Oliguria differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]

An expert algorithm to assist in the diagnosis of oliguria can be found here

Overview

There are several life-threatening causes of oliguria which need to be evaluated for first, which include; sepsis, urethral stricture, dehydration and shock . The other possible causes of oliguria can be evaluated by carefully assessing the nature of the symptoms, and obtaining a thorough patient history.

Differential Diagnosis

Life Threatening Causes

Life threatening diseases to exclude immediately include:^[1]^[2]

Common Causes

Differential Diagnosis of Oliguria

The following table outlines the major differential diagnoses of Oliguria.

To review the differential diagnosis of oliguria and edema, click here.

To review the differential diagnosis of oliguria and dizzness and/or confusion, click here.

To review the differential diagnosis of oliguria and fatigue and/or lethargy, click here.

To review the differential diagnosis of oliguria, hematuria and proteinuria, click here.

To review the differential diagnosis of oliguria, hematuria, proteinuria and edema, click here.

To review the differential diagnosis of oliguria and muscle weakness, click here.

To review the differential diagnosis of oliguria and somatic and/or visceral pain click here.

To review the differential diagnosis of oliguria and tachypnea, click here.

To review the differential diagnosis of oliguria and thirst, click here.

To review the differential diagnosis of oliguria and vomiting, click here.

To review the differential diagnosis of oliguria, vomiting and diarrhea, click here.

Abbreviations: ABG = Arterial blood gases, CBC = Complete blood count, CT = Computed tomography, CRP = C - reactive protein, ECG = Electrocardiogram, ESR = Erythrocytie sedimentation rate, KFT = Kidney function test, GI = Gastrointestinal, GFR = Glomerular filtration rate, MRI = Magnetic resonance imaging, PT = Prothrombin time, BUN = Blood urea nitrogen,

