Schrier RW, Wang W, Poole B, Mitra A. Acute renal failure: definitions, diagnosis, pathogenesis, and therapy. J Clin Invest. 2004 Jul. 114(1):5-14. [Medline]. [Full Text].
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004 Aug. 8(4):R204-12. [Medline]. [Full Text].
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007. 11(2):R31. [Medline]. [Full Text].
Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008 Nov 4. 52(19):1527-39. [Medline].
Gandhi S, Fleet JL, Bailey DG, McArthur E, Wald R, Rehman F, et al. Calcium-channel blocker-clarithromycin drug interactions and acute kidney injury. JAMA. 2013 Dec 18. 310 (23):2544-53. [Medline]. [Full Text].
Durand F, Graupera I, Ginès P, Olson JC, Nadim MK. Pathogenesis of Hepatorenal Syndrome: Implications for Therapy. Am J Kidney Dis. 2015 Oct 21. [Medline].
Rennie TJW, De Souza N, Donnan PT, Marwick CA, Davey P, Dreischulte T, et al. Risk of acute kidney injury following community prescription of antibiotics: self-controlled case series. Nephrol Dial Transplant. 2018 Jun 28. [Medline].
Talving P, Karamanos E, Skiada D, Lam L, Teixeira PG, Inaba K, et al. Relationship of creatine kinase elevation and acute kidney injury in pediatric trauma patients. J Trauma Acute Care Surg. 2013 Mar. 74(3):912-6. [Medline].
Mancini E, Caramelli F, Ranucci M, et al. Is time on cardiopulmonary bypass during cardiac surgery associated with acute kidney injury requiring dialysis?. Hemodial Int. 2011 Nov 8. [Medline].
Ronco C, Reis T, Husain-Syed F. Management of acute kidney injury in patients with COVID-19. Lancet Respir Med. 2020 Jul. 8 (7):738-742. [Medline]. [Full Text].
Ali H, Daoud A, Mohamed MM, Salim SA, Yessayan L, Baharani J, et al. Survival rate in acute kidney injury superimposed COVID-19 patients: a systematic review and meta-analysis. Ren Fail. 2020 Nov. 42 (1):393-397. [Medline]. [Full Text].
Batlle D, Soler MJ, Sparks MA, Hiremath S, South AM, Welling PA, et al. Acute Kidney Injury in COVID-19: Emerging Evidence of a Distinct Pathophysiology. J Am Soc Nephrol. 2020 Jul. 31 (7):1380-1383. [Medline]. [Full Text].
Nadim MK, Forni LG, Mehta RL, ET AL. COVID-19-associated acute kidney injury: consensus report of the 25th Acute Disease Quality Initiative (ADQI) Workgroup. Nat Rev Nephrol. 2020 Dec. 16 (12):747-764. [Medline]. [Full Text].
Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set. Anesthesiology. 2009 Mar. 110(3):505-15. [Medline].
Ronco C, Bellomo R, Kellum JA. Acute kidney injury. Lancet. 2019 Nov 23. 394 (10212):1949-1964. [Medline].
Panek R, Tennankore KK, Kiberd BA. Incidence, Etiology and Significance of Acute Kidney Injury in the Early Post Kidney Transplant Period. Clin Transplant. 2015 Oct 24. [Medline]. [Full Text].
Harding JL, Li Y, Burrows NR, Bullard KM, Pavkov ME. US Trends in Hospitalizations for Dialysis-Requiring Acute Kidney Injury in People With Versus Without Diabetes. Am J Kidney Dis. 2020 Jun. 75 (6):897-907. [Medline].
Holmes J, Rainer T, Geen J, Roberts G, May K, Wilson N, et al. Acute Kidney Injury in the Era of the AKI E-Alert. Clin J Am Soc Nephrol. 2016 Oct 28. [Medline].
Alobaidi R, Morgan C, Goldstein SL, Bagshaw SM. Population-Based Epidemiology and Outcomes of Acute Kidney Injury in Critically Ill Children. Pediatr Crit Care Med. 2020 Jan. 21 (1):82-91. [Medline].
Feest TG, Mistry CD, Grimes DS, Mallick NP. Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. BMJ. 1990 Oct 20. 301(6757):897-900. [Medline]. [Full Text].
Pannu N, James M, Hemmelgarn BR, Dong J, Tonelli M, Klarenbach S. Modification of Outcomes After Acute Kidney Injury by the Presence of CKD. Am J Kidney Dis. 2011 Aug. 58(2):206-13. [Medline].
Wang AY, Bellomo R, Cass A, Finfer S, Gattas D, Myburgh J, et al. Health-related quality of life in survivors of acute kidney injury: The Prolonged Outcomes Study of the Randomized Evaluation of Normal versus Augmented Level Replacement Therapy study outcomes. Nephrology (Carlton). 2015 Jul. 20 (7):492-8. [Medline].
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005 Aug 17. 294(7):813-8. [Medline].
Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, et al. Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. Clin J Am Soc Nephrol. 2007 May. 2(3):431-9. [Medline].
Ricci Z, Cruz D, Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review. Kidney Int. 2008 Mar. 73(5):538-46. [Medline].
Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD. Fluid Balance, Diuretic Use, and Mortality in Acute Kidney Injury. Clin J Am Soc Nephrol. 2011 May. 6(5):966-973. [Medline]. [Full Text].
