Nonoliguric versus oliguric acute tubular necrosis
- Orfeas Liangos, MD, FASN
Orfeas Liangos, MD, FASN
- Adjunct Assistant Professor of Medicine
- Tufts University School of Medicine
- Bertrand L Jaber, MD, MS, FASN
Bertrand L Jaber, MD, MS, FASN
- Professor of Medicine
- Tufts University School of Medicine
The glomerular filtration rate (GFR) may fall to very low levels in patients with acute tubular necrosis (ATN). However, a low GFR is not necessarily associated with a parallel reduction in urine output, which can vary from oliguria (<500 mL/day) to normal values (eg, 1 to 2 L/day) [1,2].
Although oliguria is common in patients with ATN, anuria (urine output <50 mL/day) is rare. Anuria is most often seen in two conditions: shock and complete bilateral urinary tract obstruction. Other, less common causes are the hemolytic-uremic syndrome, renal cortical necrosis, bilateral renal arterial obstruction, and rapidly progressive (crescentic) glomerulonephritis, particularly antiglomerular basement membrane (GBM) antibody disease.
DETERMINANTS OF URINE OUTPUT
The difference in urine output between oliguric and nonoliguric ATN may be due to one of two factors: Nonoliguric patients may have a higher glomerular filtration rate (GFR) than those with oliguria, and/or they may reabsorb less in the tubules. If, for example, the GFR falls to 7 L/day (equal to 5 mL/min), the urine output will be relatively normal at 1 to 2 L/day if only 5 to 6 L are reabsorbed.
Declines in urine output may not only be a result of ATN, but also predict its development. This was suggested by a retrospective analysis of 390 patients with septic shock and admitted to an intensive care unit . Oliguria, defined as urine output <0.5 mL/kg per hour and observed within the first 12 hours following recognition of septic shock, was positively associated with the development of acute kidney injury (AKI; defined by a serum creatinine increment according to the Kidney Disease: Improving Global Outcomes [KDIGO] stage II criteria), need for renal replacement therapy (RRT), and 28-day mortality (odds ratio [OR] 1.19, 95% CI 1.10-1.28). In this study, more than five hours of consecutive oliguria predicted subsequent AKI KDIGO stage II or greater with an accuracy of 82 percent .
Studies in animal models have shown that there is less morphologic and functional damage in nonoliguric compared with oliguric acute renal failure (ARF) . There is also evidence in humans suggesting that the absence of oliguria in ATN generally reflects less severe disease [1,5-7]. The following observations from different studies are illustrative:
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