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Diagnostic Approach: Differential Diagnosis, Physical Exam, Lab Tests, Imaging, and Novel Biomarkers

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Core Concepts in Acute Kidney Injury

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Abstract

Traditionally, acute kidney injury (AKI) has been classified into prerenal, intrinsic renal/intrarenal, and post-renal categories. If diagnosed early, pre- and post-renal AKI may be readily reversible, and thus earlier diagnosis may not only mitigate the severity of the AKI but potentially the morbidity and mortality that are associated with it. A revamped classification has been proposed by some authors based upon the presence or absence of changes in functional and structural/injury biomarkers. Patients without a change in either biomarker would be classified as having no AKI, while those who have changes in both are thought to have severe intrinsic AKI (e.g., ATN). A change in functional biomarkers without change in injury biomarkers would be classified as prerenal AKI, while changes in their injury biomarkers without a concomitant change in functional biomarkers may be viewed as being “subclinical AKI.”

The approach to any patient with AKI requires detailed attention to physical exam findings (which may often be subtle), several blood and urine tests (including examination of the urinary sediment), and potentially a variety of imaging test. Urinary indices such as FENa and FEUrea may aid in the differential diagnosis but have not been validated in all settings. Ultrasound is often the first-line imaging modality in the initial evaluation of AKI given its inexpensive nature, wide availability, and absence of complications. Newer imaging modalities including the blood oxygen level-dependent magnetic resonance imaging (BOLD MRI) are emerging and may prove useful in the setting of AKI. Given that serum creatinine is an imperfect marker of renal function, various biomarkers such a NGAL and TIMP-2*IGFBP7 have been studied extensively in a variety of clinical settings (e.g., sepsis, cardiac surgery). While several of these biomarkers have become available for clinical use in the last few years, none of them have gained widespread acceptance. To date no new biomarker has been incorporated into new definitions of AKI.

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Authors and Affiliations

  1. Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA

    Aparna Sharma & Jay L. Koyner

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  1. Aparna Sharma
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  2. Jay L. Koyner
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Correspondence to Jay L. Koyner .

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  1. Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Sushrut S. Waikar

  2. University College Dublin, Dublin, Ireland

    Patrick T. Murray

  3. Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

    Ajay K. Singh

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Sharma, A., Koyner, J.L. (2018). Diagnostic Approach: Differential Diagnosis, Physical Exam, Lab Tests, Imaging, and Novel Biomarkers. In: Waikar, S., Murray, P., Singh, A. (eds) Core Concepts in Acute Kidney Injury. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-8628-6_3

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