Sandbox : anmol

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

Differential Oliguria

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	Blood indices	Renal Funtion test	Electrolytes	Urine analysis	ABG	Other	Ultrasound	X-ray	CT	MRI	Other
Prerenal	Myocarditis	+/-	-	-	-	+/-	-	-	+/-	-	-	Leukocytosis may be with eosinophilia Elevated ESR and CRP	N/A	N/A	N/A	N/A	Screening for rheumatic origin of disease Cardiac enzymes to rule out infraction Serum viral antibodies to rule out viral myocarditis	N/A	N/A	N/A	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 assessment of cardiac dysfunction Scintigraphy is useful for detecting myocardial inflammation ECG is non-specific	N/A
	Peritonitis	+/-	-	+/-	-	+/-	+/-	+/-	-	-	-	N/A	N/A	N/A	N/A	N/A	Peritoneal fluid analysis demonstrates ascitic fluid neutrophil count > 500 cells/µL	N/A	N/A	N/A	N/A	N/A	N/A
	Polycythemia	+/-	-	-	-	-	-	-	+/-	-	-	Elevated hematocrit , hemoglobin, total red blood cell mass Thrombocytosis Leukocytosis with predominant neutrophils Leukocyte alkaline phosphatase >100 U/L Serum vitamin B-12 concentration >900 pg/mL Hyperuricemia may be present PT and aPTT may be prolonged	Decreased erythropoietin	N/A	Oxygen saturation ≥ 92%	N/A	May demonstrate splenomegaly	May demonstrate splenomegaly	N/A	N/A	N/A	JAK2 mutation Bone marrow biopsy demonstrates: Hypercellularity with hyperplasia of the erythroid, granulocytic, and megakaryocytic cell lines Myelofibrosis may be present	Phlebotomy is the usual form of treatment
	Respiratory distress syndrome	+	-	+/-	-	-	-	-	+	-	-	N/A	N/A	N/A	N/A	Metabolic and respiratory acidosis may occur with hypoxia	Pulse oximetry is useful in diagnosis	N/A	Demonstrates the following: Bilateral, diffuse, reticular granular or ground-glass appearance Poor lung expansion +/- Cardiomegaly Streaky opacities may indicate pneumonia	N/A	N/A	Echocardiography is useful in diagnosing patent ductus arteriosus	N/A
	Shock - Anaphylactic - Cardiogenic - Hypotensive - Septic - Toxic	+/-	+/-	+/-	+/-	+/-	+/-	-	+/-	+/-	-	Hypovolemic shock: Elevated hemotocrit Hemorrhagic shock: Anemia and/or thrombocytopenia Prolonged PT and aPTT Anaphylactic shock: Elevated eosinophils Septic shock: Elevated leukocytes Undifferentiated shock: A low white count with bandemia	Elevated BUN and creatinine Decreased GFR	Hypernatremia or hyponatremia Hypokalemia or hyperkalemia Hypochloremia	N/A	Elevated serum lactate	Elevated liver transaminases In cardiogenic shock: Elevated troponin I or troponin T levels Elevated creatine phosphokinase Elevated BNP, or NT-proBNP DIC may occur as a complication, and is determined through elevated fibrin split products and D-dimer level with low fibrinogen level	RUSH (Rapid Ultrasound for Shock and Hypotension) 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 Intestinal obstruction Bowel perforation	Can determine etiology of shock, such as: Traumatic brain injury Stroke Spinal injury Pneumonia Pneumothorax Ruptured aneurysm Aortic dissection Intestinal obstruction Bowel perforation Abscess Pulmonary embolism	N/A	N/A	N/A
	Toxic megacolon	+/-	+/-	+/-	-	+	+	+/-	-	-	-	Leukocytosis with left shift Anemia (if diarrhea is present)	Creatinine and BUN may be elevated	N/A	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	N/A	N/A	Endoscopy and colonoscopy can aid diagnosis	N/A
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	+/-	-	+/-	-	+/-	+/-	+/-	+/-	+/-	+/-	Eosinophilia may be present	Elevated creatinine High fractional sodium excretion	N/A	Eosinophiluria Sterile pyuria Microscopic hematuria Proteinuria Red cell or white cell casts	N/A	Patients with immunoglobulin G4 - related disease may have elevated serum total IgG and/or IgG4 levels	Ultrasound demonstrates normal-sized kidneys	N/A	N/A	N/A	N/A	History of long term analgesic use is common
	Acute tubular necrosis	+/-	-	-	-	-	+/-	-	-	+/-	+/-	Anemia	Elevated creatinine Elevated BUN Elevated fractional excretion of sodium	Hyponatremia Hyperkalemia Hypermagnesemia Hypocalcemia Hyperphosphatemia	Pigmented, muddy brown, granular casts	N/A	N/A	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 - 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	N/A	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	+	-	-	-	+/-	-	-	-	+	+	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	N/A
	Congenital kidney disease - Agenesis - Dysplasia - Hypoplasia - Polycystic	+/-	-	-	-	+/-	+/-	-	-	+/-	+/-	Elevated hematocrit	Decreased GFR	Hypocalcemia Hypophosphatemia	Microalbuminuria Uricosuria	N/A	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	N/A	N/A	N/A
	End stage renal disease	+	-	-	-	+/-	-	-	-	+	+	N/A	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	N/A
	Endogenous toxins - 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	N/A	Elevated creatine kinase > 1000 U/L	Ultrasound may determine the following: Malignant or cystic lesions Hydronephrosis Hydroureter Nephrocalcinosis Urolithiasis	N/A	Spiral CT may determine the following: Urolithiasis Wilms tumor Polycystic kidney disease	N/A	Voiding cystourethrograms may detect ureter or bladder abnormalities Radionuclide studies may visualize calculi	N/A
	Glomerulonephritis	+/-	-	-	-	-	-	-	-	+	+	Pleocytosis Anemia Leukocytosis	Elevated BUN and creatinine	N/A	Specific gravity > 1.020 Proteinuria Hematuria Red blood cell casts White blood cell casts Dysmorphic RBCs Acanthocytes Cellular casts Granular casts Oval fat bodies	N/A	N/A	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	N/A	Renal biopsy may aid diagnosis Light and electron microscopy may have specific findings and determine pathology Immunofluorescence may also exhibit diagnostic findings
	Goodpasture syndrome	+/-	-	-	-	-	-	-	+/-	+/-	+/-	Anemia Leukocytosis	Elevated BUN Elevated creatinine	N/A	Low-grade proteinuria Gross or microscopic hematuria [[Red blood cell] casts	N/A	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	N/A	Bilateral, basal, patchy parenchymal consolidations	N/A	N/A	Pulmonary biopsy will demonstrate diffuse alveolar hemorrhage	N/A
	Hemolytic uremic syndrome	+/-	-	+/-	+/-	+/-	+	+	-	+/-	+/-	Severe anemia Thrombocytopenia	Elevated BUN Elevated creatinine	N/A	Mild proteinuria Red blood cells Red blood cell casts	N/A	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	N/A	N/A	N/A	Renal biopsy may demonstrate the following: Diffuse thickening of the glomerular capillary wall Swelling of endothelial cells Fibrin thrombi	N/A
	Nephrolithiasis	-	-	-	-	+/-	+/-	-	-	-	-	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 cell carcinoma	N/A	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	N/A