Classification by etiology	Etiology	Clinical manifestations										Paraclinical findings											Comments
		Symptoms and signs										Lab findings						Imaging
		Fatigue/Lethargy	Thirst	Dizziness/Confusion	Muscle weakness/cramp	Somatic/visceral pain	Vomiting	Diarrhea	Tachypnea	Haematuria/Proteinuria	Edema	CBC	KFT	Electrolytes	Urine analysis	ABG	Other	Ultrasound	X-ray	CT	MRI	Other
Prerenal	Alcohol poisoning^[3]^[4]^[5]^[6]	+	-	+/-	-	+/-	+	+/-	-	-	-	Prolonged PT	Elevated creatinine with normal BUN may indicate isopropyl alcohol poisoning	Decreased serum sodium	-	Decreased bicarbonate	- Serum glucose level Serum blood alcohol level Elevated hepatic transaminases Toxicology screen for acetaminophen and salicylates	-	-	-	-	-	Serum osmolality should be calculated Thiamine must be given to avoid Wernicke's encephalopathy
	Aspergillosis^[7]^[8]^[9]	+/-	-	-	-	-	-	-	+/-	-	-	-	-	-	-	-	Aspergillus precipitins allergy test is positive IgE is > 1000 IU/dl Fungi is identified via Gomori methenamine silver stain Calcofluor Positive culture result from sputum, needle biopsy, or bronchoalveolar lavage Hyphae are demonstrated Elevated galactomannan level in bronchoalveolar fluid	-	Pulmonary infiltrates Mucoid plugging Central bronchiectasis Mass in the upper lobe surrounded by a crescent of air Solitary or multiple cavities	Halo sign (ground-glass appearance with nodules) Defines bronchiecstasis May show evidence of wedge-shaped pulmonary infarction Granulomata, tissue necrosis, and blood vessel invasion may be noted	-	-	Polymerase chain reaction (PCR) assays could be useful in diagnosis of invasive aspergillosis
	Cholera^[10]^[11]^[11]^[12]	+/-	+	-	-	-	+/-	+	-	-	-	Leukocytosis without left shift is noted Elevated hematocrit	Elevated blood urea nitrogen Elevated creatinine	Serum sodium < 135 mmol/l Elevated calcium Elevated magnesium	-	Elevated lactate Serum bicarbonate < 15 mmol/l	Stool is used in dark field examination or PCR to visualize treponema pallidum Stool culture is carried out using thiosulfate-citrate-bile-sucrose-agar Serotyping may be performed using an anti-serum Elevated serum protein is noted Elevated serum-specific gravity is noted Elevated blood glucose may be detected	-	-	-	-	-
	Congestive heart failure (CHF)^[13]^[14]^[15]^[16]^[17]^[18]	+	-	-	-	-	-	+	-	-	May indicate anemia Leukocytosis may be detected	Elevated BUN Elevated creatinine	Serum sodium may be decreased Serum potassium may be elevated	-	Serum bicarbonate may be decreased Serum lactate may be elevated Metabolic acidosis may be present	Brain natriuretic peptide (BNP) or N -terminal prohormone BNP may be elevated and indicate ventricular dilatation Cardiac troponins may be elevated Pulse oximetry may indicate hypoxemia	-	May demonstrate: Cardiomegaly Pulmonary venous hypertension Pleural effusions	More accurate visualization of pulmonary edema	-	Useful in detecting congenital cardiac abnormalities and assessment valvular heart disease Delayed enhancement cardiovascular magnetic resonance imaging is useful in identifying the etiology of acute chest pain	Echocardiography demonstrates decreased ejection fraction Also demonstrates left and right ventricular function and filling pressures Electrocardiogram (ECG) may indicate a myocardial infarction or ischemia, arrhythmia or atrioventricular block Nuclear imaging can be used to assess heart function and damage in CHF, such as: ECG-gated myocardial perfusion imaging ECG-gated single-photon emission CT
	Dehydration^[19]^[20]^[21]^[22] - Burns -Cutaneous loss e.g. sweating - Inadequate water intake - Salt-wasting nephropathy	+	+	-	+/-	-	+/-	+/-	-	-	-	-	Elevated BUN Elevated creatinine	Serum sodium < 135 mmol/l Serum chloride is decreased Elevated potassium	Ketones and glucose may be detected Urine specific gravity is elevated	Serum bicarbonate is decreased Elevated lactate	Hypoglycemia may be detected	-	-	-	-	-	Oral rehydration therapy is the usual line of treatment
	Diarrhea and/or vomiting^[23]^[24]^[25]^[26]	+/-	+/-	-	-	-	+	+	-	-	-	Leukocytosis with predominant neutrophilia may be detected Elevated ESR may be detected	-	Stool anion gap should be calculated	Urine may be postive for: Ketones Organic acids Ester-to-free carnitine ratio Porphobilinogen Aminolevulinic acid	-	Stool pH < 5.5 Stool culture may be positive for vibrio and plesiomonas species, clostridium difficile, salmonella, shigella, campylobacter, and yersinia enterocolitica Serotyping for E.coli O157:H7 Enzyme immunoassay may be positive for rotavirus or adenovirus Elevated liver transaminases may be detected Elevated pancreatic amylase and lipase may be detected	Abdominal ultrasound may be useful to detect cause	Upper gastrointestinal radiography with follow-through may be useful to detect cause	-	Brain MRI may be useful to detect cause	Esophagogastroduodenoscopy may be useful to detect cause	Treatment must include volume replacement
