Anuria

Clinically defined as urine output of less than 100 ml in 24 hours, anuria indicates either urinary tract obstruction or acute renal failure due to various mechanisms. (See Major causes of acute renal failure.) Fortunately, anuria is rare; even with renal failure, the kidneys usually produce at least 75 ml of urine daily.

Because urine output is easily measured, anuria rarely goes undetected. However, without immediate treatment, it can rapidly cause uremia and other complications of urine retention.

Emergency interventions

After detecting anuria, your priorities are to determine if urine formation is occurring and to intervene appropriately. Prepare to catheterize the patient to relieve any lower urinary tract obstruction and to check for residual urine. You may find that an obstruction hinders catheter insertion and that urine return is cloudy and foul smelling. If you collect more than 75 ml of urine, suspect lower urinary tract obstruction; if you collect less than 75 ml, suspect renal dysfunction or obstruction higher in the urinary tract.

History and physical examination

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.

Medical causes

❑ Acute tubular necrosis. Oliguria (occasionally anuria) is a common finding with acute tubular necrosis. It precedes the onset of diuresis, which is heralded by polyuria. Associated findings reflect the underlying cause and may include signs and symptoms of hyperkalemia (muscle weakness, cardiac arrhythmias), uremia (anorexia, nausea, vomiting, confusion, lethargy, twitching, seizures, pruritus, uremic frost, and Kussmaul’s respirations), and heart failure (edema, jugular vein distention, crackles, and dyspnea).

❑ Cortical necrosis (bilateral). Cortical necrosis is characterized by a sudden change from oliguria to anuria, along with gross hematuria, flank pain, and fever.

❑ Glomerulonephritis (acute). Acute glomerulonephritis produces anuria or oliguria. Related effects include a mild fever, malaise, flank pain, gross hematuria, facial and generalized edema, elevated blood pressure, headache, nausea, vomiting, abdominal pain, and signs and symptoms of pulmonary congestion (crackles, dyspnea).

❑ Hemolytic-uremic syndrome. Anuria commonly occurs in the initial stages of hemolytic-uremic syndrome and may last from 1 to 10 days. The patient may experience vomiting, diarrhea, abdominal pain, hematemesis, melena, purpura, fever, elevated blood pressure, hepatomegaly, ecchymoses, edema, hematuria, and pallor. He may also show signs of upper respiratory tract infection.

❑ Renal artery occlusion (bilateral). Renal artery occlusion produces anuria or severe oliguria, commonly accompanied by severe, continuous upper abdominal and flank pain; nausea and vomiting; decreased bowel sounds; a fever up to 102° F (38.9° C); and diastolic hypertension.

❑ Renal vein occlusion (bilateral). Renal vein occlusion occasionally causes anuria; more typical signs and symptoms include acute low back pain, fever, flank tenderness, and hematuria. Development of pulmonary emboli — a common complication — produces sudden dyspnea, pleuritic pain, tachypnea, tachycardia, crackles, pleural friction rub and, possibly, hemoptysis.

❑ Urinary tract obstruction. Severe urinary tract obstruction can produce acute and sometimes total anuria, alternating with or preceded by burning and pain on urination, overflow incontinence or dribbling, increased urinary frequency and nocturia, voiding of small amounts, or an altered urine stream. Associated findings include bladder distention, pain and a sensation of fullness in the lower abdomen and groin, upper abdominal and flank pain, nausea and vomiting, and signs of secondary infection, such as fever, chills, malaise, and cloudy, foul-smelling urine.

❑ Vasculitis. Vasculitis occasionally produces anuria. More typical findings include malaise, myalgia, polyarthralgia, fever, elevated blood pressure, hematuria, proteinuria, arrhythmia, pallor and, possibly, skin lesions, urticaria, and purpura.

Other causes

❑ Diagnostic tests. Contrast media used in radiographic studies can cause nephrotoxicity, producing oliguria and, rarely, anuria.

❑ Drugs. Many classes of drugs can cause anuria or, more commonly, oliguria through their nephrotoxic effects. Antibiotics, especially the aminoglycosides, are the most commonly seen nephrotoxins. Anesthetics, heavy metals, ethyl alcohol, and organic solvents can also be nephrotoxic. Adrenergics and anticholinergics can cause anuria by affecting the nerves and muscles of micturition to produce urine retention.

Special considerations

If catheterization fails to initiate urine flow, prepare the patient for diagnostic studies — such as ultrasonography, cystoscopy, retrograde pyelography, and renal scan — to detect any obstruction higher in the urinary tract. If these tests reveal an obstruction, prepare him for immediate surgery to remove the obstruction, and insert a nephrostomy or ureterostomy tube to drain the urine. If these tests fail to reveal an obstruction, prepare the patient for further kidney function studies.

Carefully monitor the patient’s vital signs and intake and output, initially saving any urine for inspection. Restrict daily fluid allowance to 600 ml more than the previous day’s total urine output. Restrict foods and juices high in potassium and sodium, and make sure that the patient maintains a balanced diet with controlled protein levels. Provide low-sodium hard candy to help decrease thirst. Record fluid intake and output, and weigh the patient daily.

Pediatric pointers

In neonates, anuria is defined as the absence of urine output for 24 hours. It can be classified as primary or secondary. Primary anuria results from bilateral renal agenesis, aplasia, or multicystic dysplasia. Secondary anuria, associated with edema or dehydration, results from renal ischemia, renal vein thrombosis, or congenital anomalies of the genitourinary tract. Anuria in children commonly results from loss of renal function.

Geriatric pointers

In elderly patients, anuria is a gradually occurring sign of underlying pathology. Hospitalized or bedridden elderly patients may be unable to generate the necessary pressure to void if they remain in a supine position.

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Book Source Details

• Book Title: Handbook of Signs & Symptoms (Third Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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More About This Book: Title: Handbook of Signs & Symptoms (Third Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-402-1

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