• Oliguria is defined as a decrease in urine production below the minimal acceptable rate of 1 to 2 ml/kg/hr.
• Oliguria can occur as a normal physiologic response or as a manifestation of pathology within the renal system.
• Differentiating between physiologic and pathologic oliguria is essential to making appropriate clinical decisions and assessing the severity of disease.
• Physiologic oliguria is usually characterized by a high urine specific gravity and maximal reabsorption of urine sodium.
• Pathologic oliguria resulting from renal failure is characterized by an inappropriately isosthenuric urine and an increase in fractional excretion of sodium.
• Pathologic oliguria usually is seen with severe renal impairment but also can be seen when urine cannot be eliminated from the body.

CAUSES OF OLIGURIA

• Pre Renal:
  • Dehydration
  • Hemorrhage
  • Sepsis
  • Hypoalbuminemia
  • Cardiac failure

• Intrinsic renal
  • Glomerulonephritis
    • Post infectious/Post streptococcal
    • Lupus erythematosis
    • HSP
    • Membranoproliferative
    • Anti–Glomerular basement membrane
  • HUS
  • Acute tubular necrosis
  • Renal vein thrombosis
  • Rhabdomyolysis
  • Tumor lysis syndrome

• Post Renal
  • Posterior urethral valve
  • Uretero pelvic junction obstruction (10% B/L)
  • Ureterovesical junction obstruction (B/L)
  • Ectopic ureterocele causing bladder outlet obstruction
  • Tumor (rhabdomyosarcoma)
  • Urolithiasis (Vesicle calculi, B/L ureteral calculi)
  • Neurogenic bladder (Spina bifida, trauma or tumor of spinal cord)

History

• Onset and duration:
  • Sudden onset: Snake bite, trauma
  • Acute: AGE,HUS, AGN, obstruction, HSP
• Age/sex: Post Strep AGN ( 5-12 yrs), HUS ( <4yrs) HSP ( 2- 8yrs Male>female), NS (2-6 yr Male 2x>female)SLE adolescent femalesObstruction PUV in males, PUJ (M2x>F), Ureterocele (F>M)
• Asses urine output, number of times passed in last 24 hr
• App oral intake last 24 hr
• Associated symptoms
  • Diarrhea : AGE, HSP, SLE, HUS (preceding), RVT
  • Vomiting: AGE, HUS
  • Bleeding from any site: Good Pastures syndrome, Sepsis, DIC
  • H/O trauma (rhabdomyolysis), hemorrhage, burns
  • Pain abdomen: HSP, HUS, Ureteric calculi, Renal vein thrombosis (flank pain), SLE
  • Fever: AGN, Sepsis, SLE, HSP, HUS, infections (leptospirosis, malaria)
  • Swelling: AGN, NS, ARF, HSP (dependent parts)
  • Rash over body :HSP, HUS, SLE, AGN
  • Joint pains: SLE, HBV, HSP
  • Icterus: HBV, leptospirosis, Malaria
  • Pallor: HUS, hemorrhage
  • Red urine: AGN, malignancy, calculi, Alport, IgA nephropathy
  • Drug ingestion: diuretics, methotraxate, anticholinergic/ exposure snake bite

• R/O Complications
  • SOB: Fluid over load, HTN, CCF
  • Pedal edema: AGN, NS, ARF
  • Abd distention: NS, AGN, CCF
  • Headache, visual disturbance, epistaxsis: ↑BP
  • Altered sensoruim
  • Seizures: Dyselectrolytemia, ↑BP, uremia, meningitis, thrombotic event (Nephrotic Syndrome, HUS)
• Past history
  • Recent URTI/ AGE: HUS, HSP
  • Skin infection, sore throat: AGN, Hemoptysis (Good pastures disease, SLE, HSP)

• Treatment history: NS (Steroid Toxicity, indication for biopsy), Nephrotoxic drug received or not.
• Family History: Similar complaints infections, Hereditary disorders :- deficiency of factor v leiden, SLE, Alports syndrome, IgA nephropathy
• Dietary history: AGE, Cereal diet without milk (vesicle calculi)
• Contact history: Contact with animal (leptospirosis, mosquito bite:- malaria)

General physical examination

VITALS:
Pulse: Rapid weak and feeble pulse in hemorrhage
Sepsis : rapid bounding pulse
RR: Deep and rapid: acidotic in ARF
Temp: with fever, hemorrhage. in sepsis
BP: in AGN, ARF. in hemorrhage , sepsis, shock
Anthropometry: wasting and stunting in Acute on chronic RF, increased weight gain in AGN with edema
Icterus: HBV, Leptospirosis, Malaria
Pallor: ARF, HUS, SLE, Malignancy, Malaria
Cyanosis: CCF, Subglottic obstruction- post strep AGN
LNP: SLE, HSP, leptospirosis, pyoderma, Malignancy
Pedal edema: CCF
Increased JVP: CCF

