Contents

Search

acute renal failure (ARF)

An abrupt decline in renal function (elevation of serum creatinine or decrease in urine output) that occurs over hours to days. Classification: - oliguric: urine volume < 400 mL/24 hours - nonoliguric: urine volume > 400 mL/24 hours Etiology: 1) prerenal (70% of community-, 40% of hospital-acquired ARF) a) volume depletion - GI losses - diarrhea - vomiting - blood loss, hemorrhage - renal loss - inadequate fluid intake - insensible losses - burns - sweating b) diminished effective blood volume - hypotension - sepsis - excessive response to antihypertensive agent - in older adults with unplanned hospitalizations, frailty or polypharmacy, starting antihypertensive treatment is linked to acute kidney injury & risk of falls [36] - anaphylaxis - anesthesia - heart failure - acute coronary syndrome [5] - massive pulmonary embolism [5] c) vasospasm, intrarenal vasoconstriction - ischemia - drugs: NSAIDs, COX-2 inhibitors calcineurin inhibitors (cyclosporine), amphotericin B, contrast agents - malignant hypertension - pre-eclampsia - hypercalcemia - hepatorenal syndrome d) efferent arteriolar vasodilation - ACE inhibitors, ARB - renin inhibitors e) bilateral renal artery occlusion f) abdominal compartment syndrome g) common mechanism is ischemia h) elderly are especially susceptible to pre-renal azotemia - predisposition to hypovolemia - prevalence of renal artery atherosclerosis 2) intrinsic renal failure a) acute tubular necrosis (85%) - prolonged ischemia (50%) - sustained pre-renal azotemia - nephrotoxic agents (35%) - heavy metals - aminoglycosides - radiographic contrast media - ARF within 24 hr with rapid resolution - especially hazardous in diabetics with serum creatinine > 2 mg/dL - amphotericin B - myoglobin, rhabdomyolysis - hemoglobin (intravascular hemolysis) [5] - combined factors involving nephrotoxins - aminoglycoside & sepsis - radiocontrast agent & ACE inhibitor - NSAID & congestive heart failure (CHF) b) arteriolar injury - accelerated hypertension - vasculitis - polyarteritis nodosa - microangiopathic - TTP/HUS - preeclampsia - HELLP syndrome - sickle cell disease - scleroderma renal crisis - hypertensive crisis - snake bite - hypercalcemia - scleroderma c) glomerulonephropathies (5%) rapidly progressive glomerulonephritis - ANCA-associated vasculitis - anti-glomerular basement membrane disease - immune complex glomerulonephritis - lupus nephritis - endocarditis - post-infectious glomerulonephritis - cryoglobulinemia - IgA nephropathy - Henoch-Schonlein purpura d) acute interstitial nephritis (AIN) (10%) - allergic reaction to drug (most common) - autoimmune disease (SLE) - lupus nephritis, Sjogren syndrome, IgG4 disease - sarcoidosis - infectious agents (pyelonephritis) - Legionella - Hantavirus - Leptospirosis [4] - lymphoma, leukemia, myeloma [5] e) intrarenal (tubular) deposition/precipitation - uric acid in tumor lysis syndrome - immunoglobulin in myeloma - drugs: sulfonamides, triamterene, ciprofloxacin, acyclovir, indinavir, methotrexate, orlistat, vitamin C (large doses), sodium phosphate - toxins: ethylene glycol (calcium oxalate) f) atheroembolic renal failure (cholesterol embolization) - post arterial procedure, i.e. left heart catheterization - ARF after 24 hr (slower onset than ARF due to radiographic contrast media) - other evidence of cholesterol emboli - poor prognosis for recovery of renal function g) atherosclerosis - renal artery atherosclerotic plaque - dissecting aneurysm affecting renal artery h) renal allograft rejection i) renal cortical necrosis (complete anuria) 3) postrenal (obstructive uropathy) a) obstruction in the renal pelvis b) ureteral obstruction - blood clot - calculus - oxalate - sloughed papillae (papillary necrosis) - external compression - tumor (colon) - retroperitoneal fibrosis - radiation c) bladder outlet obstruction (98% of males) - neurogenic bladder - prostatic hypertrophy - carcinoma (prostate cancer, cervical, bladder cancer) - calculus - blood clot - urethral stricture d) bilateral renal vein occlusion (renal vein thrombosis) - membranous nephropathy most common cause [5] 4) risk factors - chronic renal failure - proteinuria - diabetic nephropathy - heart failure - liver disease - hypovolemia - age > 50 years - medications, especially NSAIDs, ACE inhibitors, ARBs, diuretics [10] - surgery [19] Epidemiology: - incidence of acute renal failure requiring dialysis is higher than that of end-stage renal disease [11] - incidence higher with older age, among men, & among blacks - 39,000 deaths/year from acute renal failure in U.S. (2009) - 5-7% of hospital admissions, up to 30% of ICU admissions [5] - common among critically ill children & young adults & is associated with poor outcomes, including increased mortality [24] - hospitalization for acute kidney injury increased in U.S. from 2000-2014 from 23 to 55 per 1000 persons [25] - among patients without diabetes, from 4 to 12 per 1000 - prerenal azotemia is the most common form of acute renal failure in outpatients - prolonged prerenal azotemia may lead to acute tubular necrosis - the most common cause of hospital acquired acute kidney injury is acute tubular necrosis - acquired acute tubular necrosis is most commonly caused by toxins, in particular nephrotoxic antibiotics such as aminoglycosides - obstruction of the ureters or renal pelvis must be bilateral to cause acute kidney injury Pathology: - kidney function generally normal with prerenal azotemia - intrinsic renal disease - complete or partial impairment of renal function resulting in an increase of serum creatinine of 0.5-2.0 mg/dL/day - with complete renal failure, serum creatinine increases 1-2 mg/dL/day - an increase of serum creatinine of 1 mg/dL/day indicates a creatinine clearance of < 10 mL/min History: - nephrotoxic agents (see etiology) Clinical manifestations: 1) generally non-specific - may be asymptomatic until advanced disease 2) dependent upon rapidity of onset - acute tubular necrosis from aminoglycoside toxicity 5-7 days - drug-induced acute interstitial nephritis 7-10 days - contrast nephropathy 24-48 hours, serum creatinine peak at 3 days - infection-related glomerulonephritis 1-6 weeks 3) symptoms of uremia 4) gastrointestinal: a) anorexia b) nausea/vomiting c) diarrhea/constipation d) metallic taste 5) cardiovascular: symptoms of volume overload a) shortness of breath b) dyspnea on exertion c) edema: lower extremity, periorbital 6) hematologic: a) symptoms of anemia b) symptoms of thrombocytopenia 7) genitourinary: a) oliguria or anuria - urine volume < 0.5 mL/kg/hour for 6 hours [5] b) costovertebral angle (CVA) tenderness c) hematuria d) foamy urine Laboratory: 1) serum chemistries a) serum creatinine - increase of >= 0.3 mg/dL within 48 hours or - >= 1.5 X baseline within 7 days [5] b) serum urea nitrogen (BUN) c) BUN/creatinine ratio - prerenal: > 20/1 - acute tubular necrosis: 10/1 - acute interstitial neprhitis, glomerulonephritis, vascular injury, intrarenal obstruction: variable - postrenal: > 20/1 d) serum potassium e) serum bicarbonate f) serum transaminases g) serum creatine kinase 2) complete blood count (CBC) a) white blood cell count (WBC) b) hematocrit c) platelet count 3) peripheral blood smear: - schistocytes, evidence of hemolysis (TTP/HUS) 4) urinalysis a) specific gravity: 1] > 1.020 prerenal azotemia 2] < 1.012 intrinsic renal failure b) red blood cells (RBC): AIN, glomerulonephritis - dysmorphic erythrocytes (glomerulonephritis) c) white blood cells (WBC) 1] urine eosinophils (AIN, cholesterol emboli) 2] pyuria (pyelonephritis, AIN) 3] leukocyte casts (AIN) d) urine protein e) urine volume of < 0.5 mL/kg/hr for 6 hours f) RBC casts: intrinsic renal failure, glomerulonephritis g) hyaline casts (prerenal azotemia) h) muddy brown, broad casts or tubular epithelial cells (ATN) 5) urine chemistries a) fractional excretion of sodium (FENA) 1] < 1% prerenal & glomerulonephritis 2] > 1% renal or post renal (obstructive