Pre renal success is an interesting way to think about increases in serum creatinine when overall the patient is improving due to a therapy. Classically, this has been utilized when one uses ACEI/ARBs. Too often the internists ( and even nephrologists) diagnose initial decline in GFR following ACEI/ARB as “pre renal” AKI and reverse the beneficial effects of these amazing therapies. Many times I have seen such meds taken off due to an increase in creatinine. Long term effects on mortality and CKD are more important than short term hardships of elevated creatinine. In an article many years ago in Kidney International, a term pre renal success was suggested rather than renal failure for such cases to allow for non nephrologists to feel that it’s a success from a patient stand point even though the serum creatinine increased mild to moderately. We see this a lot in HTN control as well. A patient bp runs in 170/100 range and after few months of good therapy, you have got it good control to 130-140 SBP range but serum creatinine increased from 1 to 1.3mg/dl—big deal! – This is PRE RENAL SUCCESS as long term- this bp control is benefiting the patient from cardio vascular benefits.
A recent article in AJN, this term is being re introduced.
Similarly, in CHF patients, aggressive diuresis also leads to the rise in creatining that scares the cardiologists and nephrologist to further diuresis the patients. A recent publication in Circulation confirms the assertion with use of tubular markers such as NGAL and KIM-1 that aggressive diuresis associated increases in creatinine are not bad. This is also pre renal success as overall, the patient benefits from being “less short of breath” and decreased hospitalizations. Levels of NAG and KIM-1 did not change with aggressive diuresis. Worsening renal function occurred in 21.2% of the population and was not associated with an increase in any marker of renal tubular injury: Interesting, these increases in NGAL, NAG, and KIM-1 were paradoxically associated with improved survival (adjusted HR: 0.80 per 10 percentile increase, 95% CI: 0.69-0.91; P=0.001)—again suggesting this concept of Pre renal success
These findings reinforce the notion that the small to moderate deteriorations in renal function commonly encountered with aggressive diuresis are dissimilar from traditional causes of acute kidney injury.
It’s about time we called the following situations Pre Renal Success( this is personal opinion and there is room for debate)
1. Increases in creatinine 25-30% after initiation of ACEI/ARB and perhaps we can add SGLT-2 inhibitors here as well
2. Increase in creatinine 25-30% after aggressive 2-4 months of blood pressure control in a patient with severe HTN
3. Increases in creatinine 25-30% after aggressive diuresis and a patient with severe CHF