How to manage a patient with anuria?

Management of Anuria

Stop furosemide immediately if the patient is anuric, as it is pharmacologically inert without tubular function and is contraindicated by the FDA. 1, 2

Immediate Assessment and Urgent Interventions

Rule Out Obstructive Causes First

• In cases of obstructive anuria with sepsis, perform urgent decompression via percutaneous nephrostomy or ureteral stenting immediately. 3
• Obtain urine cultures before and after decompression, start empiric antibiotics immediately, and adjust based on antibiogram results. 3
• Delay definitive stone treatment until sepsis resolves. 3
• Consider renal imaging (ultrasound, CT) and arteriography if bilateral renal artery occlusion is suspected, particularly in patients with sudden-onset anuria and vascular risk factors. 4

Assess Volume Status and Hemodynamics

• Determine if anuria is due to hypovolemia versus established acute kidney injury (AKI). 3
• In hypovolemic patients (prolonged capillary refill, tachycardia, hypotension), initiate rapid volume expansion with crystalloids (normal saline or balanced solutions without potassium). 3
• In disaster/crush injury settings with anuria, adopt a conservative fluid approach as these patients likely have established AKI; aggressive fluids will cause hypervolemia requiring dialysis. 3
• Avoid potassium-containing fluids (Lactated Ringer's, Hartmann's) in crush syndrome or rhabdomyolysis due to risk of life-threatening hyperkalemia. 3

Medication Management

Discontinue Nephrotoxic and Ineffective Agents

• Furosemide must be stopped in anuria as it cannot be secreted into tubules and provides no benefit. 3, 1, 2
• Stop diuretics if serum sodium drops below 125 mmol/L or if serum creatinine is elevated (>150 mmol/L or rising). 3
• In congenital nephrotic syndrome with anuria, furosemide must be discontinued. 3

Avoid Harmful Interventions

• Do not use starch-based fluids, which increase AKI risk and bleeding. 3
• Mannitol offers no proven benefit over crystalloid resuscitation and may be nephrotoxic. 3
• Avoid unnecessary bicarbonate administration, which can worsen hypocalcemia in crush injury. 3

Renal Replacement Therapy Considerations

Indications for Urgent Dialysis

• Initiate renal replacement therapy (RRT) for anuric AKI with uremia, hyperkalemia, metabolic acidosis, or volume overload refractory to conservative management. 5
• Anuric AKI is associated with higher mortality, more frequent need for continuous RRT, and multi-organ dysfunction compared to non-anuric AKI. 5
• In septic or postoperative anuric AKI (the most common causes), early RRT consideration is critical. 5

Dialysis Prescription in Chronic Anuria

• For anuric peritoneal dialysis patients, maintain minimum weekly peritoneal Kt/V ≥1.7. 3, 6
• Measure small solute clearance within the first month of anuria onset, then at least every 4 months. 3, 6
• Peritoneal Kt/V below 1.5 is associated with significantly increased mortality (RR 3.28). 3
• For hemodialysis patients, adjust ultrafiltration targets and consider increasing dialysis frequency for volume management. 1

Specific Clinical Scenarios

Cirrhosis with Ascites and Anuria

• In hypovolemic hyponatremia during diuretic therapy, discontinue diuretics and expand plasma volume with normal saline. 3
• Reserve fluid restriction (1-1.5 L/day) only for clinically hypervolemic patients with severe hyponatremia (<125 mmol/L). 3
• For serum sodium <120 mmol/L, stop diuretics and consider volume expansion with colloid or saline, but avoid increasing sodium by >12 mmol/L per 24 hours. 3

Congenital Nephrotic Syndrome

• Use albumin infusions based on clinical hypovolemia indicators (oliguria/anuria, prolonged capillary refill, tachycardia, hypotension), not serum albumin levels alone. 3
• Avoid central venous lines when possible due to thrombosis risk; if necessary, provide prophylactic anticoagulation. 3

Hyperammonemia in Neonates

• In anuric neonates with hyperammonemia, continuous venovenous hemodialysis (CVVHD) or hybrid therapy (hemodialysis followed by CVVHD) achieves faster ammonia reduction than peritoneal dialysis. 3

Dietary and Supportive Management

Sodium and Fluid Restriction

• Implement strict dietary sodium restriction (<2-3 g/day) to minimize interdialytic weight gain in chronic anuric dialysis patients. 1
• Fluid restriction is the primary intervention for hyponatremia in anuric dialysis patients, as diuretics cannot induce diuresis. 1

Common Pitfalls to Avoid

• Never continue furosemide in anuric patients expecting a diuretic response—it is contraindicated and wastes time while potentially delaying appropriate interventions. 1, 2
• Do not assume all anuria is irreversible; in neonates and ELBW infants, diuresis recovery can take 50+ days even with prolonged anuria. 7, 8
• Avoid aggressive fluid resuscitation in established anuric AKI (>48-72 hours post-insult), as this causes volume overload without restoring kidney function. 3
• Do not overlook bilateral renal artery occlusion in patients with sudden anuria and vascular disease—early revascularization (within days) can restore function. 4