uropathy) - FENA may be low in early obstructive uropathy but may be high in late obstructive uropathy (ATN), thus is not helpful 3] > 2% ATN [5] 4] FENA may be increased in patients taking diuretics - calculate fractional excretion of urea b) urine sodium: 1] < 20 meq/L prerenal 2] > 40 meq/L renal (ATN, AIN) 3] < 40 meq/L acute glomerulonephritis 4] postrenal: variable c) urine osmolality: 1] > 500 mosm/kg prerenal azotemia 2] < 250-300 msom/kg intrinsic renal failure 3] postrenal: variable d) urine/serum creatinine ratio 1] > 40 prerenal azotemia 2] < 20 intrinsic renal failure e) fractional excretion of urea < 35% consistent with diuretic-associated prerenal acute kidney injury [5] f) renal failure index 6) urine myoglobin of questionable utility 7) serologies a) CH50 for complement deficiency b) antinuclear antibody (ANA) c) antistreptolysin O (ASO) titer d) antiglomerular basement membrane (anti GBM) titer e) anti-neutrophil cytoplasmic antibody (ANCA) 8) serum protein electrophoresis 9) urine protein electrophoresis - Bence-Jones proteins 10) 24 hour urine a) creatinine clearance b) 24-hour urine protein: nephrotic syndrome c) oliguria, anuria 11) renal biopsy a) diagnosis remains unclear b) pre-renal & post-renal etiologies excluded Diagnostic criteria: - an increase in serum creatinine of >= 0.3 mg/dL within 48 hours - an increase in serum creatinine of >= 1.5 time baseline over 7 days - a urine volume of < 0.5 mL/kg/hr for 6 hours [5] Radiology: 1) ultrasound a) renal ultrasound (kidneys, ureters, bladder) is preferred imaging modality - diagnostic procedure of choice in obstructive uropathy - oliguria, normal urine (priority over FENA) [33] - kidney size, solitary kidney - large kidney: amyloidosis, early diabetes, HIV nephropathy - small kidney - hydronephrosis - may not show hydronephrosis within 24 hours of onset or with retroperitoneal fibrosis - evidence of obstructive uropathy a] nephrolithiasis b] BPH with urinary obstruction c] urinary neoplasm d] retroperitoneal fibrosis b) pelvic ultrasound 2) pyelogram - gold standard, but seldom utilized 3) renal flow scan Complication: - acute renal failure requiring hemodialysis is a cardiovascular risk factor [14] - acute renal failure does not independently predict progession to chronic renal failure [30] - acute renal failure demonstrated by rising serum creatinine may be associated with diminished clearance of renally cleared drugs - elevated gabapentin levels due to diminished clearance may manifest as dizziness [34] Differential diagnosis: - minimal proteinuria, no hematuria or pyuria, muddy brown casts - acute tubular necrosis - erythrocytes, eruythrocyte casts, dysmorphic erythrocytes in urine - glomerulonephritis - pyruria: pyelonephritis or acute interstitial nephritis - eosinophilia, eosinophiluria, rash - acute interstitial nephritis or cholesterol emboli - livedo reticularis: cholesterol emboli or vasculitis - hypercalcemia & anemia: multiple myeloma - nephrotic syndrome: diabetes mellitus, renal vein thrombosis - obstructive uropathy on ultrasound - benign prostatic hypertrophy, nephrolithiasis, retroperitoneal fibrosis malignancy - anuria: renal cortical necrosis - large kidneys on ultrasound - amyloidosis, early diabetes mellitus, HIV1 nephropathy - renal failure following bowel preparation - renal calcium phosphate crystal deposition - recent abdominal surgery, hemorrhage or acute pancreatitis - abdominal compartment syndrome - schistocytes in peripheral blood, thrombocytopenia - microangiopathic hemolytic anemia, TTP/HUS, DIC, scleroderma renal crisis - urine dipstick positive for blood, no erythrocytes on urine microscopy - hemolysis, rhabdomyolysis - acute kidney injury associated with acute leukemia, lymphoma or treatment - tumor lysis syndrome - acute renal failure with diuretic-resistant heart failure - cardiorenal syndrome - acute renal failure with cirrhosis & ascites - hepatorenal syndrome Management: 1) general a) prerenal & postrenal causes are often rapidly