James MT, Hemmelgarn BR, Wiebe N, Pannu N, Manns BJ, Klarenbach SW, et al. Glomerular filtration rate, proteinuria, and the incidence and consequences of acute kidney injury: a cohort study. Lancet. 2010 Dec 18. 376(9758):2096-103. [Medline].
Wahl TS, Graham LA, Morris MS, Richman JS, Hollis RH, Jones CE, et al. Association Between Preoperative Proteinuria and Postoperative Acute Kidney Injury and Readmission. JAMA Surg. 2018 Jul 3. e182009. [Medline].
Philips B, MacPhee I. Do statins prevent acute kidney injury?. Expert Opin Drug Saf. 2015 Oct. 14 (10):1547-61. [Medline].
Dormuth CR, Hemmelgarn BR, Paterson JM, James MT, Teare GF, Raymond CB, et al. Use of high potency statins and rates of admission for acute kidney injury: multicenter, retrospective observational analysis of administrative databases. BMJ. 2013 Mar 18. 346:f880. [Medline]. [Full Text].
Giacoppo D, Capodanno D, Capranzano P, Aruta P, Tamburino C. Meta-analysis of randomized controlled trials of preprocedural statin administration for reducing contrast-induced acute kidney injury in patients undergoing coronary catheterization. Am J Cardiol. 2014 Aug 15. 114 (4):541-8. [Medline].
Marenzi G, Cosentino N, Werba JP, Tedesco CC, Veglia F, Bartorelli AL. A meta-analysis of randomized controlled trials on statins for the prevention of contrast-induced acute kidney injury in patients with and without acute coronary syndromes. Int J Cardiol. 2015 Mar 15. 183:47-53. [Medline].
Molnar AO, Coca SG, Devereaux PJ, Jain AK, Kitchlu A, Luo J, et al. Statin use associates with a lower incidence of acute kidney injury after major elective surgery. J Am Soc Nephrol. 2011 May. 22(5):939-46. [Medline]. [Full Text].
Pan SY, Wu VC, Huang TM, Chou HC, Ko WJ, Wu KD, et al. Effect of preoperative statin therapy on postoperative acute kidney injury in patients undergoing major surgery: systemic review and meta-analysis. Nephrology (Carlton). 2014 Dec. 19 (12):750-63. [Medline].
Lewicki M, Ng I, Schneider AG. HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass. Cochrane Database Syst Rev. 2015 Mar 11. 3:CD010480. [Medline].
Kuhn EW, Slottosch I, Wahlers T, Liakopoulos OJ. Preoperative statin therapy for patients undergoing cardiac surgery. Cochrane Database Syst Rev. 2015 Aug 13. 8:CD008493. [Medline].
Wang J, Gu C, Gao M, Yu W, Yu Y. Preoperative Statin Therapy and Renal Outcomes After Cardiac Surgery: A Meta-analysis and Meta-regression of 59,771 Patients. Can J Cardiol. 2015 Aug. 31 (8):1051-60. [Medline].
Gallagher M, Cass A, Bellomo R, Finfer S, Gattas D, Lee J, et al. Long-term survival and dialysis dependency following acute kidney injury in intensive care: extended follow-up of a randomized controlled trial. PLoS Med. 2014 Feb. 11(2):e1001601. [Medline]. [Full Text].
[Guideline] National Clinical Guideline Centre (UK). Acute Kidney Injury: Prevention, Detection and Management Up to the Point of Renal Replacement Therapy. 2013 Aug. [Medline]. [Full Text].
Billings FT 4th, Pretorius M, Schildcrout JS, Mercaldo ND, Byrne JG, Ikizler TA, et al. Obesity and oxidative stress predict AKI after cardiac surgery. J Am Soc Nephrol. 2012 Jul. 23 (7):1221-8. [Medline]. [Full Text].
Kelz RR, Reinke CE, Zubizarreta JR, Wang M, Saynisch P, Even-Shoshan O, et al. Acute kidney injury, renal function, and the elderly obese surgical patient: a matched case-control study. Ann Surg. 2013 Aug. 258 (2):359-63. [Medline]. [Full Text].
Soto GJ, Frank AJ, Christiani DC, Gong MN. Body mass index and acute kidney injury in the acute respiratory distress syndrome. Crit Care Med. 2012 Sep. 40 (9):2601-8. [Medline]. [Full Text].
Danziger J, Chen KP, Lee J, Feng M, Mark RG, Celi LA, et al. Obesity, Acute Kidney Injury, and Mortality in Critical Illness. Crit Care Med. 2015 Oct 22. [Medline].
American College of Radiology. ACR Appropriateness Criteria® renal failure. National Guideline Clearinghouse. Available at http://guideline.gov/content.aspx?id=13685. Accessed: March 24, 2011.
Koyner JL, Davison DL, Brasha-Mitchell E, Chalikonda DM, Arthur JM, Shaw AD, et al. Furosemide Stress Test and Biomarkers for the Prediction of AKI Severity. J Am Soc Nephrol. 2015 Aug. 26 (8):2023-31. [Medline]. [Full Text].
Chawla LS, Davison DL, Brasha-Mitchell E, Koyner JL, Arthur JM, Shaw AD, et al. Development and standardization of a furosemide stress test to predict the severity of acute kidney injury. Crit Care. 2013 Sep 20. 17 (5):R207. [Medline]. [Full Text].
