Diagnosis of Anuria
Anuria Diagnosis: Book Excerpts
Diagnostic Tests for Anuria: Online Medical Books
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ANURIA OR OLIGURIA:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Has the patient been on any drugs? Sulfonamides are notorious for causing renal failure, but one must also consider amphotericin B, gold compounds that might be administered in arthritis, and lead and other drugs or heavy metals.
- What is the blood pressure? If there is hypertension and anuria, one should consider acute or chronic glomerulonephritis, polycystic kidneys, and acute tubular necrosis. If there is a low blood pressure, one should consider prerenal causes of anuria such as dehydration, blood loss, the acute abdomen, and other causes of shock.
- Is there cardiomegaly or chest pain? If there is an enlarged heart, one should consider congestive heart failure. If there is chest pain, one should consider myocardial infarction or pulmonary infarction. If there is chest or abdominal pain with hypertension, then one should consider dissecting aneurysm.
- Is there enlargement of the kidneys? Enlargement of both kidneys should suggest bilateral hydronephrosis or polycystic kidneys. Unilateral enlargement of the kidneys is not usually associated with anuria.
- Is there bladder enlargement? Enlarged bladder would make one think of bladder neck obstructions due to prostatic hypertrophy or carcinoma or a urethral stricture. Occasionally, what is thought to be an enlarged bladder is actually a pelvic mass that is obstructing the ureter.
- Is there hematuria? Hematuria would suggest glomerulonephritis, acute tubular necrosis, intravascular hemolysis, and nephrolithiasis.
- What has been the patient's recent intake of fluid? Dehydration is a frequent cause of oliguria and anuria.
DIAGNOSTIC WORKUP
The first thing to determine is whether the patient really has anuria or oliguria. A Foley catheter should be passed and attached to drainage to determine the urine output. If there is obstructive uropathy due to bladder neck obstruction, obviously this will determine the diagnosis, as there will be a large volume of urine and it should be taken off gradually. Then studies of obstructive uropathy can be done, including cystoscopy and retrograde pyelography. If the obstructive uropathy is due to obstruction of the ureter, renal ultrasonography can be reliable in detecting the dilated calyces or dilated ureter.
If the patient presents with anuria and hypotension, the most important thing is to reestablish the blood pressure. If the anuria does not cease at this point, high-dose furosemide or a mannitol infusion can be started. Meanwhile, a CBC, chemistry panel, urinalysis, spot urine sodium, serum protein electrophoresis, an ANA assay, an EKG, and chest x-ray should be done. A flat plate of the abdomen should give an idea of the kidney size. The clinician should examine the urinary sediment himself, and this will identify cases of acute glomerulonephritis, lupus erythematosus, and acute tubular necrosis with considerable accuracy. The blood urea nitrogen (BUN) and creatinine ratio are helpful in distinguishing pre-renal from renal azotemia.
If intravascular hemolysis is suspected, serum haptoglobins and serum hemoglobin should be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. Renal angiography and aortography should be done in cases of suspected dissecting aneurysm or bilateral renal artery stenosis. Abdominal ultrasound will also be helpful in diagnosing polycystic kidneys and pelvic masses that may be obstructing the ureter. A CT scan may be necessary as well.
In difficult cases, a renal biopsy may be necessary to diagnose the various collagen diseases and the various forms of glomerulonephritis. Referral to a nephrologist would be best at this point.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
ANURIA AND OLIGURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will be helpful in determining the cause of anuria. In cases of prerenal azotemia, there will be decreased skin turgor and orthostatic hypotension if the cause is volume depletion. If the cause is CHF, there will be jugular vein distention, hepatomegaly, and pedal edema. Patients with postrenal azotemia may have an enlarged prostate, a distended bladder, and other signs of obstructive uropathy. Patients with renal azotemia may have bilateral flank masses (polycystic kidney), hypertension, peripheral emboli (embolic glomerulonephritis), or a rash (collagen disease, interstitial nephritis).
The initial workup includes a CBC; urinalysis; urine culture and sensitivity; personal examination of the urine for casts, and so forth; chemistry panel; spot urine sodium; serum and urine osmolality; flat plate of the abdomen for kidney size; chest x-ray; and ECG. The bladder is catheterized for residual urine and if this is significant, postrenal azotemia is likely and a urologist is consulted. He will most likely do a cystoscopy and retrograde pyelography once the patient’s condition is stabilized. Ultrasonography can be used to determine if there is significant residual urine also.