reversible [5] b) monitor input & output - foley catheter - the lower the urine output, the worse the prognosis [5] c) identify nephrotoxic agents 2) optimize intravascular volume a) a fluid challenge is indicated in the absence of volume overload: 1] 500-1000 mL of normal saline over 30-60 min 2] increased urine flow may result in patients with: a] prerenal azotemia b] patients with intrinsic renal disease 3] if no response to saline bolus a] 100 to 400 mg of IV Lasix b] metolazone 5-10 mg PO in addition to Lasix may facilitate urine output b) loop diuretic if volume overloaded of uncertain benefit [6,8] c) invasive monitoring of central venous pressure may be indicated d) IV albumin (25%) for cirrhotic patients with intravascular volume depletion [5] e) dopamine & mannitol of no value 3) optimize cardiac output 4) avoid further renal insults a) discontinue nephrotoxic agents 1] ACE inhibitors 2] diuretics 3] cyclosporine 4] NSAIDs b) avoid contrast agents c) dose adjustment as needed for renally-cleared pharmaceutical agents d) hydromorphone, fentanyl, methadone, buprenorphine, hydrocodone show minimal pharmacokinetic changes in patients with renal failure [32] 5) treat hyperkalemia 6) treat underlying conditions a) sepsis - antibiotics b) glomerulonephritis - immunosuppressive agents c) relieve obstruction - foley catheter for bladder outlet obstruction - nephrostomy if obstruction is above the bladder d) metabolic acidosis: IV bicarbonate or hemodialysis e) hypertension: 1] vasodilators, beta-blockers, calcium-channel blockers 2] avoid renally-cleared antihypertensives f) sclerodermal renal crisis - ACE inhibitor regardless of serum creatinine or dialysis g) surgical decompression for abdominal compartment syndrome h) contrast nephropathy: - prophylaxis with IV saline for CKD4 or acute kidney injury - acute kidney injury not prevented by dialysis immediately after contrast administration - do not use acetylcysteine or IV bicarbonate to prevent acute kidney injury 7) fluid restriction if euvolemic or volume overloaded - 1 to 1.5 L/day 9) avoid Mg+2 containing antacids - do not use dopamine or mannitol [5] 10) hemodialysis or renal replacement therapy a) indications: 1] refractory hyperkalemia 2] refractory acidosis (pH < 7.20) 3] volume overload - pulmonary edema refractory to medical management 4] signs or symptoms of uremia a] altered mental status b] asterixis c] uremic pericarditis; pericardial friction rub d] vomiting 5] certain drug toxicities [5] 6] prolonged acute renal failure (> a few days) 7] do not withhold dialysis until BUN & serum creatinine reach a threshold value 8) early initiation of hemodialysis does not improve outcomes (mean serum creatinine 7.4 mg/dL vs 10.6 mg/dL) [13] or (serum creatinine 3.7 mg/dL vs ESRD) [20] 9) no benefit to early hemodialysis [22,31] - when hemodialysis is delayed, nearly 1/2 of patients never require it [22]; those that do need hemodialysis are more likely to die - early hemodialysis of no benetit to patients with septic shock or ARDS [22] b) continuous renal replacement therapy 1] continuous venovenous hemofiltration (CVVH) 2] continuous arteriovenous hemofiltration (CAVH) 3] treatment of choice in patients who are hemodynamically unstable & unable to tolerate standard hemodialysis 11) diet a) protein restriction for control of uremia (do not restrict dietary protein in acute renal failure) [5] b) sodium restriction < 2 g/day c) potassium restriction < 2 g/day d) phosphate restriction & PhosLo (calcium acetate) 12) post-acute tubular necrosis (ATN) diuresis a) generally occurs prior to drop in creatinine b) avoid volume depletion 13) treatment of hyperuricemia generally not necessary if serum uric acid is < 15 mg/dL 14) prevention: - fenoldopam may reduce risk of acute renal failure in critically ill patients - fenoldopam of no benefit for acute kidney injury* after cardiac surgery [18] - neither aspirin nor clonidine given perioperatively lowers risk for acute renal failure [19]

