NEPHROLOGY

Definition and classification/staging system for acute kidney

injury (AKI)
AKI stage

AKI stage I

Creatinine criteria

Urine output criteria

Increase of serum creatinine by

0.3 mg/dl ( 26.4 mol/L)
or
increase to 150% 200% from baseline
< 0.5 ml/kg/hour for > 6 hours
------------------------------------------------------------------------------------------------------------------AKI stage II
Increase of serum creatinine to
> 200% 300% from baseline
< 0.5 ml/kg/hour for > 12 hours
------------------------------------------------------------------------------------------------------------------AKI stage III
increase of serum creatinine to
> 300% from baseline
< 0.3 ml/kg/hour for > 24 hours
or
or
serum creatinine 4.0 mg/dl
anuria for 12 hours
354 mol/L) after a rise of at least 44 mol/L
or
treatment with renal replacement therapy

ATN vs. Prerenal Azotemia

Indices

Prerenal

ATN

UNa

< 20

> 40

FeNa

< 1%

> 4%

U/PCreat

> 40

< 20

FeUN

< 35%

>70%

Urinary Sediment Findings in Intra-Renal Acute

Renal Failure
Intra-renal Acute
Renal Failure

Albuminuria

Dysmorphic Hematuria
Red cell casts

Glomerulonephritis
Atheroembolic disease
Thrombotic
microangiopathy

Oval fat bodies

Fatty Casts

Minimal change
disease
Focal segmental
glomerulosclerosis

Tubular proteinuria

Muddy brown casts

Renal tubular epithelial
cells and casts

White cells
White cell casts
Eosinophiluria

Tubular epithelial
injury
-Ischemic
-Nephrotoxic

Interstitial
nephritis
Urinary tract
infection

Crystalluria

Drug toxicity
Urate crystals
-Urate nephropathy
Calcium oxalate
crystals
-ethylene glycol

Acute Renal failure

Introduction to casts
Hyaline Casts:
Better seen
with low light.
Non-specific.

Composed of
Tamm-Horsfall
mucoprotein.

Acute Renal Failure

Granular Casts:

Represent degenerating
cellular casts or aggregated
protein.
Nonspecific.
Waxy Casts:
Smooth appearance.
Blunt ends.
May have a crack.
Felt to be last stage of
degenerating cast
representative of chronic
disease.

Acute Renal Failure

Fatty Casts:
Seen in patients with
significant proteinuria.
Refractile in appearance.
May be associated with
free lipid in the urine.
Can see also oval fat
bodies RTEs that
have ingested lipid.
Polarize demonstrate
Maltese cross.

Acute Renal Failure

Muddy Brown Casts:
Highly suggestive
of ATN.
Pigmented
granular casts as
seen in
hyperbilirubinemia
can be confused
for these.

Acute Renal Failure

White Blood Cell Casts:
Raises concern for
interstitial nephritis.
Can be seen in
other inflammatory
disorders.
Also seen in
pyelonephritis.

Acute Renal Failure

Hematuria

Nonglomerular hematuria:
Urologic causes.

Bladder/Foley trauma.
Nephrolithiasis.
Urologic malignancy.
May be crenated based
upon age of urine, osmolality
NOT dysmorphic.

Acute Renal Failure

Dysmorphic Red Cells:
Suggestive of glomerular
bleeding as seen with
glomerulonephritis.
Blebs, buds, membrane
loss.
Rarely reported in other
conditions DM, ATN.

Red Blood Cell Casts:

Essentially diagnostic of
vasculitis or
glomerulonephritis.

Acute Renal Failure

Crystals Pretty and important.
Uric acid crystals:
Seen in any setting of elevated
uric acid and an acidic urine.
Seen with tumor lysis syndrome.
Calcium oxalate crystals:
Monohydrate dumbell shaped,
may be needle-like.
Dihydrate envelope shaped.
Form independent of urine pH.
Seen acutely in ethylene glycol
ingestion.