Lowes R. FDA OKs NephroCheck to Assess Risk for Acute Kidney Injury. Medscape Medical News. Sep 5 2014. [Full Text].
Tuladhar SM, Püntmann VO, Soni M, Punjabi PP, Bogle RG. Rapid detection of acute kidney injury by plasma and urinary neutrophil gelatinase-associated lipocalin after cardiopulmonary bypass. J Cardiovasc Pharmacol. 2009 Mar. 53(3):261-6. [Medline].
Breidthardt T, Christ-Crain M, Stolz D, et al. A combined cardiorenal assessment for the prediction of acute kidney injury in lower respiratory tract infections. Am J Med. 2012 Feb. 125(2):168-75. [Medline].
Hall IE, Coca SG, Perazella MA, et al. Risk of Poor Outcomes with Novel and Traditional Biomarkers at Clinical AKI Diagnosis. Clin J Am Soc Nephrol. 2011 Dec. 6(12):2740-9. [Medline].
Spahillari A, Parikh CR, Sint K, Koyner JL, Patel UD et al. Serum cystatin C- versus creatinine-based definitions of acute kidney injury following cardiac surgery: a prospective cohort study. Am J Kidney Dis. 2012 Dec. 60(6):922-9. [Medline]. [Full Text].
Nainggolan L. Two Antihypertensives Plus NSAID Ups Risk of Acute Kidney Injury. Two Antihypertensives Plus NSAID Ups Risk of Acute Kidney Injury. Heartwire. Jan 9 2013. [Full Text].
Lapi F, Azoulay L, Yin H, Nessim SJ, Suissa S. Concurrent use of diuretics, angiotensin converting enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-inflammatory drugs and risk of acute kidney injury: nested case-control study. BMJ. 2013 Jan 8. 346:e8525. [Medline]. [Full Text].
Hammoud K, Brimacombe M, Yu A, Goodloe N, Haidar W, El Atrouni W. Vancomycin Trough and Acute Kidney Injury: A Large Retrospective, Cohort Study. Am J Nephrol. 2016 Oct 28. 44 (6):456-461. [Medline].
Lauschke A, Teichgräber UK, Frei U, Eckardt KU. Low-dose' dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int. 2006 May. 69(9):1669-74. [Medline].
Macedo E, Mehta RL. When should renal replacement therapy be initiated for acute kidney injury?. Semin Dial. 2011 Mar-Apr. 24(2):132-7. [Medline].
Palevsky PM, Zhang JH, O'Connor TZ, Chertow GM, Crowley ST, Choudhury D, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008 Jul 3. 359(1):7-20. [Medline]. [Full Text].
Pannu N, Manns B, Lee H, Tonelli M. Systematic review of the impact of N-acetylcysteine on contrast nephropathy. Kidney Int. 2004 Apr. 65(4):1366-74. [Medline].
Marenzi G, Assanelli E, Marana I, Lauri G, Campodonico J, Grazi M, et al. N-acetylcysteine and contrast-induced nephropathy in primary angioplasty. N Engl J Med. 2006 Jun 29. 354(26):2773-82. [Medline].
Majumdar SR, Kjellstrand CM, Tymchak WJ, Hervas-Malo M, Taylor DA, Teo KK. Forced euvolemic diuresis with mannitol and furosemide for prevention of contrast-induced nephropathy in patients with CKD undergoing coronary angiography: a randomized controlled trial. Am J Kidney Dis. 2009 Oct. 54 (4):602-9. [Medline].
Yang B, Xu J, Xu F, Zou Z, Ye C, Mei C, et al. Intravascular administration of mannitol for acute kidney injury prevention: a systematic review and meta-analysis. PLoS One. 2014 Jan 14. 9 (1):e85029. [Medline]. [Full Text].
Chorin E, Ben-Assa E, Konigstein M, Rofe MT, Hochstadt A, Galli N, et al. Prevention of post procedural acute kidney injury in the catheterization laboratory in a real-world population. Int J Cardiol. 2016 Oct 11. 226:42-47. [Medline].
Briguori C. Renalguard system in high-risk patients for contrast-induced acute kidney injury. Minerva Cardioangiol. 2012 Jun. 60 (3):291-7. [Medline].
Briguori C, Visconti G, Focaccio A, Airoldi F, Valgimigli M, Sangiorgi GM, et al. Renal Insufficiency After Contrast Media Administration Trial II (REMEDIAL II): RenalGuard System in high-risk patients for contrast-induced acute kidney injury. Circulation. 2011 Sep 13. 124 (11):1260-9. [Medline].
Reducing Incidence of Contrast-Induced Nephropathy. RenalGuard. Available at http://www.renalguard.com/. Accessed: December 23, 2020.
Zarbock A, Schmidt C, Van Aken H, Wempe C, Martens S, Zahn PK, et al. Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: a randomized clinical trial. JAMA. 2015 Jun 2. 313 (21):2133-41. [Medline].
Zacharias M, Mugawar M, Herbison GP, Walker RJ, Hovhannisyan K, Sivalingam P, et al. Interventions for protecting renal function in the perioperative period. Cochrane Database Syst Rev. 2013 Sep 11. 9:CD003590. [Medline].
Ho KM, Morgan DJ. Meta-analysis of N-acetylcysteine to prevent acute renal failure after major surgery. Am J Kidney Dis. 2009 Jan. 53(1):33-40. [Medline].

