Renal insufficiency: Difference between revisions

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   MeshNumber    = C12.777.419.780.500 |
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{{Renal insufficiency}}
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{{CMG}}


{{SK}} Renal failure; azotemia; kidney failure; kidney insufficiency
{{SK}} Renal failure; azotemia; kidney failure; kidney insufficiency; renal disease; kidney injury; renal injury


'''For more detailed information please see the chapters on [[acute renal failure]] and [[chronic renal failure]].  This chapter is simply an overview of these more specific disease states.'''
'''For more detailed information please see the chapters on [[acute kidney injury]] and [[chronic kidney disease]].  This page is simply an overview of these disease states.'''


==Overview==
==Overview==
Renal insufficiency may broadly be divided into two categories: [[Acute kidney injury]] vs. [[chronic kidney disease]]:


==Classification==
Renal failure can broadly be divided into two categories (see flowchart below): [[Acute (medical)|acute]] renal failure and [[chronic (medicine)|chronic]] renal failure. 
'''Renal failure classification'''
{{familytree/start}}
{{familytree/start}}
{{familytree | | | |A11| | | | |A11 =Renal Failure}}
{{familytree | | | |A11| | | | |A11 =<div style="text-align:center; padding:3em">Renal Insufficiency</div>}}
{{familytree | |,|-|-|^|-|-|.|}}
{{familytree | |,|-|-|^|-|-|.|}}
{{familytree | B11 | | | | B12 |B11=[[Chronic renal failure|Chronic]]|B12=[[Acute renal failure|Acute]]}}
{{familytree | B11 | | | | B12 |B11=<div style="text-align:center; padding:0.7em">[[Acute kidney injury|'''Acute Kidney Injury''']]</div><br><div style="text-align:left; padding:0.7em">''Defined as any of the following:''<br>❑ Increase in serum creatinine concentration by 0.3 mg/dL in 48 hours, '''OR'''<br>❑ Increase in serum creatinine concentration by more than 50% of baseline or 1.5 times baseline concentration within the past 7 days, '''OR'''<br>❑ Decrease in urine volume <0.5 mL/kg/h for 6 or more hours</div>|B12=<div style="text-align:center; padding:0.7em">[[Chronic renal insufficiency|'''Chronic Kidney Disease''']]</div><br><div style="text-align:left; padding:0.7em">''Defined as any of the following:''<br>❑ Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either pathological abnormalities or markers of kidney damage (including abnormalities in the composition of the blood or urine or imaging abnormalities), '''OR'''<br>❑ GFR <60 mL/min/1.73 m<sup>2</sup> for ≥3 months with or without kidney damage</div>}}
{{familytree/end}}
{{familytree/end}}


==Definition of Terms==
===Acute kidney injury (AKI)===
Acute kidney injury (AKI), formerly known as acute renal failure, is characterized by an abrupt loss of kidney function resulting in a failure to excrete nitrogenous waste products (among others), and a disruption of fluid and electrolyte homeostasis. AKI is defined as any of the following:
*Increase in serum creatinine concentration by 0.3 mg/dL in 48 hours, ''OR''
*Increase in serum creatinine concentration by more than 50% of baseline or 1.5 times baseline concentration within the past 7 days, ''OR''
*Decrease in urine volume <0.5 mL/kg/h for 6 or more hours
===Chronic kidney disease (CKD)===
Chronic kidney disease (or chronic renal insufficiency) is a broad spectrum of disorders that disturb the structural or functional integrity of the kidney for more than 3 months. CKD is defined as any of the following:
*Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either pathological abnormalities or markers of kidney damage (including abnormalities in the composition of the blood or urine or imaging abnormalities), ''OR''
*GFR <60 mL/min/1.73 m<sup>2</sup> for ≥3 months with or without kidney damage


The type of renal failure (acute vs. chronic) is determined by the trend in the serum creatinine. Other factors which may help differentiate acute and chronic renal failure include the presence of [[anemia]] and the kidney size on [[medical ultrasound|ultrasound]]. Long-standing, i.e. chronic, renal failure generally leads to anemia and small kidney size.
===Acute-on-chronic renal failure (AoCRF)===
Acute-on-chronic renal failure (AoCRF) is defined as the presence of acute kidney injury on top of chronic renal disease. AKI of AoCRF may be reversible, and the aim of treatment is to return the patient to baseline renal function prior to the acute insult.