Specific examination:

• Abdomen:
  • Distended ( ascitis : CCF, AGN, NS)
  • Hepatomegaly: CCF (tender), Hepatitis (tender), leptospirosis, SLE, HUS
  • Splenomegaly: Malaria, leptospirosis, HUS
  • Flank mass : RVT, HUS, Uretero pelvic junction obstruction, Tumor, hematoma, abscess
• CVS: Gallop rhythm, Locate apex beat (CCF, cardiomyopathy)
• Chest: Wheeze or crepts , pulmonary edema in CCF
• CNS: Focal (Thrombosis, hemorrhage) or general neurological signs.
• Ophthalmoscopy: Hypertensive retinopathy, Alports syndrome ( anterior lenticonus)
• Hearing examination : Alports syndrome

INVESTIGATION

• CBC
  • Hb decrease: Hemorrhage, Hemolysis (HUS, SLE, Malaria, RVT), dilutional ARF, Tumor, HSP (malena), Sepsis
  • Platelet decrease: HUS, RVT, Bacterial sepsis, SLE. Mod increased in HSP

• • P/S: Microangiopathic hemolytic anemia: HUS, RVT, DIC

• ASO titer: ↑post strep AGN, SLE
• AntiDNAse B: post strep AGN
• C3: Decreased in post strep AGN, SLE, membranoproliferative GN
• Serum electrolytes: Na, K, Ca
• Blood Urea
• Serum Creatinine
• URE
  • RBC : AGN, nephrocalcinosis, Alports disease.
  • WBC: UTI, AGN
  • RBC casts : AGN, SLE, IgA nephropathy
  • WBC casts: UTI, SLE

Differentiating pre and post renal ARF

• Chest Xray: Cardiomegaly, features of pulmonary edema
• ECG: Evidence of Hyperkalemia, Cardiomyopathy
• Plain Xray abdomen: radio opaque calculi (Struvite stones)
• CT/MRI: Spinal cord tumor, MS, Ureteral calculus
• USG abd: Renal size
  • ARF normal/↑ size (hydronephrosis, RVT, cystic disease, tumor, AGN)
  • Acute on Chronic renal failure: small contracted kidney.

USG Abd: Structural anomaly, Dilatation of urinary tract, Calculi, Tumor. Other abdominal organs, lymphadenopathy, tumor

• Obstructive lesions: VCUG, IVP, DTPA (diethylene tetra pentaacetic acid)

Management

General Management

• Vitals maintenance: ABCD
  • Fluid support in dehydration
  • Blood transfusion in hemorrhage, blood products in sepsis
  • Dopermine : ARF, Sepsis
  • Maintain electrolyte balance, treat complication
  • Dialysis as indicated
  • Control BP

Indications of dialysis in ARF

• Volume overload with evidence of hypertension and/or pulmonary edema refractory to diuretic therapy
• Persistent hyperkalemia (k⁺> 6.5meq/l; k⁺>5.5 – 6.5 with ECG changes
• Severe metabolic acidosis (pH<7.2) unresponsive to medical management, or NaHCO₃ administration not feasible due to volume overload
• Neurological symptoms (altered mental status, seizures)
• BUN > 100–150 mg/dl or lower if rapidly raising
• Calcium/phosphorus imbalance , with hypocalcemic tetany
• Hyponatremia Na⁺ < 120 – 125 especially if symptomatic
• Hypercatabolic state; marked tissue injury, crush syndrome, burns, sepsis
• Inability to provide adequate nutritional intake because of severe fluid restriction

Decreased urine output

No signs of fluid over load or CCF

Intravenous fluid (Isotonic saline 20ml/kg over 30 min, may repeat as required)

Furosemide 3-4ml/kg after 2hrs with urine output <1ml/kg/hr. with no evidence of intravascular volume deficit.

If not passed urine go for fluid restriction, 400ml/m²/day with estimated urine output for the day

Indications of kidney biopsy

• Steroid resistant NS
• ARF of unknown cause
• Rapidly progressive ARF
• Systemic renal disease
• Inherited nephropathies
• Renal allograft dysfunction
• AGN with
  • ARF
  • Nephrotic syndrome
  • Absence of evidence of streptococcal infection
  • Persistent hematuria and proteinuria
  • Decreased C3 level persisting for more than 2months
• Nephrotic syndrome with
  • unexplained hematuria and proteinuria, HTN
  • age <1yr, >8yr
  • Hypocomplemantemia
  • Renal insufficiency

Specific management:

• Antibiotics for sepsis and infection
• Vasculitis: steroids
• SLE : Steroids
• Obstruction: Catheterization
  • PUJ obstruction: Pyeloplasty
  • PUV: Surgical ablation
  • Ureterocele: Excision of ureterocele and ureteral reimplantation
  • Vesical calculi (suprapubic cystolithotomy)
• Neurogenic bladder: Catheterization, Anticholinergic agents (Oxybutynin)

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