Media Gallery

Pigmented, muddy brown, granular casts are visible in the urine sediment of a patient with acute tubular necrosis (400x magnification).
Photomicrograph of a renal biopsy specimen shows renal medulla, which is composed mainly of renal tubules. Features suggesting acute tubular necrosis are the patchy or diffuse denudation of the renal tubular cells with loss of brush border (blue arrows); flattening of the renal tubular cells due to tubular dilation (orange arrows); intratubular cast formation (yellow arrows); and sloughing of cells, which is responsible for the formation of granular casts (red arrow). Finally, intratubular obstruction due to the denuded epithelium and cellular debris is evident (green arrow); note that the denuded tubular epithelial cells clump together because of rearrangement of intercellular adhesion molecules.

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Table 1. RIFLE Classification System for Acute Kidney Injury

Stage	GFR^ Criteria**	Urine Output Criteria	Probability
Risk	SCreat^† increased × 1.5 or GFR decreased >25%	UO^‡< 0.5 mL/kg/h × 6 h	High sensitivity (Risk >Injury >Failure)
Injury	SCreat increased × 2 or GFR decreased >50%	UO < 0.5 mL/kg/h × 12 h
Failure	SCreat increased × 3 or GFR decreased 75% or SCreat ≥4 mg/dL; acute rise ≥0.5 mg/dL	UO < 0.3 mL/kg/h × 24 h (oliguria) or anuria × 12 h
Loss	Persistent acute renal failure: complete loss of kidney function >4 wk		High specificity
ESKD*	Complete loss of kidney function >3 mo		High specificity
ESKD—end-stage kidney disease; *GFR—glomerular filtration rate; †SCreat—serum creatinine; ‡UO—urine output Note: Patients can be classified by GFR criteria and/or UO criteria. The criteria that support the most severe classification should be used. The superimposition of acute on chronic failure is indicated with the designation RIFLE-F_C; failure is present in such cases even if the increase in SCreat is less than 3-fold, provided that the new SCreat is greater than 4.0 mg/dL (350 µmol/L) and results from an acute increase of at least 0.5 mg/dL (44 µmol/L).

