Renal failure, acute diagnosis

Category Classification of Acute Renal Failure Differential Diagnosis... 

CDC Case Definition A mosquito-borne viral illness characterized by acute onset and constitutional symptoms followed by a brief remission and a recurrence of fever, hepatitis, albuminuria, and symptoms and, in some instances, renal failure, shock, and generalized hemorrhages. Laboratory criteria for diagnosis is (1) fourfold or greater rise in yellow fever antibody titer in a patient who has no history of recent yellow fever vaccination and cross-reactions to other flaviviruses have been excluded or (2) demonstration of yellow fever virus, antigen, or genome in tissue, blood, or other body fluid. 

Differential Diagnosis of Acute Renal Failure on the Basis of Urine Microscopic Examination Findings... 

The pathophysiology, clinical manifestations, diagnosis, and treatment of acute renal failure and chronic kidney disease (CKD) or end-stage renal disease are discussed in Chaps. 75 and 76, respectively. 

Because of the severe pain, the physician (Patient 5) with exercise-induced acute renal failure (ALPE) made a self-diagnosis of acute pancreatitis. Initially, most patients are diagnosed as having ureteral stone, but some physicians diagnose lumbar pain or lumbar disc hernia. 

Table 11. Differential diagnosis of exercise-induced acute renal failure (ALPE) from myoglo-binuric acute renal failure...

In addition to ALPE, mild acute renal failure, including dehydration, acute pyelonephritis, and renal pelvic tumors, is visualized as wedge-shaped contrast enhancement [15]. However, acute pyelonephritis and renal pelvic tumors are visualized as unilateral lesions, whereas ALPE is visualized as a bilateral lesion therefore, differentiation is possible. For a definitive diagnosis, the presence of patchy contrast enhancement must be demonstrated when the serum creatinine level is in the range from 1.2 to 3.5 mg/dl. However, as described above, a definitive diagnosis is not always necessary in clinical practice. 

We are able to identify the presence of this disorder, and summarize the diagnosis and treatment because (a) we had personal contact with the patients, (b) we had previous knowledge of the hemodynamics of acute renal failure, (c) we had been carrying out animal experiments into glycerol-induced acute renal failure (myohemoglobin-uric acute renal failure) for many years, and (d) a new diagnostic procedure, a computed tomography (CT) scan, had been developed and could be employed. 

Fig. 11. Cluster analysis used to assist in diagnosis of kidney diseases (adapted from Batchelor 418>). (A) acute nephritis, (B) nephrotic syndrome, (C) normal, (D) acute renal infection, (E) essential hypertension, and (F) chronic renal failure...

Carvounis CP, Nisar S, Guro-Razuman S (2002) Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney Int 62 2223-2229 Dunn SR, Qi Z, Bottinger EP et al. (2004) Utility of endogenous creatinine clearance as a measure of renal function in mice. Kidney Int 65 1959-1967... 

Thrombotic thrombocytopenic purpura is a rare acute or subacute disease in adults, rather similar to the hemolytic uremic syndrome in children, in which there is systemic malaise, fever, skin purpura, renal failure, hematuria and proteinuria. Hemorrhagic infarcts caused by platelet microthrombi occur in many organs in the brain they may cause stroke-like episodes (Matijevic and Wu 2006) although more commonly there is global encephalopathy. The blood film shows thrombocytopenia, hemolytic anemia and fragmented red cells. The differential diagnosis includes infective endocarditis, idiopathic thrombocytopenia, heparin-induced thrombocytopenia with thrombosis, systemic lupus erythematosus, non-bacterial thrombotic endocarditis and disseminated intravascular coagulation. 

After exclusion of these differential diagnostic possibilities in liver diseases with renal symptoms, the likely diagnosis is hepatorenal syndrome. In the case of a severe and protracted course, this functional impairment of the kidneys can progress to true, acute renal failure, even with tubular necrosis. 

Nephrotoxicity can present as acute tubular necrosis or, more commonly, as gradually evolving non-ohguric renal failure. The time-course of toxicity is variable, but it usually develops only after several days of treatment. Early diagnosis is difficult, since there can be a reduction in glomerular filtration before a significant rise in serum... 

Carvounis CP, Nisar S, Guro-Razuman S. Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure. Kidney int 2002 62 2223-2229. 

The effects of amphetamines on the kidney are mainly acute tubular necrosis on the basis of rhabdomyolysis (with myoglobinuria) and a disseminated intravascular coagulopathy. But, malignant hypertension and the resultant effects on the kidneys, must always be a consideration in the differential diagnosis of renal failure [45-50]. These effects are likely to be chronic and irreversible. Bingham et al reported a case of necrotising vasculopathy after the ingestion of... 

Chronic salicylism presents clinically in a similar fashion to the acute situation, although it is often associated with a delay in diagnosis, and a higher morbidity and mortality. Chronic salicylism is more often associated with pronounced hyperventilation, dehydration, pulmonary edema, renal failure, coma, seizures, and acidosis. Chronic salicylism can occur at serum salicylate levels as low as 15mgdl. ... 

Although the kidneys continually produce urine, the bladder stores the urine for intermittent elimination. For the initial diagnosis and management of acute circulatory insufficiency, a catheter can be inserted into the bladder for measuring urine output. In contrast to thirst, which is a relatively insensitive indicator of volume depletion, urine output is generally diminished with inadequate fluid administration and increases with appropriate resuscitation. This presumes, of course, that acute renal failure or medications such as diuretics are not altering the expected response. Adults should produce at least 0.5 to 1 mL/kg per hour of urine, whereas children up to 12 years of age should produce at least 1 mL/kg per hour (2 mL/kg per hour if younger than 1 year of age). ... 

Physical Examination Finding Possible Diagnosis Category of Acute Renal Failure... 

NSAID-induced acute renal failure is treated by discontinuation of therapy and supportive care. Renal failure may be severe, but recovery is usually rapid and dialysis is rarely necessary. Occasionally the hemodynamic insult is sufficiently severe to cause frank tubular necrosis, which can prolong recovery. The differential diagnosis of NSAID hemodynamically-mediated acute renal failure must include NSAID-induced acute interstitial nephritis, with or without the nephrotic syndrome, because steroid therapy may benefit this type of renal injury. 

---