKIN)
** Sloughed renal pappilae
| align="center" style="background:#d3ffb0;"|'''CLASSIFICATION'''
** External compression ([[retroperitoneal fibrosis]])
| align="center" style="background:#d3ffb0;"|'''SERUM CREATININE CRITERIA'''
* Bladder:
| align="center" style="background:#d3ffb0;"|'''URINE OUTPUT CRITERIA'''
** [[Medication]] interfering with normal bladder emptying
|-
** [[Neurogenic bladder]]
| Stage 1||style="text-align:center;"|Increase in SCr ≥0.3 mg/dL or 1.5x to 2x increase from baseline||style="text-align:center;"|<0.5 mL/kg/h for 6 hours
** [[Benign prostatic hypertrophy]] or [[prostate cancer]].
|-
* Urethal:
| Stage 2||style="text-align:center;"|2x  to 3x increase in SCr from baseline||style="text-align:center;"|<0.5 mL/kg/h for 12 hours
** Obstructed urinary catheter
|-
** [[Urethral stricture]]s
| Stage 3||style="text-align:center;"|>3x increase in SCr or SCr≥ 4.0 mg/dL with acute increase >0.5 mg/dL||style="text-align:center;"|<0.3 mL/kg/h for 24 hours or anuria for 12 hours
** [[Phimosis]]
|}
** [[Poterior urethral valve]]
 
In March 2012, the Kidney Disease – Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Acute Kidney Injury retained the AKIN staging criteria while implementing modifications to the definition of AKI. AKI was defined as either an increase in serum creatinine by 50% in 7 days, an increase in serum creatinine by 0.3 mg/dL in 2 days, or anuria for more than 12 hours.<ref name="KDIGO Clinical guidelines for Acute Kidney Injury">{{cite journal| author=Acute Kidney Injury Work Group| title=KDIGO Clinical Practice Guideline for Acute Kidney Injury. | journal= Kidney inter | year= 2012 | volume= 6 | issue= 2 | pages= 1-138 | doi:10.1038/kisup.2012.6 | url=http://www.nature.com/kisup/journal/v2/n1/full/kisup20126a.html  }} </ref>


==References==
==References==
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[[Category:Nephrology]]
[[Category:Medical emergencies]]
[[Category:Medical emergencies]]
[[Category:Kidney diseases]]
[[Category:Kidney diseases]]
[[Category:Organ failure]]
[[Category:Organ failure]]
[[Category:Causes of death]]
[[Category:Causes of death]]
[[Category:Nephrology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Intensive care medicine]]

Latest revision as of 15:25, 22 February 2013

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]; Serge Korjian; Yazan Daaboul; Rim Halaby

Overview

Acute renal failure can complicate a wide spectrum of disorders, and for the purpose of diagnosis and management is divided according to the mechanism that lead to renal compromise. The three categories are pre-renal azotemia (diseases that cause renal hypoperfusion), renal azotemia (diseases directly affecting the renal parenchyma), and post-renal azotemia (diseases affecting the urinary tract causing obstruction). However, the first consensus definition described and the most used definition is known as the RIFLE criteria. The acronym combines a classification of 3 levels of renal dysfunction (Risk, Injury, Failure) with 2 clinical outcomes (Loss, ESRD) to give the RIFLE stages of AKI.

Classification

The Levels of Renal Dysfunction

Acute renal failure is usually categorized (as in the flowchart below) according to pre-renal, renal and post-renal causes.

 
 
 
 
 
 
 
 
Acute Renal
Failure
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pre-renal
 
 
Renal
 
 
Post-renal

1. Pre-renal

  • Compromise in the renal blood flow

2. Renal

  • Damage to the kidney itself

3. Post-renal

  • Obstructive causes in the urinary tract

RIFLE Criteria

The RIFLE (Risk of renal dysfunction, Injury to the kidney, Failure or Loss of kidney function, and End-stage kidney disease) criteria classifies acute renal failure according to the probable clinical outcomes[1][2]. The acronym combines a classification of 3 levels of renal dysfunction (Risk, Injury, Failure) with 2 clinical outcomes (Loss, ESRD). This unified classification was proposed to enable a viable comparison in trials of prevention and therapy and to observe clinical outcomes of the defined stages of AKI.

Proposed classification scheme for acute kidney injury (RIFLE) according to the Acute Dialysis Quality Initiative.
CLASSIFICATION GFR CRITERIA URINE OUTPUT CRITERIA
Risk 1.5x increase in SCr or GFR decrease >25% <0.5 mL/kg/h for 6 hours
Injury 2x increase in SCr or GFR decrease >50% <0.5 mL/kg/h for 12 hours
Failure 3x increase in SCr or GFR decrease >75% <0.3 mL/kg/h for 24 hours or anuria for 12 hours
Loss Complete loss of renal function >4 weeks
End Stage Renal Disease Complete loss of renal function >3 months

Modified RIFLE Criteria

In 2007, the Acute Kidney Injury Network (AKIN) proposed modified diagnostic criteria based on the RIFLE criteria. AKI was defined as an acute increase in the serum creatinine of ≥ 0.3 mg/dL from baseline within 48 hours, a 50% increase in the serum creatinine concentration, or oliguria <0.5 mL/kg/h for 6 hours (following volume status optimization). The staging criteria retained the Risk, Injury, & Failure stages from the RIFLE criteria, with modifications related to serum creatinine increase.[3]

Modified RIFLE classification scheme for acute kidney injury according to the Acute Kidney Injury Network (AKIN)
CLASSIFICATION SERUM CREATININE CRITERIA URINE OUTPUT CRITERIA
Stage 1 Increase in SCr ≥0.3 mg/dL or 1.5x to 2x increase from baseline <0.5 mL/kg/h for 6 hours
Stage 2 2x to 3x increase in SCr from baseline <0.5 mL/kg/h for 12 hours
Stage 3 >3x increase in SCr or SCr≥ 4.0 mg/dL with acute increase >0.5 mg/dL <0.3 mL/kg/h for 24 hours or anuria for 12 hours

In March 2012, the Kidney Disease – Improving Global Outcomes (KDIGO) Clinical Practice Guidelines for Acute Kidney Injury retained the AKIN staging criteria while implementing modifications to the definition of AKI. AKI was defined as either an increase in serum creatinine by 50% in 7 days, an increase in serum creatinine by 0.3 mg/dL in 2 days, or anuria for more than 12 hours.[4]

References

  1. ↑ Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P (2004). "Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group". Critical Care (London, England). 8 (4): R204–12. doi:10.1186/cc2872. PMC 522841. PMID 15312219. Unknown parameter |month= ignored (help)
  2. ↑ Lameire N, Van Biesen W, Vanholder R (2005). "Acute renal failure". Lancet. 365 (9457): 417–30. doi:10.1016/S0140-6736(05)17831-3. PMID 15680458.
  3. ↑ Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG; et al. (2007). "Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury". Crit Care. 11 (2): R31. doi:10.1186/cc5713. PMC 2206446. PMID 17331245.
  4. ↑ Acute Kidney Injury Work Group (2012). "KDIGO Clinical Practice Guideline for Acute Kidney Injury". Kidney inter. 6 (2): 1–138. Text " doi:10.1038/kisup.2012.6 " ignored (help)

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