Acute renal failure causes

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

Overview

Glomerular filtration rate depends on multiple factors, particularly the renal blood flow. The pressure difference across the renal vasculature i.e the difference in pressure between the renal arterioles and venules is directly proportional to the GFR. Any decrease in renal blood flow, injury to the renal tubules or obstruction to the urinary tract outflow can cause decreased urine output.

Causes

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

Acute Renal Failure

Pre-renal

Renal

Post-renal

Pre-renal (compromise in the renal blood flow)

• Hypovolemia (decreased blood volume) -
  • Shock, hemorrhage, burns, dehydration
  • Fluid loss from diuretics use, diabetes mellitus, hypoadrenalism
  • Gastrointestinal fluid loss: vomiting, surgical drainage, diarrhea
  • Extra-vascular space sequestration: pancreatitis, hypoalbuminemia, peritonitis, trauma, burns
• Low cardiac output -
  • Cardiac arrhthymia's
  • Congestive heart failure: left ventricular failure, right ventricular failure
  • Valvular disorders: severe aortic stenosis
  • Severe pulmonary hypertension, massive pulmonary emobolism
• Systemic vasodilatation -
  • Anaphylaxis
  • Sepsis
  • Antihypertensives
• Hepatorenal syndrome in which renal perfusion is compromised in liver failure (cirrhosis with ascites)
• Vascular problems -
  • Atheroembolic disease
  • Renal vein thrombosis (which can occur as a complication of the nephrotic syndrome)
  • Renal hypoperfusion from cyclooxygenase inhibitors, ACE inhibitors
  • Renal vasoconstriction from hypercalcemia, cyclosporine, tacrolimus and amphotericin B
• Hyperviscosity syndrome -
  • Multiple myeloma
  • Polycythemia
  • Waldenstrom's macroglobulinemia

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 immunoglobulins in multiple myeloma, uric acid crystals, etc.
• Interstitial nephritis
  • Infections: Acute pyelonephritis, cytomegalovirus infection, etc.
  • Allergic: Penicillin's, sulphonamides, rifampin, diuretics, ACE inhibitors
  • Infiltration: Malignancies (leukemias and lymphoma's)
• Graft rejection

Post-renal (obstructive causes in the urinary tract)

• Ureteric:
  • Ureteric calculi
  • Blood clot
  • Sloughed renal pappilae
  • External compression (retroperitoneal fibrosis)
• Bladder:
  • Medication interfering with normal bladder emptying
  • Neurogenic bladder
    • Syringomyelia
    • Tabes dorsalis
    • Neurosyphilis
    • Multiple sclerosis
  • Benign prostatic hypertrophy or prostate cancer.
• Urethal:
  • Obstructed urinary catheter
  • Urethral strictures
  • Phimosis
  • Posterior urethral valve

