Pathophysiology - Acute Kidney Injury (AKI)

Pre-renal
Pre-Renal Intrinsic Post-renal

Hypovolemia Bladder outlet

Glomerular (Acute Tubules and Vascular obstruction
Decreased cardiac
glomerulonephritis) interstitium -Vasculitis
output
(Acute Tubular - Malignant Bilateral
Decreased effective
Necrosis) HPN pelvoureteral
circulating volume
- TTP/HUS obstruction
Hx: MI with Left Pansystolic murmur at apex
- Congestive ventricular dysfunction Orthostatic
Heart Failure Ischemic
Relative hypotension ACUTE TUBULAR NECROSIS
- Liver Failure Unresolved and -Cardiogenic shock,
in Cardiac
sustained pre- sepsis, severe volume Filtration INITIAL PHASE
Output
Impaired renal renal factors depletion impairment: -cellular adaptation
Ciprofloxacin,
autoregulation Cotrimoxazole, Effacement/loss - obstruction in flow of
Nephrotoxic Clarithromycin, Arterial
of PCT brush filtrate due to cast
Colchicine underfilling
- NSAIDs Diclofenac Na (Endogenous: borders (tubular injury) - DROP ACE-I (Enalapril)
- ACE-I/ARB aminoglycosides Activation of SNS, RAAS, INTRAGLOMERULAR intraglomerular
Enalapril and Arginine Vasopressin , Patchy loss of
- Cyclosporine inflammatory vasoactive PRESSURE pressure
Exogenous: hemolysis) substances and
endothelin tubular cells
Patient’s GFR =
EXTENSION PHASE 28.21 ml/min
RENAL Sloughing of
VASOCONSTRICTION -Persistent Ischemia
tubular cells
ACE-I/ARB impair afferent more than 99% of filtered Na+ and ongoing hypoxia
is reabsorbed, FE Na will be less into the lumen
arterial dilatation than 1 % ( except when the
- imbalance vasoactive
patient is on a diuretic, i.e.
U/A Cast: 12
mediators and
NSAIDs impair efferent furosemide). This allows Cast obstruction
accurate identification of Na+
persistent
arterial vasoconstriction
retention states even when
Urine output
necrosis vasoconstriction
there is water retention as a
Serum creatinine: 2.4 mg/dL
- WORSENING DROP
result of vasopressin release.
BUN: 40 mg/dL of GFR
Fractional Excretion of NA: BUN: Crea RATIO: 16.67
Legend: Actual signs and (<20:1 ratio) – Acute Tubular Necrosis
=UNa x PCr (100)
symptoms and lab results PNa x UCr
=18 x2 (100)
MAINTENANCE PHASE Oliguric for
148x 970
=0.03%
-MARKED DEPRESSION more than 12

Hypokalemia
AKI OF GFR but kidney
attempts to repair
hours

K+ level: 2.9 mg/dL

CC: Watery CC: Muscle weakness

Diarrhea (10- Hypernatremia -sunken eyeballs MAINTENANCE PHASE
Na level: 148 mg/dL - dry axillae Hypovolemic Decreased
12x/day) -Cellular regeneration
-Hyperactive bowel - dry lips perfusion to
sounds - dry oral mucosae - DIURETIC PHASE
kidneys
- mild epigastric - tachycardic - GFR increases to
tenderness - tachypneic
- colicky abdominal normal
pain