Last reviewed: 27 Aug 2023
Last updated: 06 Jun 2023



History and exam

Key diagnostic factors

  • reduced urine production
  • vomiting
  • dizziness
  • orthopnea
  • paroxysmal nocturnal dyspnea
  • pulmonary edema
  • hypotension
  • tachycardia
  • orthostatic hypotension
  • hypertension
  • peripheral edema
  • muscle tenderness
  • limb ischemia
  • seizures
  • prostatic obstructive symptoms
  • hematuria
  • fever
  • rash
  • arthralgia/arthritis
  • altered mental status
  • signs of uremia

Other diagnostic factors

  • nausea
  • thirst
  • flank pain
  • abdominal distention
  • 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, nonsteroidal anti-inflammatory drugs, or ACE inhibitors)
  • trauma
  • hemorrhage
  • 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 blood urea nitrogen [BUN] and creatinine)
  • ratio of serum BUN to creatinine
  • urinalysis
  • urine culture
  • complete blood count
  • fractional excretion of sodium
  • fractional excretion of urea
  • urinary eosinophil count
  • venous blood gases
  • fluid challenge
  • bladder catheterization
  • urine osmolality
  • urine sodium concentration
  • renal ultrasound
  • chest x-ray
  • ECG

Investigations to consider

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

Emerging tests

  • novel serum and urinary biomarkers

Treatment algorithm



Richard A. Lafayette, MD

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 reviewers

Garabed Eknoyan, MD

Professor of Medicine

Section of Nephrology

Department of Medicine

Baylor College of Medicine




GE declares that he has no competing interests.

Dominic de Takats, MA, MRCP

Consultant Nephrologist


North Staffs Royal Infirmary

University Hospital of North Staffordshire




DdT declares that he has no competing interests.

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