===Acute renal failure===
===Azotemia===
{{main|Acute renal failure}}  <!-- FURTHER details should go in the ARF article NOT here -->
[[Azotemia]] is neither a disease entity nor a clinical syndrome. It is a laboratory finding defined as an elevation in the concentration of nitrogenous waste products in the blood. Azotemia may suggest either kidney or non-kidney diseases. Azotemia is generally caused by:
[[Acute renal failure]] (ARF) is, as the name implies, a rapidly progressive loss of [[renal function]], generally characterised by [[oliguria]] (decreased [[urine]] production, quantified as less than 400 [[millilitres|mL]] per day in adults,<ref>{{cite journal | author = Klahr S, Miller S | title = Acute oliguria. | journal = N Engl J Med | volume = 338 | issue = 10 | pages = 671-5 | year = 1998 | id = PMID 9486997}} [http://content.nejm.org/cgi/content/full/338/10/671 Free Full Text].</ref> less than 0.5 mL/kg/h in children or less than 1 mL/kg/h in infants); [[body water]] and body fluids disturbances; and [[electrolyte]] derangement. An underlying cause must be identified to arrest the progress, and [[dialysis]] may be necessary to bridge the time gap required for treating these fundamental causes. ARF can result from a large number of causes.
*Increased synthesis of nitrogenous waste products: Liver injury or skeletal muscle injury
*Reduced loss of nitrogenous waste products: Acute or chronic kidney injuries


===Chronic renal failure===
To view a comprehensive list of causes of azotemia, click [[Azotemia causes|here]].
{{main|Chronic renal failure}} <!-- FURTHER details should go in the CRF article NOT here -->
[[Chronic renal failure]] (CRF) can either develop slowly and show few initial symptoms, be the long term result of irreversible acute disease or be part of a disease progression.  There are many causes of CRF.  The most common cause is [[diabetes mellitus]]. [[End-stage renal failure]] (ESRF) is the ultimate consequence, in which case [[dialysis]] is required unless a donor for a [[Kidney transplantation|renal transplant]] is found.


===Acute on chronic renal failure===
===Uremia===
Acute renal failure can be present on top of chronic renal failure. This is called acute-on-chronic renal failure (AoCRF).  The acute part of AoCRF may be reversible and the aim of treatment, as with ARF, is to return the patient to their baseline renal function, which is typically measured by serum [[creatinine]]. AoCRF, like ARF, can be difficult to distinguish from chronic renal failure, if the patient has not been monitored by a [[physician]] and no baseline (i.e., past) blood work is available for comparison.==Causes==
[[Uremia]] (urine constituents in blood) is a clinical syndrome caused by progressive accumulation of nitrogen waste products among patients with kidney failure who with unable to clear these waste products by the kidneys.<ref name="pmid17898101">{{cite journal| author=Meyer TW, Hostetter TH| title=Uremia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 13 | pages= 1316-25 | pmid=17898101 | doi=10.1056/NEJMra071313 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17898101  }} </ref>
*Uremia is thought to account for the clinical features of chronic kidney failure that cannot be explained by other classical abnormalities of chronic kidney failure (abnormalities of ion concentrations or extracellular volume overload).<ref name="pmid17898101">{{cite journal| author=Meyer TW, Hostetter TH| title=Uremia. | journal=N Engl J Med | year= 2007 | volume= 357 | issue= 13 | pages= 1316-25 | pmid=17898101 | doi=10.1056/NEJMra071313 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17898101 }} </ref>
 
*Initially, uremia syndrome remains subclinical as eGFR ranges between 10 to 50% of normal GFR. However, when renal function worsens and GFR further declines (below 10 mL/min/1.73m<sup>2</sup>, manifestations of uremia become more prominent, signaling the need for renal replacement modalities (either [[dialysis]] or [[renal transplantation]]).  
*Although experimental studies have validated the presence of uremia in the context of [[acute kidney injury]] ([[acute uremia]]), uremia is classically a feature of [[chronic kidney disease]] given the progressive nature of the waste product accumulation associated with the disease.
 
