0022-53{'i/78/ 1202-022'7$02. Q0/0

Vol. :;_20,

1}:aE JoURNA:. CF UROLOGY

Copy1:ight © 1978 b:y The VVilliams & Wilkins Co

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ANDRIA IN INF ANTS AND CHILDREN STEPHEN R. SHAPIRO,* MICHAEL L. STRATTON

AND

RAYMOND D. ADELMAN

From the Departments of Urology and Pediatrics, University of California, Davis, California

ABSTRACT

The urologist may be involved in the initial evaluation of a child with anuria. In our experience the most common cause of anuria in neonates was perinatal hypoxia and in older children it was the hemolytic uremic syndrome. Obstructive uropathy as a cause of anuria in infants and children appears to be uncommon. It has been stated in the urological literature that the most common cause of anuria is an obstructive uropathy or a vascular accident, 1 In 38 cases of anuria in infants and children seen at our hospital during a IO-year period obstruction was uncommon. Based on this experience and a review of the literature recommendations for an approach to the anuric child are described, MATERIALS AND RESULTS

Anuria was defined as the total absence of urine output, All cases of anuria in the newborn intensive care unit from 1966 to 1976 were reviewed, Perinatal hypoxia was the most common cause (58 per cent), There were 3 cases of bilateral renal agenesis and 4 cases of sepsis (table l), All cases of anuria beyond infancy from 1973 to 1976 also were reviewed, The hemolytic uremic syndrome was the most common cause of anuria in this age group (table 2), Only 3 of the 38 cases of anuria in children at all ages had obstruction of the urinary system,

TABLE l,

Cause Perinatal hypoxia (premature in 9) ~~

No, Pts, 14 4

Unknown source, 1 Omphalitis, 1 Empyema, 1 Meningitis, 1 Bilateral renal agenesis, hypoplastic lungs and neonatal asphyxia Hypovolemia secondary to intracranial hemorrhage Urinary tract obstruction: Posterior urethral valves with neonatal ascites, 1 Bilateral hydronephrosis, pulmonary hypoplasia and pneumothorax, 1 Delayed initial voiding Infantile polycystic kidneys Cortical and medullary necrosis Total

TABLE

3

1

2

1 1 27

2, Anuria in childhood (1973 to 1976) Cause

DISCUSSION

Perinatal hypoxia was the most common cause of anuria in the neonatal series, Although this association has been recognized by others 2- 5 the pathophysiology is not entirely clear, 6 There were 3 cases of bilateral renal agenesis with hypoplastic lungs, a predictable association since the presence of amniotic fluid (derived from the fetal kidneys) is presumed necessary for the normal development of the fetal lungs, 7-n Urinary tract obstruction was not common, There was 1 case of posterior urethral valves with neonatal ascites and 1 infant with severe bilateral hydronephrosis. Other rare causes of neonatal anuria, such as urogenital sinus outlet obstruction, 10 were not seen in this series, Delayed initial voiding in the normal newborn can be confused with bona fide anuria, 1;, 12 Sherry and Kramer recorded the time of initial voiding in 500 normal-term infants and found that 3 voided after 48 hours oflife, 13 The cause of anuria in seriously ill infants is often apparent. Dehydration, hypotension, hypoxia and sepsis require prompt medical management. With unexplained anuria the bladder should be catheterized with a No, 5 pediatric feeding tube, An excretory urogram should be obtained with delayed films because of the decreased glomerular filtration rate in infants, A voiding cystourethrogram may be necessary to rule out posterior urethral valves, When visualization is poor the renal scan and/or ultrasonography may be used to rule out an obstructive uropathy, Inferior venacavography may be indicated if bilateral renal vein thrombosis is suspected, The retrograde pyelogram will only be required rarely,

Anuria in the neonatal period (1966 to 1976)

Hemolytic uremic syndrome Ruptured bladder Crush syndrome Hypotension secondary to trauma Urinary obstruction secondary to lymphoma Total