Interactions

disease interactions

Related

fractional excretion of sodium (FENA) immediate treatment of acute renal failure (ARF) nephrotoxic substances postrenal azotemia; obstructive uropathy prerenal azotemia renal failure index (RFI)

Specific

acute renal failure in malignancy acute renal failure in pregnancy acute tubular necrosis; tubulorrhexis (ATN) cardiorenal syndrome hepatorenal syndrome; acute kidney injury in cirrhosis medication-induced acute kidney injury scleroderma renal crisis

General

acute kidney disease renal failure; kidney failure

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 263-268
  2. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 535-537
  3. Thadhani R et al Acute renal failure. N Engl J Med 334:1448 1996 PMID: 8618585
  4. Mayo Internal Medicine Board Review, 1998-99, Prakash UBS (ed) Lippincott-Raven, Philadelphia, 1998, pg 596-98
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  6. Harrison's Principles of Internal Medicine, 13th ed. Isselbacher et al (eds), McGraw-Hill Inc. NY, 1994, pg 1266
  7. Journal Watch 24(20):150, 2004 Cantarovich F, Rangoonwala B, Lorenz H, Verho M, Esnault VL. High-dose furosemide for established ARF: a prospective, randomized, double-blind, placebo-controlled, multicenter trial. Am J Kidney Dis. 2004 Sep;44(3):402-9. PMID: 15332212
  8. Ho KM and Sheridan DJ Meta-analysis of furosemide to prevent or treat acute renal failure. BMJ 2006, 333:420 PMID: 16861256
  9. James MT et al Glomerular filtration rate, proteinuria, and the incidence and consequences of acute kidney injury: A cohort study. Lancet 2010 Dec 18; 376:2096 PMID: 21094997
  10. Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
  11. Hsu RK et al Temporal Changes in Incidence of Dialysis-Requiring AKI. J Am Soc Nephrology. December 6, 2012 PMID: 23222124 http://jasn.asnjournals.org/content/early/2012/12/05/ASN.2012080800.abstract
  12. Lameire N, Van Biesen W, Vanholder R. Acute renal failure. Lancet. 2005 Jan 29-Feb 4;365(9457):417-30. PMID: 15680458
  13. Jamale TE et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: A randomized controlled trial. Am J Kidney Dis 2013 Dec; 62:1116 PMID: 23932821
  14. Physician's First Watch, Feb 7, 2014 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org Journal of the American Society of Nephrology article - Hsu CY and Liu KD Cardiovascular Events after AKI: A New Dimension. JASN, Feb 6, 2014 PMID: 24503240 http://jasn.asnjournals.org/content/early/2014/02/05/ASN.2013121276.full
  15. Chuasuwan A, Kellum JA. Acute kidney injury and its management. Contrib Nephrol. 2011;171:218-25 PMID: 21625115
  16. Parikh CR, Coca SG. Acute kidney injury: defining prerenal azotemia in clinical practice and research. Nat Rev Nephrol. 2010 Nov;6(11):641-2 PMID: 20981121
  17. Patel TV, Kumar S, Singh AK. Post-renal acute renal failure. Kidney Int. 2007 Oct;72(7):890-4. Epub 2007 May 2. PMID: 17495862
  18. Bove T et al. Effect of fenoldopam on use of renal replacement therapy among patients with acute kidney injury after cardiac surgery: A randomized clinical trial. JAMA 2014 Sep 29; PMID: 25265449
  19. Garg AX et al Perioperative Aspirin and Clonidine and Risk of Acute Kidney Injury. A Randomized Clinical Trial. JAMA. Published online November 15, 2014. PMID: 25399007 http://jama.jamanetwork.com/article.aspx?articleid=1936024 - Winkelmayer WC, Finkel KW Prevention of Acute Kidney Injury Using Vasoactive or Antiplatelet Treatment. Three Strikes and Out? JAMA. Published online November 15, 2014. PMID: 25399014 http://jama.jamanetwork.com/article.aspx?articleid=1936023
  20. Wald R et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int 2015 Oct; 88:897. PMID: 26154928 - Prowle JR, Davenport A. Does early-start renal replacement therapy improve outcomes for patients with acute kidney injury? Kidney Int 2015 Oct; 88:670. PMID: 26422624
