This topic comes up fairly frequently. The usual trend is to ask for a list of differentials in the context of some sort of oliguric scenario, eg. "this post-AAA repair patient is producing no urine; why is that?" In the absence of anything terribly clever, one can always fall back on the old "pre, intra, post" classification of the causes.

Previous such scenarios have included the following CICM SAQs:

  • Question 9.3 from the second paper of 2018 (pseudorenal failure due to bladder rupture)
  • Question 13.3 from the second paper of 2016 (interstitial nephritis due to a β-lactam)
  • Question 11 from the first paper of 2008 (list of differentials in a septic patient)
  • Question 24 from the first paper of 2007 (list of differentials after AAA repair)
  • Question 2a from the second paper of 2001 (list of differentials in a septic patient)
Causes of Acute Renal Failure (Arranged by Pathophysiology)

Pre-renal

Intra-renal

Post-renal

  • Hypovolemia:
    • Haemorrhage
    • Vomiting or diarrhoea
    • Burns
    • Excessive diuresis
  • Redistribution of fluid
    • Sepsis
    • Hypoalbuminaemia
    • Aseptic SIRS, eg. pancreatitis
  • Decreased cardiac output
    • Cardiac failure
  • Renal vasoconstriction
    • Hepatorenal syndrome
    • Scleroderma crisis
    • Prostaglandin inhibition
    • Hypercalcemia
    • Malignant hypertension
  • Renal vascular obstruction
    • Embolic phenomena
    • Aortic dissection
    • By cross-clamping
    • By perinephric abscess
    • By perirenal neoplasm
    • Traumatic renal vessel injury
  • Acute Tubular Necrosis
    • Vascular insufficiency (pre-renal)
    • Drug-related:
      • Antibiotics
      • Organic solvents
      • Heavy metals
      • Ionic contrast media
    • Myoglobin (rhabdomyolysis)
    • Haem (haemolysis)
    • Light chains (myeloma)
    • Hyperuricaemia (eg. TLS)
    • Radiation-induced
  • Acute interstitial nephritis
    • Antibiotics
    • NSAIDs
    • SLE
    • Renal transplant rejection
    • Lymphoma infiltration
  • Glomerulonephritis
    • SLE
    • Post-streptococcal
    • Henoch-Schonlein
    • IgA nephropathy
    • Mesangiocapillary GN
    • Goodpasture's syndrome
    • DIC of any cause
    • MAHA of any cause
  • Upper tract obstruction
    • Retroperitoneal neoplasm
    • Retroperitoneal fibrosis
    • Surgical SNAFU / trauma
    • Tuberculosis
    • Staghorn calculus
    • Renal haemorrhage
  • Vesicoureteric junction obstruction
    • Renal calculus
    • Pelvic neoplasm
    • Surgical SNAFU / trauma
    • Pyelonephritis
  • Bladder outlet obstruction
    • Renal calculus
    • Pelvic neoplasm
    • Surgical SNAFU / trauma
    • Cystitis
    • Haemorrhage in the bladder
    • Pregnancy, labour
    • Uterine prolapse
    • Anticholinergic drugs
  • Reverse autodialysis
    • Urinary tract injury, eg. bladder rupture

This list can be reorganised into aetiological categories according to a familiar acronymic structure (VINDICATE).

Causes of Acute Renal Failure (Arranged by Aetiology)

Vascular causes

  • Malignant hypertension
  • Vascular insufficiency
  •  
  • Embolic phenomena
  • Aortic dissection
  • By cross-clamping during aortic surgery
  • Cardiac failure

Infectious causes

  • Renal vascular or ureteric obstruction by perinephric abscess
  • Pyelonephritis
  • Sepsis
  • Tuberculosis

Neoplastic causes

  • Renal vascular or ureteric obstruction by perirenal neoplasm
  • Retroperitoneal fibrosis following radiotherapy
  • Obstruction of ureters by retroperitoneal neoplasm
  • ATN due to myeloma light chains
  • ATN due to hyperuricaemia in tumour lysis syndrome
  • Obstructuive uropathy due to bladder or prostate malignancy
  • Lymphoma infiltration

Drug-related causes

  • Antibiotics:
    • Amphotericin, aminoglycosides, β-lactams, aciclovir, NSAIDs, cyclosporin, tacrolimus, starchy fluids, sulfonamides, methotrexate
  • Organic solvents
  • Heavy metals
  • Ionic contrast media
  • Anticholinergic drugs causing urinary retention

Idiopathic causes

  • Excessive diuresis
  • Vomiting or diarrhoea
  • Aseptic SIRS, eg. pancreatitis
  • Hypoalbuminaemia, redistribution (eg. in hepatic failure)
  • Hepatorenal syndrome
  • Obstructive calculi anywhere in the tract
  • ATN due to haem toxicity in haemolysis
  • Pregnancy, labour
  • Uterine prolapse

Congenital causes

  • Congenital abnormalities of renal vessels or urinary tract

Autoimmune causes

  • Scleroderma crisis
  • Renal transplant rejection
  • Goodpasture's syndrome
  • SLE nephritis
  • Post-streptococcal GN
  • Henoch-Schonlein purpura
  • IgA nephropathy
  • Mesangiocapillary GN
  • DIC or MAHA of any cause

Traumatic causes

  • Renal vascular or ureteric obstruction by perirenal neoplasm
  • Myoglobin (rhabdomyolysis)
  • Haemorrhage
  • Traumatic renal vessel injury
  • Burns
  • Surgical damage to renal vessels, ureters or bladder
  • Haemorrhage in the bladder with obstructive clots
  • Obstructed IDC
  • Bladder rupture or urinary tract injury at any level

Endocrine causes

  • Prostaglandin inhibition
  • Hypercalcemia

References

Oh's Manual: Chapter 47 (pp. 535)  Acute  kidney  injury by Rinaldo  Bellomo

Schrier, Robert W., et al. "Acute renal failure: definitions, diagnosis, pathogenesis, and therapy." The Journal of clinical investigation 114.1 (2004): 5-14.

Perazella, Mark A., and Glen S. Markowitz. "Drug-induced acute interstitial nephritis." Nature Reviews Nephrology 6.8 (2010): 461-470.

Heyns, C. F., and P. D. Rimington. "Intraperitoneal rupture of the bladder causing the biochemical features of renal failure." British journal of urology 60.3 (1987): 217-222.

Sockett, D. C., et al. "Metabolic changes due to experimentally induced rupture of the bovine urinary bladder." The Cornell veterinarian 76.2 (1986): 198-212.

Kilari, S. K., et al. "Pseudo-renal failure due to intraperitoneal bladder rupture and silent subdural hematoma following a fall in an alcoholic." International urology and nephrology 39.3 (2007): 947-949.

Wystrychowski, A., M. Nowicki, and F. Kokot. "Hyponatraemic renal pseudofailure—don't forget the possibility of uroperitoneum." Nephrology Dialysis Transplantation 11.12 (1996): 2491-2492.

Pintar, Thomas J., and Russell A. Wilke. "Urinary ascites: spontaneous bladder rupture presenting as acute oliguric renal failure." The American journal of medicine 105.4 (1998): 347-349.