Most Common Causes of Renal Failure in a 22-Year-Old
In a 22-year-old patient, glomerular diseases are the most common cause of renal failure, particularly glomerulonephritis, which accounts for about 10% of acute kidney injury (AKI) in adults and is one of the most common causes of irreversible kidney damage in young adults. 1
Primary Etiologies by Category
Glomerular Diseases (Most Common)
Primary glomerulonephritides:
- IgA nephropathy (Berger disease) - most common primary glomerulonephritis worldwide
- Minimal change disease
- Focal segmental glomerulosclerosis (FSGS)
- Membranous nephropathy
Secondary glomerular diseases:
- Lupus nephritis
- ANCA-associated vasculitis
- Post-infectious glomerulonephritis
- Anti-GBM antibody disease (Goodpasture syndrome)
Nephrotic Syndrome-Related Causes
- Acute kidney injury occurs in approximately one-third of hospitalizations related to childhood-onset nephrotic syndrome 2
- Risk factors include:
- Age ≥9 years
- Combined use of cyclosporine and renin-angiotensin system inhibitors
- Infection
- Dehydration
- High-dose methylprednisolone treatment
Medication-Related Causes
- Drug-induced nephrotoxicity is responsible for 8-60% of all in-hospital AKI cases 3
- Common culprits in young adults:
- Aminoglycosides (gentamicin, amikacin)
- Amphotericin B
- Vancomycin
- Beta-lactam antibiotics
- NSAIDs
- Contrast media
Other Important Causes
- Hemodynamic causes:
- Volume depletion/dehydration
- Hypotension
- Sepsis
- Acute tubular necrosis (ATN)
- Interstitial nephritis
- Urinary tract obstruction (less common, <3% of AKI cases) 1
Diagnostic Approach
Initial Evaluation
Urinalysis with microscopic examination is crucial:
- Dysmorphic red blood cells and red cell casts suggest glomerulonephritis
- White cell casts suggest interstitial nephritis or pyelonephritis
- Muddy brown casts suggest ATN
Urine albumin-to-creatinine ratio:
300 mg/g suggests significant glomerular disease 1
Laboratory Tests
- Complete blood count
- Comprehensive metabolic panel
- Complement levels (C3, C4)
- ANCA testing if vasculitis is suspected
- Anti-GBM antibodies
- Antinuclear antibodies for lupus nephritis
Imaging
- Renal ultrasound is the preferred initial imaging modality to:
- Assess kidney size and echogenicity
- Rule out obstruction
- Evaluate before potential biopsy 1
Risk Factors for AKI in Young Adults
- Diabetes mellitus (increases risk 2.6-fold) 3
- Dehydration (increases risk 3.4-fold) 3
- Administration of nephrotoxic medication combinations (increases risk 2.1-fold) 3
- Hypertension
Clinical Pearls and Pitfalls
Important Considerations
- In young adults with renal failure, glomerular diseases should be high on the differential diagnosis
- Rapidly progressive glomerulonephritis can cause renal failure within weeks and requires urgent evaluation 4
- Minimal change disease can cause reversible renal failure in nephrotic syndrome patients, even with relatively normal glomeruli on biopsy 5
Common Pitfalls
- Failing to recognize medication-induced nephrotoxicity
- Not adjusting medication dosages for declining kidney function (responsible for 63% of potential adverse drug events) 6
- Continuing nephrotoxic medications during AKI (responsible for 28% of potential adverse drug events) 6
- Overlooking non-renal causes of elevated creatinine (e.g., rhabdomyolysis)
When to Refer to Nephrology
- eGFR <30 mL/min/1.73 m² (absolute indication)
- Rapidly declining eGFR
- Significant proteinuria (>300 mg/g)
- Uncertainty about the etiology of kidney disease 7
In a 22-year-old with renal failure, prompt evaluation for glomerular disease is essential, as early diagnosis and treatment can significantly impact morbidity, mortality, and long-term quality of life.