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, BUN = Blood urea nitrogen, 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

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 - - - - - - -
Aspergillosis[7][8][9] +/- - - - - - - +/- - - - - - - - -
  • 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
- -
Cholera[10][11][11][12] +/- + - - - +/- + - - - -
  • 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] + - - - - - + - - - - -
Dehydration[19][20][21][22]

- Burns

-Cutaneous loss e.g. sweating

- Inadequate water intake

- Salt-wasting nephropathy

+ + - +/- - +/- +/- - - - -
  • Ketones and glucose] may be detected
  • Urine specific gravity is elevated
- - - - -
Diarrhea and/or vomiting[23][24][25][26] +/- +/- - - - + + - - - -
  • Stool anion gap should be calculated
-
  • 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

+/- +/- +/- +/- +/- +/- +/- +/- +/- +/- -
  • 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
- -
Esophageal varices bleeding[31][32] +/- - - - +/- - - - - - - - - -
  • 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
Heart disease[33][34][35]

-Congenital

-Acquired

+/- - - - - - - +/- - +/- - - -
  • 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
- -
  • History and physical examination (auscultation of the heart) are important for diagnosis
Hemorrhage[36][37][38][39] - - - - - - - - - - - - -
  • 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] +/- - - - - - - - +/- - - - - - - - - -
Hepatorenal syndrome[44][45][46][47] +/- - - - +/- +/- - - +/- +/- -
  • Abdominal ultrasound 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] +/- - - - - - - +/- - +/- - - -
  • May detect abnormal cardiac silhouette
  • MRI with gadolinium–diethylene-triamine pentaacetic acid (DTPA) can evaluate mid-wall fibrosis
Liver cirrhosis[52][53][54] +/- - +/- +/- +/- - - - - +/- - - - - -
Malignant hypertension[55][56] +/- - + - - +/- - +/- - +/- - - -
  • Electrocardiography may indicate the following:
    • Ischemia
    • Infarct
    • Evidence of electrolyte abnormalities or drug overdose
  • Echocardiography may indicate the following:
Myocarditis[57][58][59][60] +/- - - - +/- - - +/- - - - - - - - - -
  • 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:
Peritonitis[61][62] +/- - +/- - +/- +/- +/- - - - - - - - -
  • Peritoneal fluid analysis is the most important component of diagnosis and demonstrates the following:
- - - - -
Perinatal asphyxia[63][64][65] +/- - +/- - - +/- - +/- - - - -
  • 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
- -
  • Acute brain injury may be seen on MRI
  • ECG may demonstrate ischemia with changes in the ST segment
  • Echocardiography may demonstrate the following:
Polycythemia[66][67][68][69][70] +/- - - - - - - +/- - - -
  • Oxygen saturation ≥ 92%
- - - -
Respiratory distress syndrome[71][72][73][74] + - +/- - - - - + - - - - - -
  • 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
- -
Shock[75][76][77][78]

- Anaphylactic

- Cardiogenic

- Hypotensive

- Septic

- Toxic

+/- +/- +/- +/- +/- +/- - +/- +/- - - - -
Third space losses[79][80][81]

- Capillary leak

- Surgery

- Trauma

+/- +/- +/- +/- +/- +/- - +/- +/- -
  • 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] +/- +/- +/- - + + +/- - - - -
  • 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:
- -
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] +/- - +/- - +/- +/- +/- +/- +/- +/- - -
  • Patients with immunoglobulin G4 - related disease may have elevated serum total IgG and/or IgG4 levels
  • Ultrasound will show normal-sized kidneys
- - - -
Acute tubular necrosis[90][91][92][93][94] +/- - - - - +/- - - +/- +/-
  • Pigmented, muddy brown, granular casts
- -
  • 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
Cancer[95][96][97][98][99]

