Acute Kidney Injury (Pre-renal)MANAGEMENT

GENITOURINARY AND REPRODUCTIVE PRESENTATIONS · 12 SECTIONS

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555 items

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Acute Kidney Injury (ATN)Acute Kidney Injury (Post-renal)Acute Kidney Injury (Pre-renal)Amniotic Fluid Embolism Balanitis Bladder Rupture Breast Abscess Cystitis Dialysis access complications Ectopic pregnancy Epididymitis Glomerulonephritis Hematuria (gross)Hydrocele Interstitial Cystitis Mastitis Mittelschmerz Nephrolithiasis Nephrotic Syndrome Flare Nutcracker Syndrome Orchitis Ovarian Cyst Rupture Ovarian hyperstimulation syndrome Ovarian torsion Paraphimosis Pelvic Congestion Syndrome Pelvic Inflammatory Disease (PID)Peritoneal dialysis peritonitis Phimosis Priapism Prostatitis Pyelonephritis Renal laceration Renal transplant complications and rejection Ruptured ovarian cyst Testicular torsion Torsion of Appendix Testis Tubo-ovarian abscess Ureteral Rupture Urethritis Urinary Retention Urinary tract infection (uncomplicated)Urolithiasis (renal colic)Vaginal bleeding (non-pregnant)Vaginitis (Bacterial)Vaginitis (Candidal)Varicocele Vulvovaginal Hematoma