No. Pts, 7 l 1 1 1 11

Beyond the neonatal period the most common cause for anuria in our patients was the hemolytic uremic syndrome. The syndrome consists of a viral-like prodromal illness followed by acute renal failure, thrombocytopenia and a typically abnormal blood smear with fragmented erythror,ytes. 14 It is endemic in California, Other causes for anuria may predominate in other parts of the country, No cases of anuria owing to acute glomerulonephritis were seen during the study, Case reports of obstructive anuria in children in the English literature have included trauma (blood clot obstructing a solitary kidney 15 and bilateral ureteropelvic junction avulsionrn), calculi (stones obstructing a solitary kidney 17 and bilateral obstructive cystine stones 18), fecal impaction with urinary retention 19 and ureteropelvic obstruction in a solitary kidney, In our series only 1 older child had obstruction, which was owing to a retroperitoneal lymphoma with extrinsic compression of the ureters, In summary, obstruction was an uncommon etiology in 38 infants and children with anuria seen at our institution, REFERENCES

L Giangiacomo, J.: Unilateral renal agenesis presenting as anuria. J, UroL, 116: 790, 1976, 2, Drago, J, R., Rohner, T, J,, Jr,, Sanford, E, J, and Maisels, M, J,: Perinatal asphyxia and renal failure in neonatal patients, J, UroL, 118: 80, 1977.

Accepted for publication October 21, ,1977, , , , Read at annual meeting of American Urological Association, Chicago, Illinois, April 24-28, 1977. , , * Requests for reprints: 4301 X St,, Smte 249, Sacramento, California 95817, 227

228

SHAPIRO, STRATTON AND ADELMAN

3. Dauber, I. M., Krauss, A. N., Symchych, P. S. and Auld, P.A. M.: Renal failure following perinatal anoxia. J. Pediat., 88: 851, 1976. 4. Guignard, J. P., Torrado, A., Mazouni, S. M. and Gentier, E.: Renal function in respiratory distress syndrome. J. Pediat., 88: 845, 1976. 5. Reimold, E. W., Don, T. D. and Worthen, H. G.: Renal failure during the first year of life. Pediatrics (neonatology supplement, part 2), 59: 987, 1977. 6. Kwittken, J. and Reiner, L.: Acute tubular nephrosis in the newborn infant, a manifestation of anoxia. Pediatrics, 33: 380, 1964. 7. Perlman, M. and Levin, M.: Fetalpulmonaryhypoplasia, anuria and oligohydramnios: clinicopathologic observations and review of the literature. Amer. J. Obst. Gynec., 118: 1119, 1974. 8. Renert, W. A., Berdon, W. E., Baker, D. H. and Rose, J. S.: Obstructive urologic malformations of the fetus and infantrelation to neonatal pneumomediastinum and pneumothorax (air-block). Radiology, 105: 97, 1972. 9. Bashour, B. N. and Balfe, J. W.: Urinary tract anomalies in neonates with spontaneous pneumothorax and/or pneumomediastinum. Pediatrics (neonatology supplement, part 2), 59: 1048, 1977.

10. Tank, E. S., Konnak, J. W. and Lapides, J.: Urogenital sinus outlet obstruction. J. Urol., 104: 769, 1970. 11. Thomson, J.: Observations on the urine of the newborn infant. Arch. Dis. Child., 19: 169, 1944. 12. Moore, E. S. and Galvez, M. B.: Delayed micturition in the newborn period. J. Pediat., 80: 867, 1972. 13. Sherry, S. N. and Kramer, I.: The time of passage of the first stool and first urine by the newborn infant. J. Pediat., 46: 158, 1955. 14. Stratton, M. L., Adelman, R. D. and Shapiro, S. R.: Nonobstructive anuria in children: hemolytic uremic syndrome. Urology, 9: 256, 1977. 15. Simpson, A. and Ashby, E. C.: Anuria due to ureteric obstruction by blood clot. Brit. J. Urol., 38: 177, 1966. 16. Boston, V. E. and Smyth, B. T.: Bilateral pelvi-ureteric avulsion following closed trauma. Brit. J. Urol., 47: 149, 1975. 17. Selzer, G.: Anuria in a 30-month-old child. Israel J. Med. Sci., 10: 1567, 1974. 18. Farr, M. J., Newling, D. W. W., Eldrissy, A. H., Mirghani, G. A. and Pugh, R. J.: Anuria due to cystine stones in a baby. Brit. Med. J., 1: 562, 1976. 19. Gallo, D. and Presman, D.: Urinary retention due to fecal impaction in children. Pediatrics, 45: 292, 1970.

Anuria in infants and children.

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