Causes of renal failure | Deranged Physiology

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 29 from the second paper of 2019 (list of differentials after AAA repair)
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 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.

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Pre-renal

Intra-renal

Post-renal

Vascular causes

Infectious causes

Neoplastic causes

Drug-related causes

Idiopathic causes

Congenital causes

Autoimmune causes

Traumatic causes

Endocrine causes

References