Complete list of Causes by Organ System

Cardiovascular	Malignant hypertension, Systemic hypertension
Chemical / poisoning	Amyl Alcohol, Aristolochic acid, Arsenic, Bismuth, Cadmium, Carbon Tetrachloride, Carmustine, Cephaloridine, Chloroform, Chromium, Copper, Diethylene glycol, Dioxane, Gallium, Gasoline, Germanium, Glue sniffing, Gold, Herbicide, Lead, Lithium, Lomustine, Mercury, Methanol, Nitrosourea compounds, Paint thinner, Para-amino salicylic acid, Paraquat ochratoxin A, Perchloroethylene, Pesticide, Platinum, Radiocontrast agents, Silica, Silver, Styrene, Sulphonamides, Thallium, Toluene, Trichloroethane, Trichloroethylene, Uranium, Zinc overdose
Dermatologic	Dermatomyositis
Drug Side Effect	Acetaminophen, Aminoglycosides, Amphotericin B, Anticancer agents, Aspirin, Bacitracin, Capreomycin, Chlortetracycline, Cidofovir, Cisplatin, Cyclophosphamide, Cyclosporin, Ibuprofen, Ifosfamide, Methicillin, Methotrexate, Mithramycin, Neomycin, Nonsteroidal anti-inflammatory drugs, Oxytetracycline, Polymyxin B, Rifampin, Trimethoprim, Vancomycin
Ear Nose Throat	No underlying causes
Endocrine	No underlying causes
Environmental	Agents causing methemoglobinemia
Gastroenterologic	Hepatorenal syndrome
Genetic	Adenine phosphoribosyltransferase deficiency, McArdle disease, Glycogen storage disease type V
Hematologic	Capillary leak syndrome with monoclonal gammopathy, Disseminated intravascular coagulation, Hemolytic uremic syndrome, Thrombotic thrombocytopenic purpura
Iatrogenic	No underlying causes
Infectious Disease	Boutonneuse fever, Clostridium tetani, Diphtheria, Ehrlichiosis, Escherichia coli O157:H7, Hantavirus, Hemorragic fever with renal syndrome, India tick typhus, Israeli spotted fever, Kenya tick typhus, Kenya tick typhus, Leptospirosis, Marseilles fever, Mediterranean Spotted Fever, Toxic shock syndrome
Musculoskeletal / Ortho	Dermatomyositis, Rhabdomyolysis
Neurologic	No underlying causes
Nutritional / Metabolic	Hyperuricemia
Obstetric/Gynecologic	Eclampsia, Pre-eclampsia
Oncologic	No underlying causes
Opthalmologic	No underlying causes
Overdose / Toxicity	No underlying causes
Psychiatric	No underlying causes
Pulmonary	No underlying causes
Renal / Electrolyte	Mesangial proliferative glomerulonephritis, Post-streptococcal glomerulonephritis, Renal artery stenosis, Membranoproliferative glomerulonephritis, Hemolytic uremic syndrome, Hepatorenal syndrome, Thrombotic thrombocytopenic purpura, Rhabdomyolysis
Rheum / Immune / Allergy	No underlying causes
Sexual	No underlying causes
Trauma	No underlying causes
Urologic	Obstructive uropathy, Reflux nephropathy, Hydronephrosis
Dental	No underlying causes
Miscellaneous	Automobile exhaust, Blood transfusion and its complications, Cholesterol embolism, Crush syndrome, Dehydration, Epidemic dropsy, Heat stroke, Hyperosmolar non-ketotic diabetic coma, Post-surgical complication, Shock, Tumor lysis syndrome

Causes in Alphabetical Order

Automobile exhaust Bacitracin Bismuth Blood transfusion and complications Boutonneuse fever Bruch's disease Cadmium Capillary leak syndrome with monoclonal gammopathy Capreomycin sulfate Carbon tetrachloride Carmustine Caterpillar-induced bleeding syndrome Cephaloridine Chloroform Chlortetracycline Cholesterol embolism Chromium Cidofovir Cisplatin Clostridium tetani Conor's disease Copper Crush syndrome Cyclophosphamide Cyclosporin Degreasing solvents Dehydration Dermatomyositis Diethylene glycol Dioxane Diphtheria Disseminated intravascular coagulation Eclampsia Ehrlichiosis Epidemic dropsy Erythroderma Escherichia coli O157:H7 Ethylene glycol Gallium nitrate Gasoline Germanium Glue solvent vapors Gold Hairdressing solvents Hantavirus Heat stroke Hemolytic uremic syndrome Hemorragic fever with renal syndrome Hepatorenal syndrome Herbicide Hexachloro-1,3-butadiene Hyperosmolar non-ketotic diabetic coma Hyperuricemia Ibuprofen Ifosfamide India tick typhus Indian tick fever Israeli spotted fever Kenya fever Kenya tick typhus

Lead Leptospirosis Lithium Lomustine Malignant hypertension Marseilles fever McArdle disease Mediterranean spotted fever Membranoproliferative glomerulonephritis Mercury Mesangiocapillary glomerulonephritis Methanol Methemoglobin-producing agents Methicillin Methotrexate Mithramycin Neomycin Nitrosourea compounds Nonsteroidal anti-inflammatory drugs Oxytetracycline Paint solvents Paint thinners Paints Para-amino salicylic acid Paraquat ochratoxin A Perchloroethylene Pesticide solvents Pesticides Phosphine poisoning Platinum Polymyxin Polymyxin B Post-streptococcal glomerulonephritis Pre-eclampsia Prostaglandin synthetase inhibitors Radiocontrast agents Renal artery stenosis Rhabdomyolysis Rifampin Shock Silica Silver Styrene Sulphinpyrazone Sulphonamides Surgery complication Thallium Thrombotic thrombocytopenic purpura Thrombotic thrombocytopenic purpura Toluene Toxic shock syndrome Trichloroacetylene Trichloroethane Trichloroethylene Trimethoprim Tumor lysis syndrome Type V Glycogen Storage Disease Uranium Vancomycin Zinc overdose