	Drugs/toxins^[27]^[28]^[29]^[30] - ACE inhibitor - Aminoglycosides - Amphotericin B - Contrast material - Cyclosporin - Diuretics - Digitalis - Heavy metals - Indomethacin - Tacrolimus - NSAIDs	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	+/-	-	Elevated BUN Elevated creatinine Elevated creatine kinase	Potassium > 5.5 mEq/l with ACE inhibitors Hypomagnesemia, hypokalemia, hypocalcemia, and hypophosphatemia with aminoglycosides	Urine sample may detect drug Glucosuria, aminoaciduria, phosphaturia, ketonuria and uricosuria may be detected Urine osmolality should be calculated Urine pH should be detected Bland urine sediment may be detected Hyaline casts may be detected Granular casts may be detected Red blood cell casts may be detected Dysmorphic red blood cells may be present Red blood cell casts may be detected Absence of proteinuria differentiates between acute kidney injury and acute interstitial nephritis	Serum osmolar gap should be calculated Elevated lactate may be detected Metabolic acidosis may be present	Blood glucose should be measured Toxicology screening is crucial in aiding diagnosis Rapid immunoassay screens may also aid diagnosis	Useful in drug-induced nephropathies	Some radio-opaque substances may be visualized Ingested drug packets may also be visualized	-	-	ECG may be helpful in diagnosing arrhythmias
	Esophageal varices bleeding^[31]^[32]	+/-	-	-	-	+/-	-	-	-	-	-	May show normocytic normochromic anemia Hematocrit may be decreased	In uncontrolled bleeding: Elevated BUN Elevated creatinine	-	-	-	-	Duplex doppler ultrasonography can determine: Velocity and direction of portal flow Determine portal vein patency Endoscopic ultrasonography may also be useful	Abnormal opacities representing paraesophageal varices may be detected outside the esophageal wall The short or long segment of the descending aorta may be obliterated A posterior mediastinal or intraparenchymal mass may be noted A dilated azygous vein may be noted and is described as a "downhill varix" Dilated collaterals may lead to a widened superior mediastinum Barium swallow demonstrates snake-like filling defects	Can visualize the entire portal venous system	Can visualize the entire portal venous system Portrays esophageal varices as flow voids	Positive emission tomography can determine portal hypertension and evaluate esophageal varices A flexible endoscope may also aid diagnosis Bleeding is stopped by vasopressin, balloon tamponade, or transjugular intrahepatic portosystemic shunt to name a few.
	Heart disease^[33]^[34]^[35] -Congenital -Acquired	+/-	-	-	-	-	-	-	+/-	-	+/-	ESR and CRP may be elevated	BUN and creatinine may be elevated	-	-	-	For coronary heart disease, cardiac stress testing may be performed: For rheumatic heart disease, the following tests may be performed: Throat culture may be positive for group A beta hemolytic Streptococcus Rapid antigen detection test may be positive for group A streptococcal antigen Antistreptococcal antibodies may be detected Heart reactive antibodies may be detected against M protein Rapid detection test for D8/17 B cell markers Hyperoxia test can distinguish cardiac from non - cardiac causes of cyanosis Pulse oximetry is useful in congenital heart diseases	Ultrasound visualizes anatomy of the heart and in particular, the chambers and chamber flow	May visualize heart anatomy and vessels such as: Cardiomegaly Dextrocardia Abnormal cardiac silhouette	-	-	ECG may demonstrate: Arrhythmias such as: Sinus tachycardia Multifocal atrial tachycardia Prolonged PR interval in atrioventricular block Atrial fibrillation Atrial flutter Pericarditis by ST segment elevation mostly in lead II, III, aVF, and V4 - V6 Echocardiography may detect the following: Ventricular dysfunction Left and right ventricular hypertrophy Chronic mitral valve disease Mitral stenosis Mitral insufficiency Left atrial dilation Left atrial enlargement Aortic stenosis Aortic insufficiency Tricuspid insufficiency Pulmonary stenosis Pulmonary insufficiency	History and physical examination (auscultation of the heart) are important for diagnosis
