Hospital Medicine

Intrinsic Renal Disease

I. Problem/Condition.


II. Diagnostic Approach.

A. What is the differential diagnosis for this problem?

1. Tubulo-interstitial

2. Glomerular

a. Nephritis

b. Nephrosis

3. Vascular


1. Role of urinalysis

2. Renal ultrasonography

3. Labs

1. Historical information important in the diagnosis of this problem.

In patients admitted to intensive care units, sepsis accounts for 35 to 50% of cases of acute renal failure, usually acute tubular necrosis. In sepsis, arterial vasodilatation due to cytokines that upregulate inducible nitric oxide synthase expression leads to arterial underfilling and may be coupled with renal vasoconstriction due to endothelin release from elevated tumor necrosis factor-alpha.

Patient with pre-existing renal disease, hypertension, peripheral vascular disease, diabetes mellitus, cardiac disease, advanced age and liver disease are at increased risk of developing intrinsic renal impairment, particularly acute tubular necrosis, especially after surgery.

Exposure to nephrotoxic agents, including contrast dye, medications, such as antimicrobial and antineoplastic agents, environmental agents and recreational drugs should be investigated.


Reduced blood flow particularly to the outer medulla due to increased production of vasconstrictor substances, such as angiotensin II, thromxane A2, prostaglandin H2, leukotrienes C4 and D4, endothelin 1 and adenosine.


Urine eosinophils

C. Criteria for Diagnosing Each Diagnosis in the Method Above.


III. Management while the Diagnostic Process is Proceeding.

A. Management of Clinical Problem Intrinsic Renal Disease.

Role of renal biopsy

Volume resuscitation

Avoidance of nephrotoxic agents

Nephrology consultation




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