- Renal cell carcinoma

- Metastatic cancer

+ - - - +/- +/- - - + +/- -
  • Ultrasound can detect fluid collection and morphologic change
  • Flank mass
  • 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] + - - - +/- - - - + +
  • May demonstrate nephrolithiasis
  • Retrograde pyelogram may determine obstruction
  • May determine renal masses, stones, and cysts
  • Percutaneous renal biopsy is also useful in diagnosis
Congenital kidney disease[106][107][108][109][110]

- Agenesis

- Dysplasia

- Hypoplasia

- Polycystic

+/- - - - +/- +/- - - +/- +/-
  • Decreased GFR
-
  • 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] + - - - +/- - - - + +
  • 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

+/- - +/- + - +/- - - +/- +/- - - -
  • Voiding cystourethrograms may detect ureter or bladder abnormalities
  • Radionuclide studies may visualize calculi
Glomerulonephritis[116][117][118][119][120][121][122] +/- - - - - - - - + + - - -
  • May determine the following:
    • Kidney size
    • Echogenicity of the renal cortex
    • Obstruction
    • Degree of fibrosis
-
  • 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] +/- - - - - - - +/- +/- +/- - - -
  • Bilateral, basal, patchy parenchymal consolidations
- -
Hemolytic uremic syndrome[129][130][131][132] +/- - +/- +/- +/- + + - +/- +/- - -
  • 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] - - - - +/- +/- - - - -
  • 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
-
  • 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] +/- - - - - +/- - - + +/- - - -
  • Ultrasound scanning may demonstrate focal glomerulosclerosis
- - - - -
Thrombosis[145][146][147][148][149][150]

- Renal vein

- Renal artery

- - - - +/- + - - + +/- - - - -
  • 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] +/- - - - + +/- - - +/- +/- - - -
  • 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:
- -
  • Acute antibody-mediated rejection will demonstrate the following on histology:
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] + - +/- - +/- +/- - - +/- +/-
  • 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] - - - - +/- - - - - -
  • In chronic renal insufficiency with high post-void residual volume, the following may be noted:
- -
  • Urine culture is recommended to rule out infection
  • Prostate-specific antigen may elevated in those with prostate cancer
- - -
Catheter-related[168][169][170] - - +/- - +/- - - - - - - - - - - - -
  • CT can be the initial investigation performed
  • In addition to CT, and MRI may be carried out in order to determine the incidence of pelvic fractures
  • Retrograde urethrography is the imaging modality of choice for urethral injuries
  • Static cystography can aid diagnosis of bladder injury
  • Cystoscopy] is helpful in male urethral injury
Chronic prostatitis[171][172][173][174][175][176] +/- - +/- - + - - - +/- - - - - -
  • Expressed prostatic secretion demonstrate 10-fold increase in bacteria
  • Semen and blood culture may also detect bacterial presence > 100,000 colony - forming units
  • The following tests are useful to rule out other eitologies:
  • Prostate biopsy is definitive for diagnosis and may demonstrate leukocytic infiltration in the stroma of the prostate
  • Transrectal ultrasound may demonstrate:
- - -
  • Retrograde urethrography can confirm urethral stricture
  • Uroflowmetry asesses urodynamics
  • Postvoid residual testing determines the volume of urine left after voidance
  • Cystoscopy is used to rule out the following:
Neurogenic bladder[177][178][179][180] - - - - + +/- - - - - - - - - - - - -
  • Other investigations for neurogenic bladder include:
    • Postvoid residual bladder volume
      • Useful in urinary incontinence
      • Evaluates bladder contractility
    • Uroflow rate
      • Low uroflow rate may indicate urethral obstruction
    • Filling cystometrogram
    • Voiding cystometrogram
      • Assesses pressure within the bladder
    • Cystogram
      • May indicate stress incontinence
      • May also evaluate urethral motion and the presence of a cystocele
    • Electromyography
      • Evaluates uncoordinated voidance, also known as detrusor sphincter dyssynergia
    • Cystoscopy
      • For diagnosis of bladder lesions
    • Videourodynamics

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