The laboratory studies will determine whether there is prerenal or renal azotemia. If the sodium concentration in the spot urine is less than 10 meq/L, prerenal azotemia is likely. Also, in prerenal Azotemia, the BUN: creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm per kilogram of water or greater. The urine sediment will show granular and red cell casts in most cases of renal azotemia, and the BUN:creatinine ratio will be 10:1 or less.
Further workup will depend on what the presumptive diagnosis is. If volume depletion is the cause, intravenous saline and plasma volume expanders are given while carefully monitoring the urine output. If this is ineffective, furosemide and a mannitol drip can be utilized to reestablish urine output. If these measures are ineffective, the patient obviously has a renal cause for his/her anuria and a urologist should be consulted.
Renal causes can be differentiated by further workup. If intravascular hemolysis is suspected, serum haptoglobins should be ordered. If dissecting aneurysm or bilateral renal artery stenosis is suspected, aortography and angiography would be done. If polycystic kidney disease is suspected, ultrasonography or CT scan of the abdomen may be done. Eosinophilia of the blood or urine will be found in drug-induced nephritis. If a collagen disease is suspected, one should order an ANA, double-stranded DNA (dsDNA) antibody titer or lupus erythematosus (LE) cell prep. A renal biopsy may also be necessary in these disorders and many others.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Bladder distention:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's or Credé's maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Anuria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Take the patient’s vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Oliguria:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Bladder distention:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Ask about his drug history, including his use of over-the-counter drugs.
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Anuria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Take the patient’s vital signs and obtain a complete history. First ask about any changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys both anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Oliguria:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient’s vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds, and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine sample and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Oliguria and Anuria:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Pertinent present history. A patient may complain of decreased urine output in some clinical situations. More often, however, the clinical situation and pertinent history should lead to an evaluation of the presence of oliguria or anuria.
1. Are there symptoms of illness or trauma leading to hypotension?
a. Hypovolemia (e.g., hemorrhage, diuretic overuse, gastrointestinal fluid loss, skin fluid loss owing to burns or heat exposure, third spacing, secondary to burns, peritonitis, pancreatitis, or trauma)?
b. Decreased cardiac output (e.g., congestive heart failure, myocardial infarction, pericardial tamponade, or acute pulmonary embolus)?
c. Peripheral vasodilatation (e.g., septic shock, anaphylactic shock)?
2. Are there symptoms of vascular disease? Consider bilateral renal vascular obstruction due to severe renal artery stenosis, thrombosis, or embolism.
3. Is there any history consistent with renal parenchymal injury [e.g., recent radiocontrast agent, nephrotoxin exposure such as ethylene glycol, nonsteroidal antiinflammatory drug overdose, acute nephritis, acute vasculitis, pyelonephritis (in the elderly), papillary necrosis (in diabetic patients), or prolonged hypotension with hypoperfusion of the kidney]?
4. Is there any history consistent with urinary tract obstruction?
a. Bladder neck obstruction (e.g., benign prostatic hypertrophy, prostate cancer, bladder cancer, or functional obstruction due to drug side effects)?
b. Obstruction of the urethra or bilateral ureters—internally (2° blood clots, stones, sulfonamide or uric acid crystals, pyogenic debris, necrotizing papillitis or edema), or externally (2° tumor, periureteral fibrosis, accidental ureteral ligation during pelvic surgery, ascites, pregnancy, pelvic abscess, or hematoma).
5. Medication use must be considered—diuretics, antihypertensives, anticholinergics, aminogycosides, amphotericin B, or chemotherapeutic drugs.
B. Other pertinent past history. Is there a history of cancer, recent surgery, kidney stones, neurologic disorder, vascular disease, chronic liver disease (hepatorenal syndrome), or kidney transplant?
Physical examination
A. Focused physical examination (PE). This should include vital signs (notably blood pressure, pulse, and temperature). Orthostatic blood pressure and pulse may be necessary. Signs of hypovolemia, hypotension, and dehydration should be noted—skin turgor and color, mucous membranes, capillary refill, warmth of extremities.
