URIC ACID NEPHROPATHY

I. DEFINITION:
Acute uric acid nephropathy (AUAN, also acute urate nephropathy) is a rapidly
worsening (decreasing) kidney function (renal insufficiency) that is caused by high levels
of uric acid in the urine (hyperuricosuria).

II. CLINICAL MANIFESTATIONS:

Uric acid nephropathy is usually asymptomatic until it leads to significantly
reduced kidney function or failure. Signs of this may include:
Reduced urine output
Nausea and vomiting
Lethargy
Seizures
Abdominal pain
Painful urination
Hematuria

II. CAUSES:
Acute uric acid nephropathy is usually seen as part of the acute tumour lysis
syndrome in patients undergoing chemotherapy or radiation therapy for the treatment of
malignancies with rapid cell turnover, such as leukemia and lymphoma. It may also occur
in these patients before treatment is begun, due to spontaneous tumor cell lysis (high
incidence in Burkitt's lymphoma).
Acute uric acid nephropathy can also be caused by an acute attack of gout.

III. PATHOPHYSIOLOGY:
Acute uric acid nephropathy is caused by deposition of uric acid crystals within
the kidney interstitium and tubules, leading to partial or complete obstruction of
collecting ducts, renal pelvis, or ureter. This obstruction is usually bilateral, and patients
follow the clinical course of acute renal failure.

IV. DIAGNOSIS:
The picture of acute renal failure is observed: decreased urine production and
rapidly rising serum creatinine levels. Acute uric acid nephropathy is differentiated from
other forms of acute renal failure by the finding of a urine uric acid/creatinine ratio > 1 in
a random urine sample.

V. PREVENTION:
Patients at risk for acute uric acid nephropathy can be
given allopurinol or rasburicase (a recombinant urate oxidase) prior to treatment with
cytotoxic drugs.
VI. TREATMENT:
Treatment is focused on preventing deposition of uric acid within the urinary
system by increasing urine volume with potent diuretics such as furosemide. Raising the
urinary pH to a level higher than 7 (alkalinization) is often difficult to attain,
although sodium bicarbonate and/or acetazolamide are sometimes used in an attempt to
increase uric acid solubility. Dialysis (preferably hemodialysis) is started if the above
measures fail.