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp51

Immediate priorities

›Life threats to address first

›Hemodynamic compromise driving hypoperfusion

›MAP < 65 mmHg despite initial resuscitation

›Shock physiology with mottling and oliguria

›Refractory hyperkalemia

›K+ > 6.0 mmol/l with ECG changes

›Peaked T waves, QRS widening, or bradycardia

›Severe metabolic acidosis

›pH < 7.1

›Rising anion gap with uremia

›Pulmonary edema unresponsive to diuretics

›Hypoxemia from volume overload

›Consider urgent RRT

›Restore renal perfusion early

›Pre-renal AKI is rapidly reversible if corrected promptly

›Prolonged hypoperfusion progresses to ischemic ATN

›Window is hours to days

›Identify and reverse the perfusion insult

›Volume loss, sepsis, cardiac, or hepatorenal

›Hold offending nephrotoxins

Monitoring and targets

›Perfusion and renal targets

›Mean arterial pressure

›Target MAP >= 65 mmHg

›Individualize higher in chronic hypertension

›Urine output

›Target > 0.5 ml/kg/hr

02History/hx61

Presentation pattern

›Volume loss history

›Gastrointestinal losses

›Vomiting

›Diarrhea

›Reduced intake

›Poor oral intake or NPO status

›Limited access to fluids

›Other fluid losses

›Hemorrhage, GI or surgical

›Excessive sweating or burns

›Urine output change

›Oliguria

›< 0.5 ml/kg/hr for >= 6 hours

›KDIGO urine output criterion

›Anuria

›Suggests obstruction or severe ATN

›Less typical of simple pre-renal

Causative context

›Cardiac contributors

›Heart failure features

›Dyspnea and orthopnea

›Peripheral edema

›Decreased effective circulating volume

›Cardiorenal physiology

›Recent decompensation

›Hepatic contributors

›Cirrhosis features

03Physical Exam/exam45

Vital signs and volume status

›Hemodynamic snapshot

›Blood pressure

›Hypotension

›Orthostatic changes

›Heart rate

›Tachycardia as hypovolemia marker

›MAP < 65 mmHg concerning

›Perfusion signs

›Delayed capillary refill

›Mottling in shock

›Hypovolemia findings

›Mucous membranes

›Dry oral mucosa

›Reduced skin turgor

›Jugular venous pressure

›Flat JVP

›Low filling state

Findings by cause

›Decreased effective circulating volume

›Heart failure signs

›Elevated JVP

›S3 gallop and crackles

›Cirrhosis signs

›Ascites and abdominal distension

›Peripheral edema

›Clues to alternative diagnoses

›Skin findings

04Differential Diagnosis/ddx51

Distinguishing pre-renal from intrinsic

›Acute tubular necrosis

›Urinary indices

›FENa > 1%

›Urine sodium > 40 mmol/l

›Sediment and response

›Muddy brown granular casts

›Does not respond to volume challenge

›Coding

›ICD-10 N17.0

›Ischemic or nephrotoxic injury

›Pre-renal azotemia

›Urinary indices

›FENa < 1%

›Urine sodium < 20 mmol/l

›Coding

›ICD-10 N17.9 acute kidney failure

›SNOMED CT prerenal azotemia concept

Other categories

›Post-renal obstruction

›Imaging

›Hydronephrosis on ultrasound

›Distended bladder

›Risk context

›BPH or pelvic malignancy

›Nephrolithiasis

›Coding

›ICD-10 N13.x obstructive uropathy

05Laboratory Tests/lt48

Core renal labs

›Basic metabolic panel

›Creatinine

›Compare to baseline for staging

›Serial q6-12h in acute setting

›Urea and ratio

›BUN:Cr > 20:1 supports pre-renal

›Reflects enhanced urea reabsorption

›Potassium and bicarbonate

›Hyperkalemia screen

›Metabolic acidosis screen

›Urinary diagnostic indices

›Fractional excretion of sodium

›FENa < 1% supports pre-renal

›Pooled sensitivity 95%, specificity 91%

›Most reliable in oliguric patients off diuretics

›Fractional excretion of urea

›FEUrea < 35% alternative when on diuretics

›Moderate diagnostic accuracy

›Spot urine chemistry

›Urine sodium < 20 mmol/l

›Urine osmolality > 500 mOsm/kg

Urinalysis and sediment

›Urinalysis with microscopy

›Sediment pattern

›Bland or hyaline casts in pre-renal

›Muddy brown casts in ATN

›Concentration markers

06Diagnostic Tests/dt58

Scoring Systems

›KDIGO AKI staging

›Stage 1

›SCr rise >= 26.5 micromol/l within 48h or 1.5-1.9x baseline

›Urine output < 0.5 ml/kg/hr for 6-12h

›Stage 2

›SCr 2.0-2.9x baseline

›Urine output < 0.5 ml/kg/hr for >= 12h

›Stage 3

›SCr >= 3.0x baseline or >= 353.6 micromol/l or RRT initiation

›Urine output < 0.3 ml/kg/hr for >= 24h or anuria >= 12h

›Diagnostic indices and tools

›FENa calculator

›Key tool to separate pre-renal from intrinsic

›Requires paired urine and serum sodium and creatinine

›Novel biomarkers

›NGAL and TIMP-2 x IGFBP-7

›Detect tubular injury before creatinine rises, limited availability

MRI

›MRI role in AKI

›Limited acute utility

›Not routine for pre-renal AKI

›Time and availability constraints

›Problem-solving indications

›Renal vein thrombosis evaluation

›Mass or vascular anomaly characterization

›Contrast caution

›Avoid gadolinium in severe AKI

07Disposition/dispo37

Level of care selection

›Admission indications

›Stage 2 or 3 AKI

›KDIGO staging threshold

›Rising creatinine trajectory

›Hemodynamic instability