	Hemorrhage^[36]^[37]^[38]^[39]	-	-	-	-	-	-	-	-	-	-	May indicate normocytic normochromic anemia Prothrombin time, activated partial thromboplastin time and bleeding time may be elevated	BUN and creatinine is elevated in severe hemorrhage	-	-	pH may be 7.30-7.35 with mild to severe metabolic acidosis Serum sodium and chloride may become elevated with high volume isotonic saline Hyperchloremia may cause a non–ion gap acidosis Hypocalemia may occur with rapid blood transfusion	-	Sensitive to bleeding within body cavities Focused abdominal sonographic technique (FAST) can detect peritoneal cavity fluid	Chest x -ray may demonstrate bilateral opacities in the lung field and indicate hemothorax Abdominal x - ray may demonstrate hemoperitoneum Incomplete calcified margins of a dilated aorta may indicate a ruptured abdominal aortic aneurysm Absence of the psoas shadow may suggest retroperitoneal blood	May visualize intrathoracic, intra-abdominal, and retroperitoneal bleeding However, ultrasound is more often used	-	Esophagogastroduodenoscopy is often used to visualize the source of bleeding in the upper GI Colonoscopy may be used in the lower GI Angiography and nuclear medicine scanning are also useful in diagnosing the source of bleeding
	Hemolysis^[40]^[41]^[42]^[43]	+/-	-	-	-	-	-	-	-	+/-	-	Elevated or decreased mean corpuscular volume and mean corpuscular hemoglobin Thrombocytopenia Microcytic hypochromic anemia Macrocytic anemia Elevated red blood cell distribution width may indicate anisocytosis Reticulocyte count may be increased	-	-	-	-	Peripheral blood smear may demonstrate: Smudge cells Small lymphocytes Polychromasia Spherocytes Schistocytes Serum lactate dehydrogenase may be elevated Serum haptoglobin may be decreased Unconjugated or indirect bilirubin may be elevated The following tests may also aid diagnosis: Direct antiglobulin test Urine free hemoglobin test Urine hemosiderin test Red blood cell survival test Cold agglutinin titer Glucose-6-phosphate dehydrogenase screen Sickle cell screen	May visualize hepatomegaly or splenomegaly or hepatosplenomegaly	-	-	-	-
	Hepatorenal syndrome^[44]^[45]^[46]^[47]	+/-	-	-	-	+/-	+/-	-	-	+/-	+/-	Leukocytosis may indicate spontaneous bacterial peritonitis	Reduced glomerular filtration rate Serum creatinine > 1.5 mg/dL or 24 - hour creatinine clearance < 40 mL/min	Serum sodium < 130 mEq/L	Proteinuria < 500 mg/d Urine volume < 500 mL/d Urine sodium < 10 mEq/L Urine osmolality > plasma osmolality Urine red blood cell count < 50 per high-power field	-	Prolonged prothrombin time Alpha feto-protein may be positive Cryoglobulinemia may be seen	Abdominal ultraosund to exclude hydronephrosis and intrinsic renal disease	-	-	-	Echocardiography is used to evaluate right ventricular preload, ventricular filling pressures, and cardiac function
	Ischemic cardiomyopathy^[48]^[49]^[50]^[51]	+/-	-	-	-	-	-	-	+/-	-	+/-	In high cardiac output, anemia may be detected	Elevated creatinine	Serum sodium may be decreased Serum postassium may be chronically low Serum magnesium may be decreased	-	-	Cardiac enzymes may be elevated indicating a recent myocardial infarction, and include: Troponin Creatine kinase Creatine kinase - MB B-type natriuretic peptide level reflects volume status	-	May detect abnormal cardiac silhouette	CT scanning with angiography can detect the following: Biventricular volume Ejection fraction Wall motion Myocardial perfusion Hypertrophic cardiomyopathy Left ventricular noncompaction Arrhythmogenic right ventricular dysplasia Congenital malformation	MRI with gadolinium–diethylene-triamine pentaacetic acid (DTPA) can evaluate mid-wall fibrosis	Echocardiography is the gold standard in diagnosis and indicates an ejection fraction ≤35% Echo may also diagnose pulmonary embolism, right ventricular distention or pericardial effusion with tamponade Electrocardiogram is useful in detecting; Left ventricular enlargement Atrial fibrillation Premature ventricular complexes Left ventricular hypertrophy Left bundle-branch block Atrioventricular block Right-sided heart catheterization can determine volume status Endomyocardial biopsy may also be helpful in diagnosis
	Liver cirrhosis^[52]^[53]^[54]	+/-	-	+/-	+/-	+/-	-	-	-	-	+/-	-	-	-	-	-	Liver function testing is crucial for diagnosis The following serologic tests are used as indirect markers of fibrosis: Aspartate aminotransferase to platelet ratio FibroTest/FibroSure Hepascore FibroSpect	Doppler ultrasound may demonstrate: Portal blood flow and flow velocity Hepatic artery enlargement Vascular resistance Multifocal or focal lesions or masses Hepatic contour Hepatic texture Portal collaterals Ascites Splenomegaly Portal vein thrombosis	May demonstrate the following: Ascites Bowel perforation Gynecomastia (enlargement of breast tissue) Azygos vein enlargement Variceal hemorrhage Pleural effusion	CT can detect the following: Morphologic changes in the liver Collaterals and shunts Lesions Hyperattenuating nodule of hepatocellular carcinoma Portal vein thrombosis Splenomegaly and gallbladder enlargement	MRI can detect the following: Morphologic changes in the liver Vacular patency Lesions Tumor invasion Portal vein thrombosis Splenomegaly and gallbladder enlargement Steatosis	Nuclear imaging can determine hepatic function and portal hypertension Angiography can determine hepatic perfusion and the development of shunts and tumors	Liver cirrhosis is irreversible and a transplant is usually needed
