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 = Erythrocyte sedimentation rate, IVP = Intravenous pyelography, 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] + - - - +/- - - - + +
  • Anemia is present
  • 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
  • All types of stones are visible
  • May demonstrate the following:
    • Hydronephrosis
    • Ureteral dilation
    • Abdominal aortic aneurysm
    • Cholelithiasis
  • Safe in pregnancy but may miss small stones
  • Calcium - containing stones are radio-opaque
  • Uric acid or cystine stones are radiolucent
  • Plain or KUB (kidney-ureter-bladder) radiograph may determine stone characteristics such as:
    • Size
    • Shape
    • Composition
    • Location
    • Differentiate between a phlebolith and an obstructing calcific stone
  • Stone movement may also be monitored
  • Most sensitive modality for renal stones
  • Can estimate stone density, size and composition
  • CT is able to determine pathology secondary to renal stones. such as:
    • Ureteral dilation
    • Hydronephrosis
    • Nephromegaly
    • Perinephric fat streaking
  • No contrast needed and can diagnose other pathologies, such as:
    • Abdominal aortic aneurysm
    • Appendicitis
    • Pancreatitis
    • Cholecystitis
    • Ovarian disorders
    • Diverticular disease
    • Renal carcinoma
-
  • Intravenous pyelography (IVP) visualizes entire urinary system and is gold standard for the diagnosis of ureterolithiasis
  • Renal tomography can determine similar findings as CT, however has been largely replaced by CT
  • Nuclear renal scan can determine renal function
Nephrotic syndrome[139][140][141][142][143][144] +/- - - - - +/- - - + +/- -
  • Serum creatinine is normal in uncomplicated nephrotic syndrome
  • Serum albumin is decreased
-
  • Proteinuria > 3.5g/day
  • The following may or may not be present
    • Waxy casts
    • Oval fat bodies
    • Fatty casts
    • Granular casts
    • Microhematuria
    • Dysmorphic RBCs
-
  • Genetic screening for NPHS1 and NPHS2 mutations
  • Renal biopsy aids diagnosis
  • Other useful tests:
    • Hepatitis B and C
    • HIV
    • Syphilis
    • Antinuclear antibody
    • Anti–double stranded DNA antibodies
    • Complement
  • Absence of phospholipase A2 receptor may indicate secondary nephrotic syndrome
  • Ultrasound scanning may demonstrate focal glomerulosclerosis
- - - - -
Thrombosis[145][146][147][148][149][150]

- Renal vein

- Renal artery

- - - - +/- + - - + +/- -
  • Elevated creatinine
  • Elevated BUN
- - -
  • Hypercholesterolemia
  • Hypoalbuminemia
  • Complementemia
  • Ultrasound may demonstrate the following:
    • Echo-poor medullary pyramids
  • Visualizes the renal veins and is the modality of choice
  • Visualizes blood flow, vessel walls, and adjacent tissues
-
  • Renal biopsy, inferior vena cavography, and renal arteriography may aid diagnosis
  • IVP may reveal an enlarged kidney
Transplant rejection[151][152][153][154][155][156] +/- - - - + +/- - - +/- +/-
  • Lymphcytosis may be present
  • Eosinophilia may occur
  • Acute elevation in serum creatinine
- -
  • Proteinuria > 1g/day
  • Pyuria may be present
-
  • Plasma levels of donor-derived cell-free DNA is elevated > 1% and is released from the dead cells of the graft
  • Positive detection of complement split product C4d
  • Elevated endothelial activation and injury transcripts
  • May demonstrate the following
    • Increased graft (kidney) size
    • Loss of corticomedullary boundary
    • Hypoechoic pyramidS
    • Decreased echogenicity of renal sinuses
  • May also demonstrate other pathologies:
    • Ureteral obstruction
    • Acute tubular necrosis
    • Renal vein occlusion
    • Pyelonephritis
    • Cyclosporine toxicity
- -
  • Acute antibody-mediated rejection will demonstrate the following on histology:
    • Patchy mononuclear cell infiltrates
    • Swollen endothelium
    • Fibrinoid necrosis
    • Presence of fibrin thrombi
    • Cortical necrosis
  • Chronic rejection does not usually manifest with oliguria and/or anuria
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 Obstructive uropathy[157][158][159][160][161][162] + - +/- - +/- +/- - - +/- +/-
  • Leukocytosis
  • Anemia may be present in chronic kidney failure
  • Initially, fractional excretion of sodium < 1% then > 1%
  • Elevated creatinine and BUN
  • Initially, hyponatremia then hypernatremia
  • Hypo or hyperkalemia
  • Hypo or hyperchloremia
  • Hypo or hypercalcemia
  • Hypo or hypermagnesemia
  • Hyperuricemia
  • The following may be demonstrated:
    • Microscopic hematuria
    • Pyuria
    • Crystalluria
    • Proteinuria
  • Initially, urine osmolality is elevated then decreased
  • Decreased bicarbonate
  • Ultrasound may detect a dilation within the urinary system without an obstruction, as demonstrated by:
    • Hydronephrosis
    • Chronic massive diuresis
    • Extrarenal pelvis
    • Diverticula
    • Megacalyces
    • Ileal conduits
  • Ultrasound may also detect an obstruction without dilatation, as demonstrated by:
    • Incomplete obstructions
    • Crystals
    • Renal stones
    • Staghorn stone
    • Retroperitoneal obstruction
  • Helical CT is more sensitive than ultrasound and has the ability to detect dilatation and obstruction
  • MRI can demonstrate the following:
    • Renal function with use of contrast
    • Distinguish between calcified and noncalcified calculi
    • Distinguish between acute and chronic obstruction
  • IVP can localize obstructions, however contrast is used and may lead to nephrotxicity
  • ECG can assess effect of hyperkalemia
  • Radionucleotide scanning can accurately detect hyrdronephrosis without the use of contrast
- -
Benign prostatic hyperplasia[163][164][165][166][167] - - - - +/- - - - - -
Catheter-related[168][169][170] - - +/- - +/- - - - - -
Chronic prostatitis[171][172][173][174][175][176] +/- - +/- - + - - - +/- -
Neurogenic bladder[177][178][179][180] - - - - + +/- - - - -

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