==Causes==
===Causes by Organ System===
===Causes by Organ System===
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|-bgcolor="LightSteelBlue"
|-bgcolor="LightSteelBlue"
| '''Drug Side Effect'''
| '''Drug Side Effect'''
|bgcolor="Beige"|  [[Balsalazide]], [[Beractant]], [[Cefadroxil]], [[Ceftazidime]], [[Cladribine]], [[Cytarabine]], [[Dalfampridine]], [[Desogestrel and Ethinyl Estradiol]], [[Dolutegravir]], [[Flurbiprofen]], [[Ixabepilone]], [[Meropenem]], [[Oprelvekin]], [[Oxaprozin]], [[Pamidronic acid]], [[Pegylated interferon alfa-2b]], [[Piperacillin]], [[Ritonavir]], [[Siltuximab]], [[Sorafenib]], [[Suprofen]], [[Tiagabine]], [[Trametinib]], [[Tolmetin]]
|bgcolor="Beige"|  [[Bacitracin]], [[balsalazide]], [[beractant]], [[cefadroxil]], [[ceftazidime]], [[cladribine]], [[cytarabine]], [[cytomegalovirus immuneglobulin]] , [[dalfampridine]], [[desogestrel and ethinyl estradiol]], [[dolutegravir]], [[flurbiprofen]], [[gadoxetate]], [[Ixabepilone]], [[ibuprofen lysine]], [[lincomycin hydrochloride]], [[lomustine]], [[meropenem]], [[oprelvekin]], [[oxaprozin]], [[pamidronic acid]], [[pegylated interferon alfa-2b]], [[piperacillin]], [[polymyxin B]], [[ritonavir]], [[siltuximab]], [[sorafenib]], [[streptozocin]], [[suprofen]], [[tiagabine]], [[trametinib]], [[tolmetin]]
|-
|-
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|-bgcolor="LightSteelBlue"
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|-bgcolor="LightSteelBlue"
| '''Endocrine'''
| '''Endocrine'''
|bgcolor="Beige"| No underlying causes
|bgcolor="Beige"| [[Hyperparathyroidism]], [[Hypoparathyroidism]]
|-
|-
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===Causes in Alphabetical Order===
===Causes in Alphabetical Order===
{{col-begin|width=80%}}
{{col-break|width=33%}}
*[[Cefadroxil]]
*[[Ceftazidime]]
*[[Cytarabine]]
*[[Desogestrel and Ethinyl Estradiol]]
*[[Dolutegravir]]
*[[Flurbiprofen]]
*[[Ixabepilone]]
*[[Oprelvekin]]
*[[Oxaprozin]]
*[[Siltuximab]]
*[[Sorafenib]]
{{col-break|width=33%}}
* Disease B


{{col-break|width=33%}}
* [[Cefadroxil]]
* Disease C
* [[Ceftazidime]]
{{col-end}}
* [[Cytarabine]]
* [[Cytomegalovirus immune globulin]]
* [[Desogestrel and Ethinyl Estradiol]]
* [[Dolutegravir]]
* [[Flurbiprofen]]
* [[Gadoxetate]]
* [[Hyperparathyroidism]]
* [[Hypoparathyroidism]]
* [[Ixabepilone]]
* [[Ibuprofen lysine]]
* [[Oprelvekin]]
* [[Oxaprozin]]
* [[Siltuximab]]
* [[Sorafenib]]


==References==
==References==

Latest revision as of 15:19, 25 September 2017

Renal insufficiency
ICD-10 N17-N19
ICD-9 584-585
DiseasesDB 26060
MeSH C12.777.419.780.500

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: Renal failure; azotemia; kidney failure; kidney insufficiency; renal disease; kidney injury; renal injury

For more detailed information please see the chapters on acute kidney injury and chronic kidney disease. This page is simply an overview of these disease states.

Overview

Renal insufficiency may broadly be divided into two categories: Acute kidney injury vs. chronic kidney disease:

 
 
 
Renal Insufficiency
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Defined as any of the following:
❑ Increase in serum creatinine concentration by 0.3 mg/dL in 48 hours, OR
❑ Increase in serum creatinine concentration by more than 50% of baseline or 1.5 times baseline concentration within the past 7 days, OR
❑ Decrease in urine volume <0.5 mL/kg/h for 6 or more hours
 
 
 

Defined as any of the following:
❑ Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either pathological abnormalities or markers of kidney damage (including abnormalities in the composition of the blood or urine or imaging abnormalities), OR
❑ GFR <60 mL/min/1.73 m2 for ≥3 months with or without kidney damage

Definition of Terms

Acute kidney injury (AKI)

Acute kidney injury (AKI), formerly known as acute renal failure, is characterized by an abrupt loss of kidney function resulting in a failure to excrete nitrogenous waste products (among others), and a disruption of fluid and electrolyte homeostasis. AKI is defined as any of the following:

  • Increase in serum creatinine concentration by 0.3 mg/dL in 48 hours, OR
  • Increase in serum creatinine concentration by more than 50% of baseline or 1.5 times baseline concentration within the past 7 days, OR
  • Decrease in urine volume <0.5 mL/kg/h for 6 or more hours

Chronic kidney disease (CKD)

Chronic kidney disease (or chronic renal insufficiency) is a broad spectrum of disorders that disturb the structural or functional integrity of the kidney for more than 3 months. CKD is defined as any of the following:

  • Kidney damage for ≥ 3 months as defined by structural or functional abnormalities of the kidney, with or without decreased GFR, manifest by either pathological abnormalities or markers of kidney damage (including abnormalities in the composition of the blood or urine or imaging abnormalities), OR
  • GFR <60 mL/min/1.73 m2 for ≥3 months with or without kidney damage

Acute-on-chronic renal failure (AoCRF)

Acute-on-chronic renal failure (AoCRF) is defined as the presence of acute kidney injury on top of chronic renal disease. AKI of AoCRF may be reversible, and the aim of treatment is to return the patient to baseline renal function prior to the acute insult.

Azotemia

Azotemia is neither a disease entity nor a clinical syndrome. It is a laboratory finding defined as an elevation in the concentration of nitrogenous waste products in the blood. Azotemia may suggest either kidney or non-kidney diseases. Azotemia is generally caused by:

  • Increased synthesis of nitrogenous waste products: Liver injury or skeletal muscle injury
  • Reduced loss of nitrogenous waste products: Acute or chronic kidney injuries

To view a comprehensive list of causes of azotemia, click here.

Uremia

Uremia (urine constituents in blood) is a clinical syndrome caused by progressive accumulation of nitrogen waste products among patients with kidney failure who with unable to clear these waste products by the kidneys.[1]

  • Uremia is thought to account for the clinical features of chronic kidney failure that cannot be explained by other classical abnormalities of chronic kidney failure (abnormalities of ion concentrations or extracellular volume overload).[1]
  • Initially, uremia syndrome remains subclinical as eGFR ranges between 10 to 50% of normal GFR. However, when renal function worsens and GFR further declines (below 10 mL/min/1.73m2, manifestations of uremia become more prominent, signaling the need for renal replacement modalities (either dialysis or renal transplantation).
  • Although experimental studies have validated the presence of uremia in the context of acute kidney injury (acute uremia), uremia is classically a feature of chronic kidney disease given the progressive nature of the waste product accumulation associated with the disease.

Causes

Causes by Organ System

Cardiovascular No underlying causes
Chemical/Poisoning No underlying causes
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Bacitracin, balsalazide, beractant, cefadroxil, ceftazidime, cladribine, cytarabine, cytomegalovirus immuneglobulin , dalfampridine, desogestrel and ethinyl estradiol, dolutegravir, flurbiprofen, gadoxetate, Ixabepilone, ibuprofen lysine, lincomycin hydrochloride, lomustine, meropenem, oprelvekin, oxaprozin, pamidronic acid, pegylated interferon alfa-2b, piperacillin, polymyxin B, ritonavir, siltuximab, sorafenib, streptozocin, suprofen, tiagabine, trametinib, tolmetin
Ear Nose Throat No underlying causes
Endocrine Hyperparathyroidism, Hypoparathyroidism
Environmental No underlying causes
Gastroenterologic No underlying causes
Genetic No underlying causes
Hematologic No underlying causes
Iatrogenic No underlying causes
Infectious Disease No underlying causes
Musculoskeletal/Orthopedic No underlying causes
Neurologic No underlying causes
Nutritional/Metabolic No underlying causes
Obstetric/Gynecologic No underlying causes
Oncologic No underlying causes
Ophthalmologic No underlying causes
Overdose/Toxicity No underlying causes
Psychiatric No underlying causes
Pulmonary No underlying causes
Renal/Electrolyte No underlying causes
Rheumatology/Immunology/Allergy No underlying causes
Sexual No underlying causes
Trauma No underlying causes
Urologic No underlying causes
Miscellaneous No underlying causes

Causes in Alphabetical Order

References

  1. ↑ 1.0 1.1 Meyer TW, Hostetter TH (2007). "Uremia". N Engl J Med. 357 (13): 1316–25. doi:10.1056/NEJMra071313. PMID 17898101.


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