Anuria/Oliguria

Differential Overview

❑ 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.

Clinical Findings

Acute tubular necrosis  In ATN the urine is reddish-brown in color and has dipstick proteinuria. The usual clinical setting is transient hypotension due to decreased cardiac output, sepsis, or hypovolemia.

Prerenal azotemia  Signs of volume depletion, such as thirst, postural hypotension, tachycardia, or dry mucous membranes, are present.

Tubular toxins  Toxins include aminoglycosides, amphotericin B, heavy metals, endotoxin, myoglobin, Bence Jones proteins, iodinated contrast, organic solvents and ethylene glycol. Injury occurs especially in the presence of volume depletion or sepsis.

Bladder outlet obstruction  Acute urinary retention produces a full bladder (dullness to percussion above the symphysis pubis) and is usually preceded by obstructive signs such as decreased force of stream and hesitancy. It may occur precipitously with use of drugs having an anticholinergic effect, such as tricyclic antidepressants. The prostate is usually enlarged on exam.

Bilateral renal artery occlusion  Diffuse vascular disease (e.g., claudication with diminished pulses) and hypertension are usually present. There may be an abdominal bruit if flow is still present. Acute oliguria may occur with acute obstruction (as with embolic disease from atrial fibrillation) or with use of an angiotensin-converting enzyme inhibitor.

Nephrosclerosis  Renal failure that occurs in the setting of diabetes or poorly controlled hypertension is usually due to nephrosclerosis.

Acute glomerulonephritis  It may occur as a sequela of streptococcal infection of the skin, with systemic lupus erythematosus, cryoglobulinemia, Henoch-Schonlein purpura, or systemic vasculitis. Red blood cell casts are found on microscopic examination of the urine.

Interstitial nephritis  Concomitant fever, rash, and arthralgias are the hallmarks, and urinary eosinophils are a key clue. Drugs are the usual cause, often semisynthetic penicillins, but other antibiotics, thiazides, NSAIDs, allopurinol, cimetidine, methyldopa, and phenytoin have also been implicated. It may also be seen with infections such as streptococci, toxoplasmosis, measles, or syphilis.

Renal artery thrombosis  A source is evident, such as atrial fibrilla-
tion, recent myocardial infarction, or aortic catheterization. Acute flank/
abdominal pain is a hallmark. Peripheral livedo reticularis can be seen in atheroembolism.

Renal vein thrombosis  Suspect this condition in a patient with underlying nephrotic syndrome or hypercoagulable state when there is an acute or subacute worsening of renal function or proteinuria. Acute thrombosis is accompanied by fever and flank pain.

Ureteral calculus with a solitary kidney  It is accompanied by flank pain and hematuria (gross or dipstick). The solitary functional kidney may be a congenital variant or acquired through trauma or unilateral renal vascular disease.

Pelvic tumor  Obstruction from bladder cancer is usually preceded by symptoms of hematuria, sterile pyuria, or pain on voiding. Locally invasive prostate cancer may cause ureteral or bladder outlet obstruction and is readily detected as a stony, hard prostate on rectal exam. Uterine cancer spreads along the broad ligaments to block the ureters; thus, it may be detected on pelvic exam. Abnormal vaginal bleeding is an early sign.

Retroperitoneal fibrosis  Fibrosis is accompanied by edema of the scrotum or legs and dull, persistent lumbar back pain. It may be part of a more widespread fibrosing process involving the mediastinum, bile ducts, Dupuytren contracture, and Reidel thyroiditis. Primary or metastatic retroperitoneal tumors can cause a similar picture.

Infiltrative renal disease  Amyloidosis develops in a patient with a chronic inflammatory disease.

Vasculitis  Hematuria, severe hypertension, palpable purpura, and arthralgias are clues.

Rhabdomyolysis  The urine is brown, and there is a history of muscle trauma.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Urination pain: Introduction (review 154 causes)
• Next Book Extract About Urination pain: Dysuria (Signs & Symptoms: A 2-in-1 Reference for Nurses)
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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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