Chronic renal failure differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Aarti Narayan, M.B.B.S [2]Feham Tariq, MD [3]


Differentiating chronic renal failure from acute renal failure and from the condition of having an increased BUN with a normal GFR are the most important diagnostic step in evaluating a patient with raised serum creatinine levels, as these conditions can be treated with therapy specific to the underlying etiology.

Distinguishing chronic renal failure from acute renal failure

  • Elevated creatinine levels from recent weeks or months suggest that the current disease process is more acute and hence reversible. On the other hand, long standing elevated serum values suggests a chronic disease process.
  • Even if the elevated serum creatinine levels are chronic, there is a possibility of the patient having a superimposed acute process over a chronic condition such as: a urinary tract obstruction, infections, extra cellular fluid volume depletion, or nephrotoxin exposure.
  • If the patient's history suggests an array of recent onset symptoms e.g:fever, rash and/or polyarthralgia, it can be safely concluded that the renal insufficiency is a part of an acute process.

Distinguishing chronic renal failure from an increased BUN with normal GFR

Other differentials

Uremia due to chronic renal failure should be differentiated from other diseases causing hypertension and hypokalemia for example:[1][1][2][3][4][5][6][7][8][9][10][11][12][13][14][15]

Hypertension and Hypokalemia
Plasma renin activity
Normal or High (Plasma Renin/Aldosterone ratio <10
Suppressed (Plasma Renin/Aldosterone ratio >20
*Renin-secreting tumors
*Diuretic use
*Renovascular hypertension
*Coarctation of aorta
*Malignant phase hypertension
Urinary aldosterone
Conn's syndrome (Primary aldosteronism)
Profound K+ depletion
• 17 alpha hydroxylase deficiency
• 11 beta hydroxylase deficiency
• Liddle's syndrome
• Licorice ingestion
• Deoxycortisone producing tumor
Add Mineralocrticoid antagonist for 8 weeks
BP response
No BP response
• Deoxycorticosterone excess( Tumor, 17 alpha hydroxylase and 11 beta hydroxylase deficiency)
• Licorice ingestion
•Glucocorticoid resistance
Liddle's syndrome)
Differential Diagnoses Clinical features History Findings Laboratory Findings
Headache and hypertension Nausea and vomiting Palpitations Shortness of breath Diminished pulses Fatigue Constipation Visual abnormalities Pruritis Polyuria Ambiguous genitalia
Renin-Secreting tumors

(Due to hypertension)

- - - - - - -
  • Drug-resistant hypertension
  • Chronic headaches
Coarctation of aorta - - - - -
11-beta hydroxylase deficiency ✔ (Hypertensive crisis due to increased 11-deoxycorticosterone-11-DOC) - - - - - -
17-alpha hydroxylase deficiency - - - - - - -
Uremia - - - -
Liddle's syndrome - - - - - - -



1.Zeiger Roni F. "Harrison's Textbook of Internal Medicine". McGraw-Hill's Diagnosaurus 2.0.

2.Bargman JM, Skorecki K. "Chapter 280. Chronic Kidney Disease. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison's Principles of Internal Medicine. 18th ed". New York: McGraw-Hill; 2012.