Table 2. Acute Kidney Injury Network Classification/Staging System for AKI ^[3]

Stage	Serum Creatinine Criteria	Urine Output Criteria
1	Increase of ≥0.3 mg/dL (≥26.4 µmol/L) or 1.5- to 2-fold increase from baseline	< 0.5 mL/kg/h for >6 h
2	>2-fold to 3-fold increase from baseline	< 0.5 mL/kg/h for >12 h
3*	>3-fold increase from baseline, or increase of ≥ 4.0 mg/dL (≥35.4 µmol/L) with an acute increase of at least 0.5 mg/dL (44 µmol/L)	< 0.3 mL/kg/h for 24 h or anuria for 12 h
*Patients who receive renal replacement therapy (RRT) are considered to have met the criteria for stage 3 irrespective of the stage they are in at the time of RRT.

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Author

Biruh T Workeneh, MD, PhD, FASN Associate Professor of Medicine, University of Texas MD Anderson Cancer Center

Biruh T Workeneh, MD, PhD, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology

Disclosure: Nothing to disclose.

Coauthor(s)

Mahendra Agraharkar, MD, MBBS, FACP, FASN Clinical Associate Professor of Medicine, Baylor College of Medicine; President and CEO, Space City Associates of Nephrology

Mahendra Agraharkar, MD, MBBS, FACP, FASN is a member of the following medical societies: American College of Physicians, American Society of Nephrology, National Kidney Foundation

Disclosure: Nothing to disclose.

Rajiv Gupta, MD Assistant Professor, Department of Medicine, Texas A&M Health Science Center College of Medicine; Consulting Staff, Veterans Affairs Medical Center

Rajiv Gupta, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Specialty Editor Board

Eleanor Lederer, MD, FASN Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD, FASN is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, Phi Beta Kappa

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: American Society of Nephrology<br/>Received income in an amount equal to or greater than $250 from: Healthcare Quality Strategies, Inc<br/>Received grant/research funds from Dept of Veterans Affairs for research; Received salary from American Society of Nephrology for asn council position; Received salary from University of Louisville for employment; Received salary from University of Louisville Physicians for employment; Received contract payment from American Physician Institute for Advanced Professional Studies, LLC for independent contractor; Received contract payment from Healthcare Quality Strategies, Inc for independent cont.

Chief Editor

Vecihi Batuman, MD, FASN Huberwald Professor of Medicine, Section of Nephrology-Hypertension, Interim Chair, Deming Department of Medicine, Tulane University School of Medicine

Vecihi Batuman, MD, FASN is a member of the following medical societies: American College of Physicians, American Society of Hypertension, American Society of Nephrology, International Society of Nephrology, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Acknowledgements

Aruna Agraharkar, MD, FACP Consulting Staff, Department of Gerontology, Space Center Clinic

Aruna Agraharkar, MD, FACP is a member of the following medical societies: American Medical Assocation

Disclosure: Nothing to disclose.

Eleanor Lederer, MD Professor of Medicine, Chief, Nephrology Division, Director, Nephrology Training Program, Director, Metabolic Stone Clinic, Kidney Disease Program, University of Louisville School of Medicine; Consulting Staff, Louisville Veterans Affairs Hospital

Eleanor Lederer, MD is a member of the following medical societies: American Association for the Advancement of Science, American Federation for Medical Research, American Society for Biochemistry and Molecular Biology, American Society for Bone and Mineral Research, American Society of Nephrology, American Society of Transplantation, International Society of Nephrology, Kentucky Medical Association, National Kidney Foundation, and Phi Beta Kappa

Disclosure: Dept of Veterans Affairs Grant/research funds Research

Laura Lyngby Mulloy, DO, FACP Professor of Medicine, Chief, Section of Nephrology, Hypertension, and Transplantation Medicine, Glover/Mealing Eminent Scholar Chair in Immunology, Medical College of Georgia

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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