  21. Perazella MA, Coca SG, Hall IE, Iyanam U, Koraishy M, Parikh CR. Urine microscopy is associated with severity and worsening of acute kidney injury in hospitalized patients. Clin J Am Soc Nephrol. 2010 Mar;5(3):402-8 PMID: 20089493 Free PMC Article - Perazella MA, Coca SG, Kanbay M, Brewster UC, Parikh CR. Diagnostic value of urine microscopy for differential diagnosis of acute kidney injury in hospitalized patients. Clin J Am Soc Nephrol. 2008 Nov;3(6):1615-9. PMID: 18784207 Free PMC Article
  22. Zarbock A, Kellum JA, Schmidt C et al Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial. JAMA. 2016 May 24-31;315(20):2190-9. PMID: 27209269 - Chertow GM, Winkelmayer WC. Early to Dialyze: Healthy and Wise? JAMA. 2016 May 24-31;315(20):2171-2 PMID: 27209075 - Gaudry S, Hajage D, Schortgen F et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med 2016 May 15 PMID: 27181456 - Mehta RL. Renal-replacement therapy in the critically ill - does timing matter? N Engl J Med 2016 May 15; PMID: 27181293 - Gaudry S, Hajage D, Schortgen F et al. Timing of renal support and outcome of septic shock and acute respiratory distress syndrome. A post hoc analysis of the AKIKI randomized clinical trial. Am J Respir Crit Care Med 2018 Jul 1; 198:58 PMID: 29351007 https://www.atsjournals.org/doi/10.1164/rccm.201706-1255OC
  23. Rosner MH. Acute kidney injury in the elderly. Clin Geriatr Med. 2013 Aug;29(3):565-78. Review. PMID: 23849008
  24. Kaddourah A, Basu RK, Bagshaw SM et al Epidemiology of Acute Kidney Injury in Critically Ill Children and Young Adults. N Engl J Med. November 18, 2016 PMID: 27959707 http://www.nejm.org/doi/full/10.1056/NEJMoa1611391 - Ingelfinger JR Acute Kidney Injury in Critically Ill Children - An Ominous Legacy. N Engl J Med. November 18, 2016 PMID: 27959706 http://www.nejm.org/doi/full/10.1056/NEJMe1613456
  25. Pavkov ME, Harding JL, Burrows NR. Trends in Hospitalizations for Acute Kidney Injury - United States, 2000-2014. MMWR Morb Mortal Wkly Rep 2018;67:289-293 https://www.cdc.gov/mmwr/volumes/67/wr/mm6710a2.htm
  26. Kellum JA, Bellomo R, Ronco C. Progress in Prevention and Treatment of Acute Kidney Injury. Moving Beyond Kidney Attack. JAMA. Published online June 11, 2018 PMID: 29889939 https://jamanetwork.com/journals/jama/fullarticle/2684932
  27. Kellum JA1, Bellomo R, Ronco C. Kidney attack. JAMA. 2012 Jun 6;307(21):2265-6. PMID: 22572776
  28. Rosner MH, Perazella MA. Acute Kidney Injury in Patients with Cancer. N Engl J Med. 2017 May 4;376(18):1770-1781. Review. No abstract available. PMID: 28467867
  29. Levey AS, James MT. Acute Kidney Injury. Ann Intern Med. 2017 Nov 7;167(9):ITC66-ITC80. PMID: 29114754
  30. Hsu CY et al. Post-acute kidney injury proteinuria and subsequent kidney disease progression: The Assessment, Serial Evaluation, and Subsequent Sequelae in Acute Kidney Injury (ASSESS-AKI) study. JAMA Intern Med 2020 Jan 27 PMID: 31985750 - Muiru AN et al. Risk for chronic kidney disease progression after acute kidney injury: Findings from the chronic renal insufficiency cohort study. Ann Intern Med 2023 Jul; 176:961; PMID: 37429030 https://www.acpjournals.org/doi/10.7326/M22-3617
  31. The STARRT-AKI Investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med 2020 Jul 16; 383:240 PMID: 32672427 https://www.nejm.org/doi/10.1056/NEJMoa2000741
  32. Davison NS Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol 2019 14(6):917-931 PMID: 30833302 PMCID: PMC6556722 Free PMC article
  33. Ronco C, Bellomo R, Kellum JA. Acute kidney injury. Lancet. 2019;394:1949-1964. PMID: 31777389
  34. Levy HB. Polypharmacy reduction strategies: tips on incorporating American Geriatrics Society Beers and screening tool of older people's prescriptions criteria. Clin Geriatr Med. 2017;33:177-187. PMID: 28364990
  35. Perazella MA. Drug-induced acute kidney injury: diverse mechanisms of tubular injury. Curr Opin Crit Care. 2019;25:550-557. PMID: 31483318
  36. Jodicke AM, Tan EH, Robinson DE, et al. Risk of adverse events following the initiation of antihypertensives in older people with complex health needs: a self-controlled case series in the United Kingdom. Age Ageing. 2023 Sep 1;52(9):afad177 PMID: 37725973 PMCID: PMC10508980 Free PMC article