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IMMEDIATE MANAGEMENT OF LIFE-THREATENING CONDITIONS

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OLIGURIA/ANURIA & ACUTE KIDNEY INJURY

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Anuria or oliguria is characterized as decreased urine output (< 1 mL/kg/hr in infants, < 0.5 mL/kg/hr in children) due to a decrease in glomerular filtration rate (GFR), resulting in varying degrees of acute kidney injury (AKI), also known as acute renal failure. AKI may be nonoliguric, where urine output is normal or increased. Decreased GFR in AKI results in changes in body fluid composition, blood pressure, and regulation of electrolytes and nitrogenous waste. Complications include hyperkalemia, uremia with neurologic sequelae, severe hypertension with fluid overload, pulmonary edema, and hypertensive encephalopathy.

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AKI is categorized by the underlying etiology: prerenal, renal (intrinsic), postrenal in origin. Prerenal causes are conditions that result in inadequate renal perfusion. Renal causes are due to many etiologies that result in intrinsic injury to the components of the nephron. Insult to the glomerulus, renal tubules, interstitium, and renal vasculature may be due to prolonged hypoperfusion from a prerenal cause, sepsis, or nephrotoxins. Postrenal causes are typically due to a urinary tract obstruction distal to the kidneys, which may be congenital or acquired. AKI due to postrenal causes generally requires bilateral urinary tract obstruction, or obstruction to a known or undiagnosed solitary kidney. Neurogenic bladder and medications may cause urinary retention and AKI. Table 38–1 lists causes of AKI.

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Table Graphic Jump Location
Table 38–1.Causes of acute kidney injury in children.
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Clinical Findings

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The clinician should attempt to identify the cause of the AKI, and uncover and treat life-threatening complications. A meticulous history of chronic medical conditions, recent illnesses, medications, intravenous (IV) contrast exposure should be obtained to elicit specific etiologies of AKI. Patients may present with decreased or no urine output, or be referred for evaluation of abnormal creatinine or urinalysis (UA) results.

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Patients with prerenal causes of AKI often appear dehydrated with signs of intravascular depletion and poor perfusion. History of streptococcal pharyngitis or skin infection may be present in poststreptococcal glomerulonephritis (GN). Bloody diarrhea should prompt consideration of hemolytic uremic syndrome (HUS). Rash with joint pains or abdominal pain may be present in Henoch-Schönlein purpura (HSP). Hypertension may be accompanied by a headache or dizziness. Fever, hypotension, and tachycardia are seen with accompanying sepsis syndromes. Edema may be periorbital, scrotal/labial, dependent, or appear as anasarca. Lung examination may reveal signs of pulmonary edema. The abdomen should be palpated for masses, representing tumors. Flank pain or masses ...

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