Hospital Medicine

Intrinsic Renal Disease

I. Problem/Condition.

Acute renal failure (ARF) may occur in patients due to the presence of intrinsic renal disease, referring to pathologic processes involving the glomeruli, renal tubules, vessels or interstitium. This contrasts with prerenal causes of ARF, in which renal perfusion is compromised by true hypovolemia or a decrease in effective circulating volume, and postrenal causes due to obstruction of the urinary collecting system.

II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

1. Tubulo-interstitial

2. Glomerular

a. Nephritis

b. Nephrosis

3. Vascular

B. Describe a diagnostic approach/method to the patient with this problem.

1. Role of urinalysis

2. Renal ultrasonography

3. Labs

1. Historical information important in the diagnosis of this problem.

In patients admitted to intensive care units, sepsis accounts for 35 to 50% of cases of acute renal failure, usually acute tubular necrosis. In sepsis, arterial vasodilatation due to cytokines that upregulate inducible nitric oxide synthase expression leads to arterial underfilling and may be coupled with renal vasoconstriction due to endothelin release from elevated tumor necrosis factor-alpha.

Patient with pre-existing renal disease, hypertension, peripheral vascular disease, diabetes mellitus, cardiac disease, advanced age and liver disease are at increased risk of developing intrinsic renal impairment, particularly acute tubular necrosis, especially after surgery.

Exposure to nephrotoxic agents, including contrast dye, medications, such as antimicrobial and antineoplastic agents, environmental agents and recreational drugs should be investigated.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

Reduced blood flow particularly to the outer medulla due to increased production of vasconstrictor substances, such as angiotensin II, thromxane A2, prostaglandin H2, leukotrienes C4 and D4, endothelin 1 and adenosine.

Urinalysis

Urine eosinophils

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

N/A

III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Intrinsic Renal Disease.

Role of renal biopsy

Volume resuscitation

Avoidance of nephrotoxic agents

Nephrology consultation

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem.

N/A

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