	Malignant hypertension^[55]^[56]	+/-	-	+	-	-	+/-	-	+/-	-	+/-	May demonstrate microangiopathic hemolytic anemia	Elevated BUN Elevated creatinine Azotmeia	Hypernatremia Hyperphosphatemia Hyperkalemia or hypokalemia	Proteinuria Microscopic hematuria Red blood cell or hyaline casts	Acidosis	It is useful to also test the following: Cardiac enzymes Urinary catecholamines and vanillylmandelic acid Thyroid-stimulating hormone level Elevated plasma renin, angiotensin II, and aldosterone is often detected	-	May demonstrate the following: Cardiac enlargement Pulmonary edema Rib notching Aortic coarctation Mediastinal widening Aortic dissection	-	-	Electrocardiography may indicate the following: Ischemia Infarct Evidence of electrolyte abnormalities or drug overdose Echocardiography may indicate the following: Left atrial enlargement Left ventricular hypertrophy
	Myocarditis^[57]^[58]^[59]^[60]	+/-	-	-	-	+/-	-	-	+/-	-	-	Leukocytosis may be with eosinophilia Elevated ESR and CRP	-	-	-	-	Screening for rheumatic origin of disease Cardiac enzymes to rule out infraction Serum viral antibodies to rule out viral myocarditis, including: Coxsackie virus group B Human immunodeficiency virus (HIV), Cytomegalovirus Ebstein-Barr virus Hepatitis virus Influenza virus	-	-	-	Gadolinium-enhanced magnetic resonance imaging can detect inflammatory edema Delayed-enhanced MRI has also been to assess the degree of scarring	Endomyocardial biopsy is the gold standard for the diagnosis of myocarditis Echocardiography is useful for the following: Exclusion of amyloidosis, congenital and/or valvular diseases Assessment of cardiac dysfunction Detection of inflammatory origin, wall motion abnormalities, wall thickening, and pericardial effusion Distinction between fulminant and acute myocarditis Scintigraphy is useful for detecting myocardial inflammation ECG is non-specific but may detect the following: Heart block Ventricular arrhythmias Injury patterns, including those of myocardial ischemia and pericarditis
	Peritonitis^[61]^[62]	+/-	-	+/-	-	+/-	+/-	+/-	-	-	-	-	-	-	-	-	Peritoneal fluid analysis is the most important component of diagnosis and demonstrates the following: Ascitic fluid neutrophil count > 500 cells/µL	-	-	-	-	-
	Perinatal asphyxia^[63]^[64]^[65]	+/-	-	+/-	-	-	+/-	-	+/-	-	-	May indicate infection, hemorrhage or thrombocytopenia	Decreased glomerular filtration rate Elevated creatinine >1.5 mg/dL	-	-	Elevated cardiac troponin T and I levels are specific for cardiac dysfunction Neutrophil gelatinase-associated lipocalin is under investigation as a biomarker for acute kidney injury Fetal umbilical artery pH <7.0 Elevated liver transaminases Coagulation profile should be carried out	-	Cranial ultrasound may indicate the following: Focal hemorrhage Ventricular dilatation White matter damage Cerebral edema Cystic lesions	X -ray may demonstrate the following: Cardiomegaly Hazy lung fields indicating pulmonary edema	-	Acute brain injury may be seen on MRI	ECG may demonstrate ischemia with changes in the ST segment Echocardiography may demonstrate the following: Decreased left ventricular ejection fraction Right-to-left atrial shunting	Apgar score is very important during assessment
	Polycythemia^[66]^[67]^[68]^[69]^[70]	+/-	-	-	-	-	-	-	+/-	-	-	Hematocrit > 49% in men Hematocrit > 48% in women Hemoglobin > 16.5 g/dL in men Hemoglobin > 16 g/dL in women Total red blood cell mass ≥ 36 mL/kg in males Total red blood cell mass ≥ 32 mL/kg in females hematocrit > 49% in men Thrombocytosis > 400,000/μL Leukocytosis with predominant neutrophils > 12,000/μL Leukocyte alkaline phosphatase >100 U/L Serum vitamin B-12 concentration >900 pg/mL Hyperuricemia may be present	Decreased erythropoietin	-	Oxygen saturation ≥ 92%	-	May demonstrate splenomegaly	May demonstrate splenomegaly	-	-	-	JAK2 mutation Bone marrow biopsy demonstrates: Hypercellularity with hyperplasia of the erythroid, granulocytic, and megakaryocytic cell lines Myelofibrosis may also be present Prothrombin time and activated partial thromboplastin time may be prolonged	Phlebotomy is the usual form of treatment
