Last reviewed:September 2019
Last updated:January  2019



History and exam

Key diagnostic factors

  • presence of risk factors
  • reduced urine production
  • vomiting
  • dizziness
  • orthopnoea
  • paroxysmal nocturnal dyspnoea
  • pulmonary oedema
  • hypotension
  • tachycardia
  • orthostatic hypotension
  • hypertension
  • peripheral oedema
  • muscle tenderness
  • limb ischaemia
  • seizures
  • prostatic obstructive symptoms
  • haematuria
  • fever
  • rash
  • arthralgia/arthritis
  • altered mental status
  • signs of uraemia

Other diagnostic factors

  • nausea
  • thirst
  • flank pain
  • abdominal distension
  • abdominal bruit
  • livedo reticularis
  • petechiae
  • ecchymoses

Risk factors

  • advanced age
  • underlying renal disease
  • malignant hypertension
  • diabetes mellitus
  • myeloproliferative disorders, such as multiple myeloma
  • connective tissue disease
  • sodium-retaining states (e.g., congestive heart failure, cirrhosis, nephrotic syndrome)
  • radiocontrast
  • exposure to nephrotoxins (e.g., aminoglycosides, vancomycin + piperacillin-tazobactam, cancer therapies, non-steroidal anti-inflammatory drugs, or ACE inhibitors)
  • trauma
  • haemorrhage
  • sepsis
  • pancreatitis
  • drug overdose
  • surgery
  • cardiac arrest
  • recent vascular intervention
  • excessive fluid loss
  • nephrolithiasis
  • drug abuse
  • alcohol abuse
  • excessive exercise
  • recent blood transfusion
  • malignancy
  • genetic susceptibility
  • use of renin-angiotensin system inhibitors
  • proton pump inhibitors
  • herbal therapy

Diagnostic investigations

1st investigations to order

  • basic metabolic profile (including urea and creatinine)
  • ratio of serum urea to creatinine
  • urinalysis
  • urine culture
  • full blood count
  • fractional excretion of sodium
  • fractional excretion of urea
  • urinary eosinophil count
  • venous blood gases
  • fluid challenge
  • bladder catheterisation
  • urine osmolality
  • urine sodium concentration
  • renal ultrasound
  • chest x-ray
  • ECG
Full details

Investigations to consider

  • anti-nuclear antibodies
  • anti-DNA
  • complement (C3, C4, CH50)
  • anti-glomerular basement membrane antibodies
  • anti-neutrophil cytoplasmic antibodies
  • acute hepatitis profile
  • HIV serology
  • cryoglobulins
  • erythrocyte sedimentation rate
  • anti-streptolysin-O antibody
  • abdominal computed tomography or magnetic resonance imaging scan
  • nuclear renal flow scan
  • cystoscopy
  • renal biopsy
Full details

Emerging tests

  • novel serum and urinary biomarkers
Full details

Treatment algorithm


Professor of Medicine

Nephrology Division

Stanford University Medical Center




RAL works as a consultant and researcher for Relypsa, Inc. Although unrelated to this topic area, RAL also works as a consultant for Fibrogen, Inc.; Mallinckrodt, Inc.; and Omeros, Inc.; and as a researcher for Genentech, Inc.; Mallinckrodt, Inc.; GlaxoSmithKline, Inc.; Rigel, Inc.; Aurinia, Inc.; and the NIH.

Dr Richard A. Lafayette would like to gratefully acknowledge Dr Sandra Sabatini, Dr Neil Kurtzman, and Dr Corey D. Ball, the previous contributors to this topic. SS, NK, and CDB declare that they have no competing interests.

Peer reviewersVIEW ALL

Professor of Medicine

Section of Nephrology

Department of Medicine

Baylor College of Medicine




GE declares that he has no competing interests.

Consultant Nephrologist


North Staffs Royal Infirmary

University Hospital of North Staffordshire




DdT declares that he has no competing interests.

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