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Open Access Research article

Physicochemical analysis of blood and urine in the course of acute kidney injury in critically ill patients: a prospective, observational study

Alexandre Toledo Maciel13*, Marcelo Park1 and Etienne Macedo2

Author Affiliations

1 Intensive Care Unit, Department of Medical Emergencies, Hospital das Clínicas University of São Paulo, São Paulo, Brazil

2 Department of Nephrology, Hospital das Clínicas University of São Paulo, São Paulo, Brazil

3 Intensimed Research Group, Intensive Care Unit, Hospital São Camilo Pompéia, São Paulo, Brazil

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BMC Anesthesiology 2013, 13:31  doi:10.1186/1471-2253-13-31

Published: 10 October 2013



Sequential physicochemical alterations in blood and urine in the course of acute kidney injury (AKI) development have not been previously described. We aimed to describe these alterations in parallel to traditional renal and acid–base parameters.


One hundred and sixty eight consecutive critically ill patients with no previous kidney disease, who had an indwelling urinary catheter at ICU admission and who remained with the catheter for at least two days without dialysis were included. A sample of blood and spot urine were collected simultaneously, once daily, until catheter removal or dialysis requirement. Traditional acid–base and renal parameters were sequentially evaluated in parallel to blood and urinary physicochemical parameters. Patients were classified during this period as having or not AKI and, for patients with AKI, duration (transient or persistent) and severity (creatinine-based AKIN stage) were evaluated.


One hundred and thirteen patients (67.3%) had AKI: 92 at ICU admission and 21 during the observation period. AKI development was characterized in blood by increased values of phosphate and unmeasured anions (SIG), decreased albumin, and in urine by decreased values of sodium (NaU), chloride (ClU) as well as high urinary strong ion difference (SIDu). These alterations began to occur before AKI diagnosis, and they reverted in transient AKI but remained in persistent AKI. NaU, ClU and albumin decreased, and phosphate, SIG and SIDu increased with AKI severity progression. NaU and ClU values increased again when AKIN stage 3 was reached.


Simultaneous physicochemical analysis of blood and urine revealed standardized alterations that characterize AKI development in critically ill patients. These alterations paralleled AKI duration and severity. Future studies should consider including sequential evaluation of urine biochemistry as part of the armamentarium for AKI diagnosis and management.

Urine biochemistry; Urine electrolytes; Physicochemical analysis; Stewart approach; Acute kidney injury; Strong ion gap; Strong ion difference; Critically ill patients