	Respiratory distress syndrome^[71]^[72]^[73]^[74]	+	-	+/-	-	-	-	-	+	-	-	-	-	-	-	Metabolic and respiratory acidosis may occur with hypoxia	Pulse oximetry is useful in diagnosis	-	Demonstrates the following: Bilateral, diffuse, reticular granular or ground-glass appearance Poor lung expansion Cardiomegaly may or may not be present Streaky opacities may indicate pneumonia	-	-	Echocardiography is useful in diagnosing patent ductus arteriosus
	Shock^[75]^[76]^[77]^[78] - Anaphylactic - Cardiogenic - Hypotensive - Septic - Toxic	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	+/-	-	Elevated hemotocrit value may indicate hypovolemic shock Anemia and/or thrombocytopenia may indicate hemorrhagic shock Elevated eosinophils may indicate anaphylactic shock Elevated leukocytes may suggest septic shock A low white count with bandemia may suggest an undifferentiated shock	Elevated BUN and creatinine Decreased GFR	Hypernatremia or hyponatremia Hypo or hyperkalemia Hypochloremia	-	Elevated serum lactate	Cross matching and blood typing of blood is important for blood transfusion Prolonged prothrombin and activated partail thromboplastin time may indicate hemorrhagic shock Elevated liver transaminases In cardiogenic shock: Elevated troponin I or troponin T levels Elevated creatine phosphokinase Elevated brain natriuretic peptide, or N-terminal pro-brain natriuretic peptide Disseminated intravascular coagulopathy may occur as a complication, and is determined through elevated fibrin split products and D-dimer level with low fibrinogen level	RUSH (Rapid ultrasound in shock) may detect the following: Pulmonary embolism Pericardial effusion Cardiac tamponade Reduced contractility of the right and left ventricle Pneumothorax Pulmonary edema Thoracic or abdominal aortic aneurysm	May demonstrate the following: Pneumonia Pneumothorax Pulmonary edema Widened mediastinum Free air under the diaphragm May also determine etiology of shock, such as: Intestinal obstruction, Bowel perforation	Can determine etiology of shock, such as: Traumatic brain injury, Stroke Spinal injury Pneumonia Pneumothorax Ruptured aneurysm Dissection Intestinal obstruction Bowel perforation Abscess Pulmonary embolism	-	-
	Third space losses^[79]^[80]^[81] - Capillary leak - Surgery - Trauma	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	+/-	-	Normocytic normochromic anemia Decreased hematocrit	Elevated BUN and creatinine Elevated GFR	May demonstrate proteinuria or hematuria	Elevated lactate dehydrogenase Elevated alkaline phosphatase Hypo or hypernatremia Hypo or hyperkalemia	May visualize fluid collections	More accurately visualize the following: Margins of trauma Fluid collection	Useful for diagnosis of soft tissue injury	-	-	-
	Toxic megacolon^[82]^[83]^[84]^[85]	+/-	+/-	+/-	-	+	+	+/-	-	-	-	Leukocytosis with left shift Anemia (if diarrhea is present)	Creatinine and BUN may be elevated	-	Hyponatremia is common	Elevated ESR and CRP	Ultrasound may demonstrate the following: Loss of haustra Hypoechoic and thick bowel walls Dilated colon > 6cm Dilatation of ileal loops Presence of intraluminal gas and fluid	The following is noted with x-ray: Dilated colon Loss of haustra Soft tissue masses Segmental parietal thinning Free intraperitoneal air	May demonstrate the following: Bowel perforation Abscess			Endoscopy and colonoscopy can aid diagnosis
Classification by etiology	Etiology	Clinical manifestations										Paraclinical findings											Comments
		Symptoms and signs										Lab findings						Imaging
		Fatigue/Lethargy	Thirst	Dizziness/Confusion	Muscle weakness/cramp	Somatic/visceral pain	Vomiting	Diarrhea	Tachypnea	Haematuria/Proteinuria	Edema	CBC	KFT	Electrolytes	Urine analysis	ABG	Other	Ultrasound	X-ray	CT	MRI	Other
Intrinsic renal	Acute interstitial nephritis^[86]^[87]^[88]^[89]	+/-	-	+/-	-	+/-	+/-	+/-	+/-	+/-	+/-	Eosinophilia may be present	Elevated creatinine High fractional sodium excretion	-	Eosinophiluria Sterile pyuria Microscopic hematuria Proteinuria Red cell or white cell casts	-	Patients with immunoglobulin G4 - related disease may have elevated serum total IgG and/or IgG4 levels	Ultrasound will show normal-sized kidneys	-	-	-	-	History of long term painkiller use is common