›Ongoing volume loss

›Vasopressor requirement

›Dangerous electrolyte or acid-base state

›K+ > 6.0 mmol/l

›Significant metabolic acidosis

›Oliguria or anuria not responding to resuscitation

›Failed initial fluid challenge

›Underlying cause needing inpatient care

›ICU and RRT indications

›Refractory shock

›Vasopressor-dependent

›Rising lactate despite resuscitation

›Renal replacement therapy needs

›Refractory hyperkalemia or acidosis

›Pulmonary edema or uremic complications

Discharge and follow up

›Discharge criteria

›Creatinine trending toward baseline

›Improving after ED fluids

›Stable electrolytes

›Clinical stability

›Adequate urine output

08Treatment/t90

Initial stabilization

›Hemodynamic resuscitation

›Perfusion target

›MAP >= 65 mmHg

›Individualize in chronic hypertension

›Access and monitoring

›Establish IV access

›Foley for urine output tracking

›Vasopressor support if vasoplegia

›Norepinephrine first-line

›Start 0.05 mcg/kg/min IV infusion

›Titrate every 5-10 min to MAP >= 65 mmHg

›No fixed maximum, escalate per response

›Reserve for fluid-refractory shock

›After adequate volume given

›Distributive or septic physiology

Volume resuscitation

›Fluid selection and dosing

›Balanced crystalloid preferred

›Lactated Ringer or Plasma-Lyte over 0.9% saline

›Reduces RRT and acidosis risk

›Bolus strategy

›250-500 ml boluses with reassessment

›Goal euvolemia, not hypervolemia

›Reassess volume status after each bolus

›Avoid harmful fluids

›No synthetic colloids such as hydroxyethyl starch

›Increased RRT risk

09Special Populations/sp39

Pregnancy

›Pregnancy considerations

›Physiologic baseline shift

›GFR increased, baseline creatinine lower

›Creatinine > 70 micromol/l may be abnormal

›Pregnancy-specific causes

›Hyperemesis gravidarum volume loss

›Preeclampsia and HELLP overlap

›Management adjustments

›Avoid ACE inhibitors and ARBs

›Balanced crystalloid resuscitation

›Imaging approach

›Ultrasound first-line

›Avoid gadolinium and limit CT contrast

Geriatric

›Older adult features

›Increased susceptibility

›Predisposition to hypovolemia

›Renal artery atherosclerosis

›Atypical presentation

›Confusion as primary symptom

›Blunted thirst response

›Polypharmacy risk

›Triple whammy combination common

›Careful medication reconciliation

›Reduced reserve

›Lower baseline GFR

›Higher progression to CKD

10Background/b44

Epidemiology

›Frequency and burden

›Most common cause of AKI

›About 70% of community-acquired AKI

›About 40% of hospital-acquired AKI

›Sepsis as leading driver

›47% of severe AKI cases in ICU

›Highest mortality subgroup

›Long-term consequences

›Roughly 9x pooled risk of CKD

›Roughly 2x risk of premature death

Pathophysiology

›Mechanism of injury

›Reduced renal perfusion

›Structurally intact kidneys

›Functional decline in GFR

›Autoregulatory compensation

›Afferent arteriolar dilation via prostaglandins

›Efferent constriction via angiotensin II

›Drug-mediated failure of autoregulation

›NSAIDs block afferent dilation

›ACEi and ARBs block efferent constriction

›Progression pathway

›Reversibility window

›Rapidly reversible with restored perfusion

›Preserved tubular function

›Transition to ATN

›Prolonged ischemia injures tubules

11Patient Discharge Instructions/pdi20

copy discharge instructions

›Acute kidney injury home care

›Drink fluids as advised to stay hydrated

›Take only medications approved by your clinician

›Do not restart held blood pressure or water pills until cleared

›Avoid ibuprofen, naproxen, and other anti-inflammatories

›Sick-day rules

›Hold blood pressure pills and water pills during dehydrating illness

›Resume only after clinician review

›Seek care if unable to keep fluids down

›Warning signs to return to ER

›Little or no urine

›Persistent vomiting or diarrhea with inability to keep fluids down

›Confusion or excessive drowsiness

›Chest pain or severe shortness of breath

›Muscle weakness or palpitations

›Swelling of legs, face, or abdomen

›Follow up

›Blood test to recheck kidney function within 2-3 days

›Clinician or kidney specialist visit within 1-2 weeks

›Bring an updated list of all medications

12References/r11

Guidelines and key sources

›Guideline sources

›KDIGO 2012 Clinical Practice Guideline for Acute Kidney Injury

›AGA Clinical Practice Update on AKI in cirrhosis

›AHA guidance on hyperkalemia and ECG monitoring

›Landmark and evidence sources

›Meta-analyses on fractional excretion of sodium and urea diagnostic performance

›NEJM reviews on acute renal failure and kidney replacement therapy

›Lancet reviews on acute kidney injury epidemiology and outcomes

›Coding standards

›ICD-10 N17.9 acute kidney failure unspecified

›SNOMED CT prerenal azotemia disorder concept

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Reviewed by SymptomDx Medical Team · Last reviewed August 18, 2026

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