Conditions that Lead to Pre-renal Acute Renal Failure

Intravascular Volume Depletion
Large-vessel Renal Vascular Disease

Decreased Effective Circulating Volume

CHF Cirrhosis Nephrosis

Medications
CYA, Tacrolimus
ACE inhibitors NSAIDS
Radiocontrast Amphotericin B
Aminoglycosides

Hepatorenal
Syndrome

Generalized
or Localized Reduction in
Renal Blood Flow

Renal Artery Thrombosis

Renal Artery Embolism
Renal Artery Stenosis or Crossclamping

Sepsis

Small-vessel Renal Vascular Disease

Ischemic
Acute Renal Failure

Vasculitis Atheroemboli
Thrombotic Microangiopathies
Transplant Rejection

Common Causes of Drug Induced AIN

NSAIDS
Antibiotics
Penicillins
methacillin
Ampicillin, amoxacillin, carbenacillin, oxacillin
Cephalosporins
Quinolones (ciprofloxacin)
Anti-tuberculous medications (rifampin, INH, ethambutol)
Sulfonamides (TMP-SMX, furosemide, thiazides)
Miscellaneous
Allopurinol, cimetidine, dilantin

Acute Glomerulopathies
RPGN most commonly seen with:
Lupus nephritis (DPGN, class IV)
Pauci-immune GN (ANCA associated)
Anti-GBM disease
less commonly: IgA, post-infectious
Nephrotic presentations of ARF
Collapsing FSGS (HIV nephropathy)
Minimal change disease with ATN
Thrombotic microangiopathies (HUS, TTP, malignant hypertension,
scleroderma kidney, pre-eclampsia)

Hepatorenal Syndrome - Major Criteria

Chronic or acute liver disease with advanced hepatic failure and portal
hypertension
Low GFR, as indicated by a serum creatinine >1.5 mg/dL or a creatinine
clearance < 40 mL/min
Absence of shock, ongoing bacterial infection, fluid loss, and current or
recurrent treatment with nephrotoxic drugs. Absence of gastrointestinal fluid
losses (repeated vomiting or intense diarrhea) or renal fluid losses (as
indicated by weight loss > 500 gm/d for several days in patients with ascites
without peripheral edema or > 100 gm/d in patients with peripheral edema)
No sustained improvement in renal function (decrease in serum creatinine to
1.5 mg/dL or less or increase in creatinine clearance to 40 ml/min or more)
after withdrawal of diuretics and expansion of plasma volume with 1.5 L of
isotonic saline
Proteinuria < 500 mg/d and ultrasonographic evidence of obstructive uropathy
or parenchymal renal disease.

Hepatorenal syndrome - Minor Criteria

Urine volume < 500 mL/day

Urine sodium < 10 mEq/L
Urine osmolality > plasma osmolality
Urine red blood cells < 50 per high-power
field
Serum sodium concentration < 130 mEq/L

CURRENT STAR MCQS

Abdominal Compartment Syndrome
Presence of IAP >20 that is associated with a single or multiple organ system failure.
Causes severe oliguric or anuric renal failure. Tx: surgical decompression.
Acute Phosphate Nephropathy
AKI from Nephrocalcinosis after use of oral sodium phosphate (phospho soda) for
colonoscopy.
Orlistat associated AKI
AKI from Oxalate nephropathy due to enhancing oxalate absorption with increased
urinary excretion.
IVIG associated AKI
AKI from osmotic nephrosis from sucrose-containing formulation.
Herbal, Home remedies
Arsenal X, Chromium picolinate, Chineses Herb Xi Xin with aristolochic acid; tea from
Mouring Cypress, Snake gallbladder, Star fruit (oxalate), Ma Huang (ephedra), Noni
Juice

Definition of
CKD-Mineral and Bone Disorder
A systemic disorder of mineral and bone
metabolism due to CKD manifested by either
one or a combination of the following:
Abnormalities of calcium, phosphorus, PTH, or
vitamin D metabolism
Abnormalities in bone turnover, mineralization,
volume, linear growth, or strength
Vascular or other soft tissue calcification
Moe S, et al. Kidney Int 69: 1945, 2006

Mechanism of Cyst Formation

1. Mutation(s) leads to changes in epithelial cell behavior

2. Tubule epithelial cells proliferate to form cyst
3. Electrolytes and water accumulate in cyst lumen

Cystic diseases of kidney

ADPKD
ARPKD
VHL : AD,hemangioblastoma, RCC (40-70%)
TS: angiomyolipomas in CNS
MSK : AD, 3rd & 4th decade, stones, recurrent hematuria.
NPH =3 types:juvenille,infantile,adolescent. AR.
Cerebellar ataxia , hepatic fibrosis
MCK = AD. 3rd & 4th decade.