  1. 1.0 1.1 Wada N, Jin S, Hui SP, Yanagisawa K, Kurosawa T, Chiba H (2014). "[Differential diagnosis of primary aldosteronism by measurement of hybrid steroids using mass spectrometry]". Rinsho Byori (in Japanese). 62 (3): 276–82. PMID 24800505.
  2. Nielsen ML, Pareek M, Andersen I (2012). "[Liquorice-induced hypertension and hypokalaemia]". Ugeskr. Laeg. (in Danish). 174 (15): 1024–5. PMID 22487411.
  3. Chow KM, Ma RC, Szeto CC, Li PK (2012). "Polycystic kidney disease presenting with hypertension and hypokalemia". Am. J. Kidney Dis. 59 (2): 270–2. doi:10.1053/j.ajkd.2011.08.020. PMID 21962616.
  4. Sarafidis PA, Georgianos PI, Germanidis G, Giavroglou C, Nikolaidis P, Lasaridis AN, Madias NE (2012). "Hypertension and symptomatic hypokalemia in a patient with simultaneous unilateral stenoses of intrarenal arteries and mesangioproliferative glomerulonephritis". Am. J. Kidney Dis. 59 (3): 434–8. doi:10.1053/j.ajkd.2011.11.001. PMID 22154539.
  5. Khosla N, Hogan D (2006). "Mineralocorticoid hypertension and hypokalemia". Semin. Nephrol. 26 (6): 434–40. doi:10.1016/j.semnephrol.2006.10.004. PMID 17275580.
  6. Weiner ID (2013). "Endocrine and hypertensive disorders of potassium regulation: primary aldosteronism". Semin. Nephrol. 33 (3): 265–76. doi:10.1016/j.semnephrol.2013.04.007. PMC 3748390. PMID 23953804.
  7. Martell-Claros N, Abad-Cardiel M, Alvarez-Alvarez B, García-Donaire JA, Pérez CF (2015). "Primary aldosteronism and its various clinical scenarios". J. Hypertens. 33 (6): 1226–32. doi:10.1097/HJH.0000000000000546. PMID 25715092.
  8. Franse LV, Pahor M, Di Bari M, Somes GW, Cushman WC, Applegate WB (2000). "Hypokalemia associated with diuretic use and cardiovascular events in the Systolic Hypertension in the Elderly Program". Hypertension. 35 (5): 1025–30. PMID 10818057.
  9. Rossi E, Farnetti E, Nicoli D, Sazzini M, Perazzoli F, Regolisti G, Grasselli C, Santi R, Negro A, Mazzeo V, Mantero F, Luiselli D, Casali B (2011). "A clinical phenotype mimicking essential hypertension in a newly discovered family with Liddle's syndrome". Am. J. Hypertens. 24 (8): 930–5. doi:10.1038/ajh.2011.76. PMID 21525970.
  10. Ruecker B, Lang-Muritano M, Spanaus K, Welzel M, l'Allemand D, Phan-Hug F, Katschnig C, Konrad D, Holterhus PM, Schoenle EJ (2015). "The Aldosterone/Renin Ratio as a Diagnostic Tool for the Diagnosis of Primary Hypoaldosteronism in Newborns and Infants". Horm Res Paediatr. 84 (1): 43–8. doi:10.1159/000381852. PMID 25968592.
  11. Ardhanari S, Kannuswamy R, Chaudhary K, Lockette W, Whaley-Connell A (2015). "Mineralocorticoid and apparent mineralocorticoid syndromes of secondary hypertension". Adv Chronic Kidney Dis. 22 (3): 185–95. doi:10.1053/j.ackd.2015.03.002. PMID 25908467.
  12. Iglesias P, Tajada P, Martínez I, Díez JJ (2009). "[Salt-wasting congenital adrenal hyperplasia associated to hyperreninemic hyperaldosteronism]". Med Clin (Barc) (in Spanish; Castilian). 132 (2): 80–1. doi:10.1016/j.medcli.2008.09.002. PMID 19174076.
  13. Kikuta Y, Sanjo K, Nakajima K, Ashizawa I, Ojima M (1988). "Primary aldosteronism in childhood due to primary adrenal hyperplasia". Tohoku J. Exp. Med. 155 (1): 57–70. PMID 3413779.
  14. Hassan-Smith Z, Stewart PM (2011). "Inherited forms of mineralocorticoid hypertension". Curr Opin Endocrinol Diabetes Obes. 18 (3): 177–85. doi:10.1097/MED.0b013e3283469444. PMID 21494136.
  15. Bartter FC, Henkin RI, Bryan GT (1968). "Aldosterone hypersecretion in "non-salt-losing" congenital adrenal hyperplasia". J. Clin. Invest. 47 (8): 1742–52. doi:10.1172/JCI105864. PMC 297334. PMID 4299011.

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