B. Additional PE. Depending on the history (e.g., skin rash, cardiac examination, bruits over kidneys) palpate for a distended bladder; if a cancer or outlet obstruction is suspected, perform a rectal or pelvic examination.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Anuria/Oliguria:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Acute tubular necrosis
❑ Prerenal azotemia
❑ Tubular toxins
❑ Bladder outlet obstruction
❑ Bilateral renal artery occlusion
❑ Nephrosclerosis
❑ Acute glomerulonephritis
❑ Interstitial nephritis
❑ Renal artery thrombosis
❑ Renal vein thrombosis
❑ Ureteral calculus with a solitary kidney
❑ Pelvic tumor
❑ Retroperitoneal fibrosis
❑ Infiltrative renal disease
❑ Vasculitis
❑ Rhabdomyolysis
Diagnostic Approach
Distinguish anuria from urinary retention. Nonobstructive anuria is accompanied by symptoms of uremia with vomiting, drowsiness, muscle twitch, headache, and asterixis. Urinary retention causes suprapubic pain, constant urgency, and a palpable bladder with dullness to percussion in the suprapubic region.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Bladder distention:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Ask the patient about voiding patterns, the time and amount of the last voiding, and the amount of fluid he consumed since the last voiding. Does he have a history of difficulty when urinating? Ask whether Valsalva’s maneuver or Credé’s maneuver is required to initiate urination. Does he experience an urgent need to urinate? Does the urge to urinate arise without warning? Is urination painful or irritating? Ask about the force and continuity of the urine stream and whether the bladder is empty after voiding.
Assess the patient’s history for the presence of a urinary tract obstruction or infections, venereal disease, lower abdominal or urinary tract trauma, systemic or neurologic disorders, and neurologic, intestinal, or pelvic surgery. Note medication history, including the use of over-the-counter or recreational drugs.
Physical examination
Take the patient’s vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can’t be palpated through the abdominal wall.) Inspect the urethral meatus. Document the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Anuria:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain a complete history, including changes in voiding pattern or urine characteristics. Ask the patient how much fluid he normally ingests each day, how much he ingested in the past 24 to 48 hours, and the time and amount of his last urination. Note a history of kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about abdominal, renal, or urinary tract surgery and about drug use.
Physical examination
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
» READ BOOK EXCERPT ONLINE »
Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Bladder distention:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If distention isn’t severe, begin by reviewing the patient’s voiding patterns. Find out the time and amount of the patient’s last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva’s or Credé’s maneuver to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient’s history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Anuria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by obtaining a complete history. First ask about any changes in the patient’s voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting especially previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about any abdominal, renal, or urinary tract surgery.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Oliguria:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss, as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Bladder distention:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If distention isn't severe, begin by reviewing the patient's voiding patterns. Find out the time and amount of the patient's last voiding and the amount of fluid consumed since then. Ask if he has difficulty urinating. Does he use Valsalva's maneuver or Credé's method to initiate urination? Does he urinate with urgency or without warning? Is urination painful or irritating? Ask about the force and continuity of his urine stream and whether he feels that his bladder is empty after voiding.
Explore the patient's history of urinary tract obstruction or infections; venereal disease; neurologic, intestinal, or pelvic surgery; lower abdominal or urinary tract trauma; and systemic or neurologic disorders. Note his drug history, including his use of over-the-counter drugs and herbal medicines.
Take the patient's vital signs, and percuss and palpate the bladder. (Remember that if the bladder is empty, it can't be palpated through the abdominal wall.) Inspect the urethral meatus, and measure its diameter. Describe the appearance and amount of any discharge. Finally, test for perineal sensation and anal sphincter tone; in male patients, digitally examine the prostate gland.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Anuria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Take the patient's vital signs and obtain a complete history. First, ask about changes in his voiding pattern. Determine the amount of fluid he normally ingests each day, the amount of fluid he ingested in the last 24 to 48 hours, and the time and amount of his last urination. Review his medical history, noting previous kidney disease, urinary tract obstruction or infection, prostate enlargement, renal calculi, neurogenic bladder, or congenital abnormalities. Ask about drug use and about abdominal, renal, or urinary tract surgery.