	Acute tubular necrosis^[90]^[91]^[92]^[93]^[94]	+/-	-	-	-	-	+/-	-	-	+/-	+/-	Anemia	Elevated creatinine Elevated BUN Elevated fractional excretion of sodium	Hyponatremia Hyperkalemia Hypermagnesemia Hypocalcemia Hyperphosphatemia	Pigmented, muddy brown, granular casts	-	-	Ultrasound can determine: Obstructive uropathy Renal size Cortical thickness Hydronephrosis	May be useful in cases with nephrolithiasis	May be useful in cases with nephrolithiasis May also determine area of obstruction	May also determine area of obstruction	Renal biopsy may demonstrate the following: Loss of tubular cells or the denuded tubules Swollen tubular cells Loss of the cell brush border Useful kidney function biomarkers: Neutrophil gelatinase-associated lipocalin Interleukin-18 Kidney injury molecule 1 Cystatin C Sodium/hydrogen exchanger isoform 3	Furosemide stress testing can predict stage
	Cancer^[95]^[96]^[97]^[98]^[99] - Renal cell carcinoma - Metastatic cancer	+	-	-	-	+/-	+/-	-	-	+	+/-	May reveal normocytic or microcytic anemia Leukocytosis or lymphocytosis Elevated reticulocytes Thrombocytopenia Leukopenia Blast cells	Elevated BUN Elevated creatinine Decreased GFR Decreased or increased production of erythropoietin	Hyponatremia Hypomagnesemia Hyper or hypocalcemia Hypophosphatemia Hyper or hypokalemia	Gross hematuria		Elevated liver transaminases	Ultrasound can detect fluid collection and morphologic change Flank mass	Can delineate tumor, visualize calcification and widened mediastinae Barium contrast may show filling defects	May accurately visualize metastasis and determine staging Distinguish cystic from solid masses Determine lymph node, renal vein, and inferior vena cava involvement	May determine soft tissue invasion and staging	Percutaneous cyst puncture may aid diagnosis of malignant cystic lesions	Histology can determine type of cancer. Renal cell carcinoma can be divided into the following types: Clear cell (75%) Chromophilic (15%) Chromophobic (5%) Oncocytoma (3%) Collecting duct (2%)
	Chronic kidney failure^[100]^[101]^[102]^[103]^[104]^[105]	+	-	-	-	+/-	-	-	-	+	+		Elevated creatinine Elevated BUN Decreased GFR	Hyperkalemia	Hypoalbuminuria	Low bicarbonate	To determine renal bone disease, the following may be performed: Serum phosphate 25-hydroxyvitamin D Alkaline phosphatase Parathyroid hormone To determine kidney function, C - cystatin may be measured	May indicate hydronephrosis Retroperitoneal fibrosis Mass Enlarged or shrunken kidneys	May demonstrate nephrolithiasis Retrograde pyelogram may determine obstruction	May determine renal masses, stones, and cysts	Useful in those who are contraindicated for intravenous contrast May determine renal vein thrombosis Magnetic resonance angiography can diagnose renal artery stenosis	Percutaneous renal biopsy is also useful in diagnosis
	Congenital kidney disease^[106]^[107]^[108]^[109]^[110] - Agenesis - Dysplasia - Hypoplasia - Polycystic	+/-	-	-	-	+/-	+/-	-	-	+/-	+/-	Elevated hematocrit	Decreased GFR	Hypocalcemia Hypophosphatemia	Microalbuminuria Uricosuria	-	Genetic testing for ADPKD1 and ADPKD2	Ultrasound is the gold standard for visualization of cysts	More sensitive than ultrasound and can detect small cysts (0.5 cm)	Useful for determining kidney size and progression Magnetic resonance angiography may determine intracranial aneurysms	-	-
	End stage renal disease^[100]^[101]^[102]^[103]^[104]^[105]	+	-	-	-	+/-	-	-	-	+	+		Elevated creatinine Elevated BUN Decreased GFR	Hyperkalemia	Hypoalbuminuria	Low bicarbonate	To determine renal bone disease, the following may be performed: Serum phosphate 25-hydroxyvitamin D Alkaline phosphatase Parathyroid hormone To determine kidney function, C - cystatin may be measured	May indicate hydronephrosis Retroperitoneal fibrosis Mass Enlarged or shrunken kidneys	May demonstrate nephrolithiasis Retrograde pyelogram may determine obstruction	May determine renal masses, stones, and cysts	Useful in those who are contraindicated for intravenous contrast May determine renal vein thrombosis Magnetic resonance angiography can diagnose renal artery stenosis	Percutaneous renal biopsy is also useful in diagnosis
	Endogenous toxins^[111]^[112]^[113]^[114]^[115] - Hemoglobin - Myoglobin - Uric acid	+/-	-	+/-	+	-	+/-	-	-	+/-	+/-	May indicate anemia or thrombocytopenia	Elevated BUN Elevated creatinine Decreased GFR	Hyperkalemia Hypocalcemia due to hyperphosphatemia Hyperuricemia	Uricosuria Hematuria Myoglobinuria Casts Urinary sediment	-	Elevated creatine kinase > 1000 U/L	Ultrasound may determine the following: Malignant or cystic lesions Hydronephrosis Hydroureter Nephrocalcinosis Urolithiasis	-	Spiral CT may determine the following: Urolithiasis Wilms tumor Polycystic kidney disease	-	Voiding cystourethrograms may detect ureter or bladder abnormalities Radionuclide studies may visualize calculi
