Continuing Education Activity

Azotemia is a biochemical abnormality, defined as elevation, or buildup of, nitrogenous products (BUN-usually ranging 7 to 21 mg/dL), creatinine in the blood, and other secondary waste products within the body. Raising the level of nitrogenous waste is attributed to the inability of the renal system to filter (decreased glomerular filtration rate-GFR) such as waste products adequately. It is a typical feature of both acute and chronic kidney injury. This activity highlights the role of the interprofessional team in the diagnosis and management of azotemia.

Objectives:

• Identify the etiology of azotemia.
• Review the evaluation of a patient with azotemia.
• Summarize the management options available for azotemia.
• Explain the interprofessional team strategies for improving care and outcomes in patients with azotemia.

Introduction

Azotemia is a biochemical abnormality, defined as elevation, or buildup of, nitrogenous products (BUN-usually ranging 7 to 21 mg/dL), creatinine in the blood, and other secondary waste products within the body. Raising the level of nitrogenous waste is attributed to the inability of the renal system to filter (decreased glomerular filtration rate-GFR) such as waste products adequately. It is a typical feature of both acute and chronic kidney injury.

Azotemia is important when discussing the precipitant syndrome of acute kidney injury (AKI); there are three subtypes, prerenal, intrinsic, and post-renal azotemia. There are multiple classification systems use to define AKI: The RIFLE criteria of 2004, AKIN criteria in 2007, and the KDIGO system in 2012. AKI is generally diagnosed by an increase in creatinine (Cr) by 0.3 mg/dL, Cr increase greater than 1.5%, or even less than 0.5 mL/kg per hr. This diagnosis is made with urinalysis (UA), urine electrolytes, metabolic panel (CMP/BMP), and a renal ultrasound (US). With these labs, the clinician can discern the classification and etiology of the AKI, which guides clinical management.

Azotemia becomes manifested with a constellation of clinical signs and symptoms along with biochemical abnormalities; it is termed uremia.

Etiology

For each classification of azotemia, there are unique etiologies. 

• Prerenal azotemia manifests from some insult/injury source before the kidney. Most commonly, we see this in the form of hypoperfusion, or decreased blood flow, to the kidneys from various etiologies of volume depletion, such as the physiologic state shock, dehydration, hemorrhage, over-diuresis, burns, and even intravascular depletion from low-oncotic pressure states, such as congestive heart failure and liver failure.[1]

• Intrinsic azotemia results from damage to the structure of the kidney; the structures affected include glomeruli, renal tubules and interstitium, and renal vasculature. This can result from inflammatory conditions, such as vasculitis, toxins, drugs, infections, and damage from hypoperfusion.[2]

• Post-renal azotemia comes from issues in the ureters and bladder. Usually, a patient has some diagnosis of obstruction, seen if a patient with risk factors such as recurrent urinary tract infections, nephrolithiasis, hydronephrosis, benign prostatic hyperplasia.

Epidemiology

Interestingly, many aspects of the natural history of azotemia remain unclear to this day. With that said, azotemia is quite common, responsible for 8% to 16% of hospital admissions and more so associated with a significantly higher risk of mortality.[3] There is a need for studies to help understand new knowledge about the incidence of AKI and its epidemiology. Without this, we cannot improve our understanding and stratification of this disease process. The International Society of Nephrology initiative[4] has an ambitious aim to prevent all avoidable death from AKI worldwide by 2025. There was a global study over 10 weeks in 2014 to collect some data regarding the burden of KDIGO-based AKI across 289 centers and 72 countries. Seven-day mortality was 10 to 12% in both high- and low-income countries. Key etiologic risk factors varied between countries but included dehydration, shock, infection, sepsis, cardiac disease, and nephrotoxic medications. The study showcased the potential for global data collection to inform international strategy.

Pathophysiology

The kidney receives about 25% of the body's cardiac output. Therefore are quite sensitive to any decrease in perfusion and oxygenation. In the setting of severe/prolonged decreased blood flow or hypoxia to these organs, it impairs cellular integrity and metabolism and ultimately vascular, glomerular, and tubular dysfunction. The damage is reflected by the glomerular filtration rate (GFR), which falls in the setting of injury. However, the GFR is not always correlated to the underlying condition, demonstrating the complexity of vascular and tubular processes in renal dysfunction.

Some of the most common findings in AKI include ischemia, apoptosis, tubular necrosis, the detachment of renal epithelial cells from the basement membranes, effacement of the brush border in proximal tubules, tubular casts from sloughing of cells, interstitial edema, and even peritubular capillary congestion.[5]

History and Physical

When evaluating a patient for azotemia/AKI, there are many questions and physical findings that can help guide the appropriate diagnosis and treatment.

1. Evaluate volume status
   • Mucous membranes (dry/wet)
   • Skin tenting
   • Edema (pitting/nonpitting)
   • Hepatojugular reflux
   • Pulmonary crackles
   • Ascites
2. Check for signs of infection (lung, skin, intra-abdominal), fever, chills, diaphoresis, cough, congestion, nausea, vomiting, diarrhea, dysuria, frequency, pyuria, hematuria

Prerenal findings: Sepsis/shock, burn, bleeding, dehydration (history of diarrhea and vomiting) skin tenting, worsening third spacing from intravascular depletion (pitting edema and ascites), hypotension

Intra-renal findings: Nephrotoxic medication history, contrast exposure, poorly controlled hypertension or diabetes mellitus

Post-renal findings: Flank pain, concerning for pyelonephritis; colicky pain concern for nephrolithiasis; boggy prostate, urinary hesitancy, anuria, concerning for benign prostatic hyperplasia (BPH); smoking history, concerning for bladder cancer; spinal cord trauma, concerning for neurogenic bladder.

