Urinary osmolality in acute renal failure due to glomerulonephritis

Diagnostic accuracy of early urinary index changes in differentiating transient from persistent acute kidney injury in critically ill patients: multicenter cohort study

INTRODUCTION

Urinary indices have limited effectiveness in separating transient acute kidney injury (AKI) from persistent AKI in ICU patients. Their time-course may vary with the mechanism of AKI. The primary objective of this study was to evaluate the diagnostic value of changes over time of the usual urinary indices in separating transient AKI from persistent AKI.

METHODS

An observational prospective multicenter study was performed in six ICUs involving 244 consecutive patients, including 97 without AKI, 54 with transient AKI, and 93 with persistent AKI. Urinary sodium, urea and creatinine were measured at ICU admission (H0) and on 6-hour urine samples during the first 24 ICU hours (H6, H12, H18, and H24). Transient AKI was defined as AKI with a cause for renal hypoperfusion and reversal within 3 days.

RESULTS

Significant increases from H0 to H24 were noted in fractional excretion of urea (median, 31% (22 to 41%) and 39% (29 to 48%) at H24, P<0.0001), urinary urea/plasma urea ratio (15 (7 to 28) and 20 (9 to 40), P<0.0001), and urinary creatinine/plasma creatinine ratio (50 (24 to 101) and 57 (29 to 104), P=0.01). Fractional excretion of sodium did not change significantly during the first 24 hours in the ICU (P=0.13). Neither urinary index values at ICU admission nor changes in urinary indices between H0 and H24 performed sufficiently well to recommend their use in clinical setting (area under the receiver-operating characteristic curve≤0.65).

CONCLUSION

Although urinary indices at H24 performed slightly better than those at H0 in differentiating transient AKI from persistent AKI, they remain insufficiently reliable to be clinically relevant.

Diagnostic performance of fractional excretion of urea in the evaluation of critically ill patients with acute kidney injury: a multicenter cohort study

Introduction

Several factors, including diuretic use and sepsis, interfere with the fractional excretion of sodium, which is used to distinguish transient from persistent acute kidney injury (AKI). These factors do not affect the fractional excretion of urea (FeUrea). However, there are conflicting data on the diagnostic accuracy of FeUrea.

Methods

We conducted an observational, prospective, multicenter study at three ICUs in university hospitals. Unselected patients, except those with obstructive AKI, were admitted to the participating ICUs during a six-month period. Transient AKI was defined as AKI caused by renal hypoperfusion and reversal within three days. The results are reported as medians (interquartile ranges).

Results

A total of 203 patients were included. According to our definitions, 67 had no AKI, 54 had transient AKI and 82 had persistent AKI. FeUrea was 39% (28 to 40) in the no-AKI group, 41% (29 to 54) in the transient AKI group and 32% (22 to 51) in the persistent AKI group (P = 0.12). FeUrea was of little help in distinguishing transient AKI from persistent AKI, with the area under the receiver operating characteristic curve being 0.59 (95% confidence interval, 0.49 to 0.70; P = 0.06). Sensitivity was 63% and specificity was 54% with a cutoff of 35%. In the subgroup of patients receiving diuretics, the results were similar.

Conclusions

FeUrea may be of little help in distinguishing transient AKI from persistent AKI in critically ill patients, including those receiving diuretic therapy. Additional studies are needed to evaluate alternative markers or strategies to differentiate transient from persistent AKI.

Urinary Biochemistry and Microscopy in Septic Acute Renal Failure: A Systematic Review

BACKGROUND

Biochemistry and microscopy of urine are widely published diagnostic activities in patients with acute renal failure (ARF). However, their scientific basis in patients with septic ARF has not been assessed systematically.

METHODS

We performed a systematic review of MEDLINE, EMBASE, CINHAL, and PubMed databases and bibliographies of retrieved articles for all studies describing urinary biochemistry, indices, and microscopy in patients with septic ARF.

RESULTS

We identified 27 articles (1,432 patients). Because of substantial heterogeneity, no formal quantitative analysis could be performed. Urinary biochemistry or derived indices were reported in 24 articles (89%), and microscopy, in 7 articles (26%). The majority were small single-center reports and had serious limitations. For example, only 52% of patients were septic, only 54% of patients had ARF, many studies failed to include a control group, time from diagnosis of sepsis or ARF to measure of urinary tests was variable, and there were numerous potential confounders. Urinary sodium, fractional excretion of sodium, urinary-plasma creatinine ratio, urinary osmolality, urinary-plasma osmolality ratio, and serum urea-creatinine ratio showed variable and inconsistent results. Low-molecular-weight proteinuria was described in only 22% of articles. A few reports of urinary microscopy described muddy brown/epithelial cell casts and renal tubular cells in patients with septic ARF, whereas others described normal urinary sediment.

CONCLUSION

The scientific basis for the use of urinary biochemistry, indices, and microscopy in patients with septic ARF is weak. More research is required to describe their accuracy, pattern, and time course in patients with septic ARF.

Increased severity of renal impairment in nephritic mice lacking the EP1 receptor

In experimental glomerulonephritis, inhibition of renal prostaglandin (PG) synthesis by nonsteroidal-anti-inflammatory drugs (NSAIDs) moderates proteinuria, yet can induce harmful effects on renal blood flow and Na+–K+–water balance thereby implicating 1 or more prostanoid receptor subtypes. We investigated the role of the PGE2 EP1 receptor in nephritis since it is expressed in the glomerulus, collecting duct and vasculature in which its activity might contribute to adaptive or maladaptive responses. Accordingly, a mouse model of accelerated antiglomerular basement membrane (anti-GBM) nephrotoxic serum (NTS) nephritis was induced in mice with targeted-deletion of the EP1 receptor (EP1−/−). Proteinuria was similar between wild-type (wt) and EP1−/− NTS groups, thus negating a role for this subtype in modulating the glomerular permeability barrier in this model of anti-GBM NTS. However, overall renal damage was more acute in NTS EP1−/− mice, as evidenced by the degree of glomerular mesangial matrix expansion and the frequency of tubular dilatations. These changes in renal pathology were accompanied by stronger impairment of renal function in NTS EP1−/− mice, such that levels of serum creatinine, urea, Na+, and K+ were each significantly higher than those observed in NTS wt mice. Lastly, compared with wt mice, induction of NTS more severely reduced urine osmolality and body mass in EP1−/− mice. Taken together, the increased renal impairment seen in NTS EP1−/− mice suggests that the EP1 subtype plays a compensatory role in the context of acute nephritis.

Clinical and laboratory diagnosis of acute renal failure

Acute renal failure (ARF) is defined in general terms as an abrupt decrease in renal function sufficient enough to result in retention of nitrogenous waste and disrupt fluid and electrolyte homeostasis. There is no consensus regarding a quantifiable definition of ARF. Prompt evaluation of ARF is vital because ARF can be the end result of diverse processes which can often be reversed or attenuated through therapy directed at the underlying condition. Evaluation begins with careful review of the patient's history, previous medical records, physical examination, urinalysis, and available laboratory data. Routine urine chemical indices, calculation of the fractional excretion of sodium, and examination of the urine sediment are valuable in characterizing the cause of ARF. When this evaluation fails to yield a diagnosis, further testing may be required to evaluate intravascular volume status or diagnose a systemic disorder or glomerular cause of ARF. Response to therapeutic trials may provide a diagnosis. When a diagnosis cannot be made with reasonable certainty through this evaluation renal biopsy should be considered.