Renal Failure
Renal failure
Glomerulonephritis is characterized by hypertension, proteinuria and hematuria.6 Of the many types of glomerulonephritis, most are associated with chronic renal disease. In general, the two types of glomerulonephritis that cause acute renal failure are rapidly progressive glomerulonephritis and acute proliferative glomerulonephritis. The latter type occurs in patients with bacterial endocarditis or other postinfectious conditions.
Rapidly progressive glomerulonephritis can be a primary disorder, or it can occur secondary to systemic disease (Table 5). Renal function can decline quickly in patients with rapidly progressive glomerulonephritis, and end-stage renal disease can develop in days to weeks.8
Patients with rapidly progressive glomerulonephritis are treated withsyndrome.TABLE 5
Differential Diagnosis of Acute Renal Failure
Types of acute renal failure and underlying problemPossible disorders
Prerenal acute renal failureTrue intravascular depletionSepsis, hemorrhage, overdiuresis, poor fluid intake, vomiting, diarrheaDecreased effective circulating volume to the kidneysCongestive heart failure, cirrhosis or hepatorenal syndrome, nephrotic syndromeImpaired renal blood flow because of exogenous agentsAngiotensin-converting enzyme inhibitors, nonsteroidal anti-inflammatory drugsIntrinsic acute renal failure Acute tubular necrosis Ischemia
Toxins: drugs (e.g., aminoglycosides), contrast agents, pigments (myoglobin or hemoglobin) Glomerular disease Rapidly progressive glomerulonephritis: systemic lupus erythematosus, small-vessel vasculitis (Wegener's granulomatosis or polyarteritis nodosa), Henoch-Schönlein purpura (immunoglobulin A nephropathy), Goodpasture's syndrome
Acute proliferative glomerulonephritis: endocarditis, poststreptococcal infection, postpneumococcal infection Vascular disease Microvascular disease: atheroembolic disease (cholesterol-plaque microembolism), thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, HELLP syndrome or postpartum acute renal failure
Macrovascular disease: renal artery occlusion, severe abdominal aortic disease (aneurysm) Interstitial disease Allergic reaction to drugs, autoimmune disease: (systemic lupus erythematosus or mixed connective tissue disease), pyelonephritis, infiltrative disease (lymphoma or leukemia)Postrenal acute renal failure Benign prostatic hypertrophy or prostate cancer, cervical cancer, retroperitoneal disorders, intratubular obstruction (crystals or myeloma light chains), pelvic malignancy, bladder mass (clot, tumor or fungus ball), neurogenic bladder, urethral strictures
Vascular Disease
Microvascular or macrovascular disease (major renal artery occlusion or severe abdominal aortic disease) can cause acute renal failure.
Microvascular diseases seen with microangiopathic ARF due to glomerular capillary thrombosis or occlusion & accompanying thrombocytopenia,due to thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and HELLP syndrome (hemolysis,elevated liver enzymes andlow platelets).
The classic pentad in thrombotic thrombocytopenic purpura includes fever, neurologic changes, renal failure, microangiopathic hemolytic anemia and thrombocytopenia. Hemolytic uremic syndrome is similar to thrombotic thrombocytopenic purpura but does not present with neurologic changes. HELLP syndrome is a type of hemolytic uremic syndrome that occurs in pregnant women with the addition of transaminase elevations.
The microvascular diseases that cause acute renal failure are often treated with IVIG,plasmapheresis and corticosteroids.
Atheroembolic disease is another important cause of irreversible acute renal failure. Acute renal failure from embolic disease may present one day to seven weeks after the inciting event.12
Atheroembolism is relatively common in tertiary care and intensive care units, presenting classically with "purple toes and renal failure." Microembolism can be present in other organs (livedo reticularis, gastrointestinal tract bleeding, pancreatitis, persisting encephalopathy and retinal embolism seen as "Hollenhorst" plaques).