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Oliguria and Fluid Management
ὀλίγος-uria
• Greek prefix “few, little, scanty”
• Two definitions:– Urine output less than 400 cc/day or urine
output or urine output less than 16.6 cc/hr (1) – less than 0.5 cc/kg/hr (2)
• One of the criteria in Acute Kidney Injury
1) Klahr S, MillSB. Acute oliguria. N Engl J Med 1998;338: 671-675
© 2008 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Published by Lippincott Williams & Wilkins, Inc.
2
Figure 1.Acute kidney injury.Kellum, John; MD, FCCM
Critical Care Medicine. Acute Kidney Injury in the ICU. 36(4) Suppl:S141-S145, April 2008.DOI: 10.1097/CCM.0b013e318168c4a4
Figure 1. RIFLE criteria for acute kidney injury. GFR, glomerular filtration rate; UO, urine output; dec, decrease; ARF, acute renal failure; ESRD, end-stage renal disease. Used with permission from Bellomo et al (20). *GFR changes are shown for general reference only. The criteria fulfilled by changes in serum creatinine relative to baseline.
Epidemiology
• ARF occurs in approximately 5-8% of hospitalized patients.
• 15-30% of patients admitted to the ICU
• Mortality in ICU patients as high as 60%.
ICU admissions(excluding ESRD)
576
No AKI on admission330
(57.3% of all ICU patients)
Never develop AKI197
(34.2% of all ICU patients)
Ever AKI379
(65.8% of all ICU patients)
AKI on admission246
(42.7% of all ICU patients)
New AKI133
(40.3% of patients withoutAKI on admission)
Partial renalrecovery*
51(13.5% of AKI patients)
Complete renalrecovery*
225(59.4% of AKI patients)
No renal recovery*103
(27.2% of AKI patients)
Garzotto, F, Pasquale P, RIFLE-Based Data Collection/Management System Applied to a Prospective Cohort Multicenter Italian Study on the Epidemiology of Acute Kidney Injury in the Intensive Care Unit. 2011
Oliguria
• A clinical manifestation of:– “perfect” organ function– Kidney injury– Distal obstruction
Oliguria
• Causes of oliguria separated into 3 categories– Prerenal– Renal– Postrenal
Aetiology of acute renal failure.
Fry A C , Farrington K Postgrad Med J 2006;82:106-116
©2006 by The Fellowship of Postgraduate Medicine
Prerenal Oliguria
“Lack of urine output in the acutely hypovolemic patient is renal success, not renal failure” – Ronald Maier
- The dysfunction is systemic.
- Prolonged renal success can eventually lead to renal failure.
- Responsible for 30-40% of cases of oliguria in the ICU
Oliguria
• Pre-renal conditions– Hypovolemia– Mechanical ventilation– Aortic Stenosis– End-Stage Cardiomyopathy– Drugs that impair auto-regulation
• NSAIDS (ketorolac), ACE-I, ARBs
Pre-renal Oliguria
• Treatment– Treat the underlying cause.
• Prolonged or severe pre-renal conditions can lead to renal injury and oliguric failure.
Renal injury
• Less common than pre-renal ARF
• Three locations of injury:– Glomerulus – Tubules– interstitium