Inspect and palpate the abdomen for asymmetry, distention, or bulging. Inspect the flank area for edema or erythema, and percuss and palpate the bladder. Palpate the kidneys anteriorly and posteriorly, and percuss them at the costovertebral angle. Auscultate over the renal arteries, listening for bruits.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Oliguria:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by asking the patient about his usual daily voiding pattern, including frequency and amount. When did he first notice changes in this pattern and in the color, odor, or consistency of his urine? Ask about pain or burning on urination. Has the patient had a fever? Note his normal daily fluid intake. Has he recently been drinking more or less than usual? Has his intake of caffeine or alcohol changed drastically? Has he had recent episodes of diarrhea or vomiting that might cause fluid loss? Next, explore associated complaints, especially fatigue, loss of appetite, thirst, dyspnea, chest pain, or recent weight gain or loss (in dehydration).
Check for a history of renal, urinary tract, or cardiovascular disorders. Note recent traumatic injury or surgery associated with significant blood loss as well as recent blood transfusions. Was the patient exposed to nephrotoxic agents, such as heavy metals, organic solvents, anesthetics, or radiographic contrast media? Next, obtain a drug history.
Begin the physical examination by taking the patient's vital signs and weighing him. Assess his overall appearance for edema. Palpate both kidneys for tenderness and enlargement, and percuss for costovertebral angle (CVA) tenderness. Also, inspect the flank area for edema or erythema. Auscultate the heart and lungs for abnormal sounds and the flank area for renal artery bruits. Assess the patient for edema or signs of dehydration such as dry mucous membranes.
Obtain a urine specimen and inspect it for abnormal color, odor, or sediment. Use reagent strips to test for glucose, protein, and blood. Also, use a urinometer to measure specific gravity.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
ANURIA AND OLIGURIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The clinical picture will be helpful in determining the cause of
anuria. In cases of prerenal azotemia, there will be decreased skin turgor
and orthostatic hypotension if the cause is volume depletion. If the cause
is CHF, there will be jugular vein distention, hepatomegaly, and pedal
edema. Patients with postrenal azotemia may have an enlarged prostate, a
distended bladder, and other signs of obstructive uropathy. Patients with
renal azotemia may have bilateral flank masses (polycystic kidney),
hypertension, peripheral emboli (embolic glomerulonephritis), or a rash
(collagen disease, interstitial nephritis).
The initial workup includes a CBC; urinalysis; urine culture and
sensitivity; personal examination of the urine for casts, and so forth;
chemistry panel; spot urine sodium; serum and urine osmolality; flat plate
of the abdomen for kidney size; chest x-ray; and ECG. The bladder is
catheterized for residual urine; if this is significant, postrenal azotemia
is likely and a urologist is consulted. He will most likely do a cystoscopy
and retrograde pyelography after the patient’s condition is stabilized. Ultrasonography can be used to
determine if there is significant residual urine also.
The laboratory studies will determine whether there is prerenal or renal
azotemia. If the sodium concentration in the spot urine is less than 10
meq/L, prerenal azotemia is likely. Also, in prerenal azotemia, the
BUN/creatinine ratio is 20:1 or greater and the urine osmolality is 450 mOsm
per kilogram of water or greater. The urine sediment will show granular and
red cell casts in most cases of renal azotemia, and the BUN/creatinine ratio
will be 10:1 or less.
Further workup will depend on what the presumptive diagnosis is. If volume
depletion is the cause, intravenous saline and plasma volume expanders are
given while carefully monitoring the urine output. If this is ineffective,
furosemide and a mannitol drip can be utilized to reestablish urine output.
If these measures are ineffective, the patient obviously has a renal cause
for his or her anuria, and a urologist should be consulted.
Renal causes can be differentiated by further workup. If intravascular
hemolysis is suspected, a serum haptoglobin test should be ordered. If dissecting aneurysm or bilateral renal artery
stenosis is suspected, aortography and angiography would be done. If
polycystic kidney disease is suspected, ultrasonography or CT scan of the
abdomen may be done. Eosinophilia of the blood or urine will be found in
drug-induced nephritis. If a collagen disease is suspected, one should order
an ANA, double-stranded DNA (dsDNA) antibody titer, or lupus erythematosus
cell prep. A renal biopsy may also be necessary in these and many other
disorders.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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