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FENa

FENa Calculator

Fractional Excretion of Sodium

Unreliable in the presence of diuretics.

Fractional Analyst

Enter paired plasma and urine chemistries to determine renal etiology.

Guidelines & Evidence

Verified

Last Review: 2026-07-17

When to Use

When to Use

Differential diagnosis of Acute Kidney Injury (AKI) in oliguric patients (urine output < 400 mL/day).
Distinguishing prerenal azotemia (hypoperfusion) from intrinsic renal injury, specifically Acute Tubular Necrosis (ATN).
Assessing tubular integrity in the setting of rising serum creatinine.

Required Parameters

Requires simultaneous (paired) spot urine and serum samples for Sodium (Na) and Creatinine (Cr).

When Not to Use

Non-oliguric AKI: Accuracy is significantly lower if urine output is preserved.
Recent diuretic use (within 24 hours): Diuretics inhibit Na reabsorption, falsely elevating FENa.
Chronic Kidney Disease: Damaged tubules in CKD have a baseline defect in Na handling, making the 1% threshold unreliable.

How it Works

Formula

FENa (%) = [(Urine Na × Serum Cr) / (Serum Na × Urine Cr)] × 100

Interpretation

< 1%Prerenal Azotemia
1% – 2%Indeterminate / Mixed Etiology
> 2%Acute Tubular Necrosis (ATN)

Physiological Rationale

The kidney naturally conserves sodium in states of hypoperfusion (prerenal). A FENa < 1% indicates that the tubules are functionally intact and responding appropriately to low perfusion. A FENa > 2% suggests that the tubular cells are damaged (ATN) and unable to reabsorb filtered sodium, regardless of volume status.

Clinical Pearls

Low FENa (< 1%) in Intrinsic Disease

Contrast-induced nephropathy: Intense pre-glomerular vasoconstriction leads to a prerenal-like profile despite intrinsic injury.
Pigment nephropathy: Rhabdomyolysis or Hemolysis can present with low FENa early in the course.
Acute Glomerulonephritis: Glomerular inflammation reduces GFR while tubular function is initially preserved.
Hepatorenal Syndrome: Extreme renal vasoconstriction drives Na reabsorption.

The FEUrea Alternative

In patients on diuretics, calculate the Fractional Excretion of Urea (FEUrea). A FEUrea < 35% is more sensitive for prerenal azotemia than FENa in this population.

Next Steps

Action Plan: FENa < 1% (Prerenal)

01
Assess volume status and consider fluid resuscitation (Normal Saline or Ringer's Lactate).
02
Evaluate for extra-renal causes: Heart failure (pump failure), cirrhosis (splanchnic vasodilation), or sepsis.
03
Review and discontinue nephrotoxic medications (NSAIDs, ACEi/ARBs).

Action Plan: FENa > 2% (Intrinsic)

01
Monitor for complications of ATN: Hyperkalemia, metabolic acidosis, and volume overload.
02
Audit recent drug exposures: Aminoglycosides, Vancomycin, Amphotericin B.
03
Avoid aggressive fluid boluses if the patient is truly oliguric/anuric and shows signs of fluid overload.

Related Calculators

Fractional Excretion of Urea (FEUrea)
Renal Failure Index (RFI)
Anion Gap

The Evidence

Foundational Study

The FENa test. Use in the differential diagnosis of acute renal failure.

Espinel CH. • JAMA. 1976;236(5):579-81. Established the 1% threshold as a discriminator between prerenal and intrinsic states.

Validation in Diuretic Use

Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure.

Carvounis CP et al. • Kidney Int.. 2002;62(6):2223-9. Demonstrated the superiority of FEUrea over FENa in the setting of diuretics.

Origins & History

Dr. C.H. Espinel

The FENa test was popularized by Carlos H. Espinel in 1976. He sought a more reliable measure than simple urine sodium concentration, which is highly variable based on total urine volume. By normalizing sodium clearance to creatinine clearance, he provided a standardized metric of tubular function.

Last Comprehensive Review: 2026-07-17

Recent Journal Updates

JAMAJul 21, 2026
Correction to Primary Composite Outcome in a Trial of Transfusion Strategy

Clinical Context

We think this has broad domain relevance to FENa — Fractional Excretion of Sodium.

JAMAJul 21, 2026
PCOS Is Now Called PMOS

Clinical Context

We think this has broad domain relevance to FENa — Fractional Excretion of Sodium.

Clinical Pharmacology TherapeuticsJul 3, 2026
Human Disposition, Metabolism, and Excretion of Sevasemten (EDG‐5506), a Selective Modulator of Fast Myosin in Healthy Volunteers

Clinical Context

We think this might be relevant to the clinical guidance for FENa — Fractional Excretion of Sodium.