	Glomerulonephritis^[116]^[117]^[118]^[119]^[120]^[121]^[122]	+/-	-	-	-	-	-	-	-	+	+	Pleocytosis Anemia Leukocytosis	Elevated BUN and creatinine	-	Specific gravity > 1.020 Proteinuria Hematuria Red blood cell casts White blood cells casts Dysmorphic RBCs Acanthocytes Cellular casts Granular casts Oval fat bodies	-	-	Elevated ESR Elevated complement C3, C4, CH50 Streptozyme test to screen for streptococcal antigens Blood and tissue culture may aid diagnosis Other useful tests include: Antinuclear antibodies Anti-DNA antibodies Cryoglobulins Serum albumin Triglyceride levels Hepatitis B and C serologies Antineutrophil cytoplasmic antibody (ANCA)	May determine the following: Kidney size Echogenicity of the renal cortex Obstruction Degree of fibrosis	To exclude the following: Granulomatosis with polyangiitis (Wegener granulomatosis) Goodpasture syndrome Pulmonary congestion	To exclude the following: Granulomatosis with polyangiitis (Wegener granulomatosis) Goodpasture syndrome Pulmonary congestion To visualize visceral abscesses	-	Renal biopsy may aid diagnosis Light and electron microscopy may have specific findings and determine pathology Immunofluorescence may also exhibit diagnostic findings
	Goodpasture syndrome^[123]^[124]^[125]^[126]^[127]^[128]	+/-	-	-	-	-	-	-	+/-	+/-	+/-	Anemia Leukocytosis	Elevated BUN Elevated creatinine	-	Low-grade proteinuria Gross or microscopic hematuria Red blood cell casts	-	Anti– glomerular basement membrane antibody testing is positive by radioimmunoassays or enzyme-linked immunosorbent assays Antineutrophilic cytoplasmic antibody testing is positive for c- or p- ANCA Elevated ESR	-	Bilateral, basal, patchy parenchymal consolidations	-	-	Pulmonary biopsy will demonstrate diffuse alveolar haemorrhage
	Hemolytic uremic syndrome^[129]^[130]^[131]^[132]	+/-	-	+/-	+/-	+/-	+	+	-	+/-	+/-	Severe anemia Thrombocytopenia	Elevated BUN Elevated creatinine	-	Mild proteinuria Red blood cells Red blood cell casts	-	Peripheral blood smear demonstrates schistocytes Prolonged activated partial thromboplastin time Elevated fibrinogen degradation product and D-dimer Elevated bilirubin Elevated lactate dehydrogenase Decreased haptoglobin Stool culture may be postive for E coli 0157:H7 or Shigella ADAMTS-13 activity is severely decreased	Helpful in ruling out obstruction	-	-	-	Renal biopsy may demonstrate the following: Diffuse thickening of the glomerular capillary wall Swelling of endothelial cells Fibrin thrombi
	Nephrolithiasis^[133]^[134]^[135]^[136]^[137]^[138]	-	-	-	-	+/-	+/-	-	-	-	-	Mild leukocytosis	Elevated creatinine Elevated BUN	Hypercalcemia Hyper or hyponatremia Hyper or hypokalemia Hyperuricemia	Gross or microscopic hematuria Red blood cells or white blood cells Pyuria Urinary crystals of calcium oxalate, uric acid, or cystine Hypercalciuria Urinary pH > 7 may indicate an infection with urea-splitting bacteria such as: Proteus Pseudomonas Klebsiella, and may lead to struvite stones Urinary pH < 5 indicates likely formation of uric acid stones	Decreased serum bicarbonate with hypokalemia may indicate renal tubular acidosis	Elevated CRP		Plain or KUB (kidney-ureter-bladder) radiograph may determine stone characteristics such as: Size Shape Composition Location Differentiation between a phlebolith and an obstructing calcific stone Stone movement may also be monitored
	Nephrotic syndrome^[139]^[140]^[141]^[142]^[143]^[144]	+/-	-	-	-	-	+/-	-	-	+	+/-
	Thrombosis^[145]^[146]^[147]^[148]^[149]^[150] - Renal vein - Renal artery	-	-	-	-	+/-	+	-	-	+	+/-
	Transplant rejection^[151]^[152]^[153]^[154]^[155]^[156]	+/-	-	-	-	+	+/-	-	-	+/-	+/-
	Transient dysfunction of the newborn^[71]^[72]^[73]^[74]	+	+/-	+/-	-	-	+/-	-	+/-	+/-	+/-
Classification by etiology	Etiology	Clinical manifestations										Paraclinical findings											Comments
		Symptoms and signs										Lab findings						Imaging
		Fatigue/Lethargy	Thirst	Dizziness/Confusion	Muscle weakness/cramp	Somatic/visceral pain	Vomiting	Diarrhea	Tachypnea	Haematuria/Proteinuria	Edema	CBC	KFT	Electrolytes	Urine analysis	ABG	Other	Ultrasound	X-ray	CT	MRI	Other
Postrenal	Bladder outlet obstruction^[157]^[158]^[159]^[160]^[161]^[162]	+	-	+/-	-	+/-	+/-	-	-	+/-	+/-
	Benign prostatic hyperplasia^[163]^[164]^[165]^[166]^[167]	-	-	-	-	+/-	-	-	-	-	-
	Catheter-related^[168]^[169]^[170]	-	-	+/-	-	+/-	-	-	-	-	-
	Chronic prostatitis^[171]^[172]^[173]^[174]^[175]^[176]	+/-	-	+/-	-	+	-	-	-	+/-	-
	Obstructive uropathy^[177]^[178]^[179]^[180]^[181]	+/-	-	+/-	-	+/-	-	-	-	+/-	-
	Neurogenic bladder^[182]^[183]^[184]^[185]	-	-	-	-	+	+/-	-	-	-	-

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