Consult Rounds:Acute Anuria

What is your differential diagnosis when you have anuria?

An article in NEJM in the 1990s mentioned that when there is acute renal injury with anuria, obstruction has to be ruled out. Once that is ruled out, acute cortical necrosis or necrotizing glomerular nephritis are the more likely culprits. An editorial in the same issue by Goodkin et al suggested that acute tubular necrosis and vascular complications should be highly considered in the differential diagnosis. The authors replied back suggesting that ATN should rarely present with no urine output and anuria.  Clearly, acute cortical necrosis, obstruction, and renal vein thrombosis( bilateral) in some cases and renal arterial occlusions/tears ( sometimes seen in solitary kidneys and transplant kidneys more) might be causes high on the differential. Severe ATN and AIN have been found to have anuric AKI and perhaps cases of crystalluria as well. PAN as been noted to present such ways as well. Finally, papillary necrosis is another rare finding associated with anuria. 

There is an interesting condition called reflex anuria that occurs following certain surgeries. It is defined as cessation of urine output due to irritation of one or both kidneys due to trauma to painful stimuli leading to vasoconstriction. No obvious obstruction is found but ureteric manipulation was done perhaps in pelvic surgery. Its due to arterial vasospasm and ureteral spasm.

In general, Anuric renal disease: think obstruction; vascular catastrophe and cortical necrosis as the three most likely causes.