Evaluation

Laboratory evaluation for azotemia includes a basic metabolic panel (BMP), BUN/Cr, urinary sodium (Na), protein, Cr, urea, urine osmolality (Ur Osmo), urinalysis (UA). Radiographic evaluation can be with a renal US (ultrasound), CT of the abdomen and pelvis with or without contrast, or renal Doppler examination.

Diagnosis of Azotemia can be made by a BUN greater than 21 mg/dL

Significant findings for prerenal azotemia

• BUN: Cr ratio greater than 20:1
• Fractional excretion of sodium (FeNa) less than 1, fractional excretion of urea (FeUr) less than 35%
• Urine osmolality 500 mOsm/kg
• UA can show hyaline casts[6]

Intra-Renal Azotemia

• BUN: Cr ratio less than 20:1
• FeNa greater than 2, FeUr greater than 50%
• Ur Osmo less than 300 mOsm/kg
• UA: Cellular debris, muddy brown casts red cell casts, eosinophils, + proteinuria

Post-Renal Azotemia

• BUN: Cr ratio less than 20:1
• FeNa greater than 2
• Ur Osmo less than 300 mOsm/kg
• UA: WBC casts
• Imaging findings: pyelonephritis, nephrolithiasis, bladder mass

Treatment / Management

The goal in the management of azotemia is the treat the underlying condition. For prerenal causes, IV fluid hydration and possible vasopressor support are crucial to re-establish adequate perfusion to the kidneys to optimize and salvage the integrity of the renal vasculature and tubules. Intrinsic renal diseases are so multifaceted and variable. Cessation of the toxic substances, avoidance of further use and contrast, followed by hydration, can allow for recovery to the kidney structures. Hypertension and diabetes are two of the most common disease processes that can adversely affect renal vascular and tubular epithelium and renal interstitium if poorly managed. Therefore, optimizing blood pressure and hemoglobin A1c are crucial for renal protection. For port-renal azotemia, relief of any obstruction followed by hydration is the mainstay. A urologic evaluation might be necessary, along with catheter placement.

Along with following BUN/Cr for normalization/stabilization, urine output is very important in ensuring adequate renal function. A minimum of 0.5 mL/kg per hour is considered reassured urine output and a sign of stable kidney function.[7][8][9]

Differential Diagnosis

Differentials for an elevated BUN (azotemia)

• Gastrointestinal (GI) bleeding
• Corticosteroid use
• Ketoacidosis
• States of protein catabolism
• Congestive heart failure (CHF)
• Hyperalimentation (TPN)

Prognosis

Generally, treatment of the underlying causes of azotemia has favorable outcomes. A remarkable feature of the kidneys is the ability for cellular repair with the resolution of injury and normalization of perfusion. The GFR will stabilize so that cellular repair, migration, and proliferation can begin with the differentiation of renal epithelium.[10] Progression of renal dysfunction includes chronic kidney disease (CKD) and, more so, end-stage renal disease (ESRD), requiring dialysis.

Complications

A complication related to elevated BUN levels is mostly associated with excess nitrogenous waste production from renal failure. The toxic effects of such waste can cause uremia. Uremic complications include platelet dysfunction and bleeding, encephalopathy, peripheral neuropathy, nausea, vomiting, hypothermia, and itching. Uremia is an indication for emergent hemodialysis. Allopurinol and rasburicase are medications that control uric acid levels and are renal-protective.

Consultations

Nephrology and/or urology

Deterrence and Patient Education

Proper primary care and patient education are crucial to controlling comorbid conditions that can precipitate azotemia/AKI. Diabetes and hypertension are the two main conditions that are leading risk factors in damaging the kidneys. Avoidance of infection exposure and proper hydration are also paramount for patients to understand and practice to ensure healthy kidney function.

Enhancing Healthcare Team Outcomes

Treating azotemia is crucial to protect patients from renal failure. Renal failure is a growing complication due to many underlying conditions, including hypertension and diabetes. Adherence to guidelines and evidence-based practice optimize renal outcomes. Targetting hemoglobin A1c less than 6.5 to 7 with lab work either twice a year if meeting goals or every three months if poorly controlled is vital from the primary care/outpatient setting. Checking urinary microalbumin helps monitor if nephrotoxic effects of diabetes have progressed to the point of proteinuria. Along with that line, blood pressure goals are just important as well, not only in keeping the BP range less than 140/90 mmHg but also in ensuring the appropriate choice of medications to reduce nephrotoxic side effects of the drugs.

In the inpatient setting, monitoring serum Cr and urine output are crucial to tracking and predicting renal outcomes. Azotemia is quite common, responsible for 8 to 16% of hospital admissions and more so associated with a significantly higher risk of mortality. An interprofessional team, including the nursing staff and physicians, has to keep an open line of communication regarding the patient's blood pressure, avoiding hypotension to preserve renal perfusion and urinary output. If a patient's urine output starts to fall below 0.5 mL/kg per hour, there is more concern for worsening renal function, likely related to the underlying condition precipitating the azotemia. It is always essential to have nephrology services involved throughout the patient's hospital course to ensure expert treatment recommendations. With this, the patient will have established care with the necessary specialty service for outpatient follow-up and care if needed.