Anuria

ANURIA (from Greek a- negative particle, and ouron-urine), complete cessation of urine secretion by the kidneys, may be a consequence of various diseases not only of the kidneys and urinary tract, but also of other organs of the abdominal cavity. Since in this case the pathogenesis of A. is also different, one can distinguish: 1) A. as a result of widespread inflammatory or degenerative lesion of the secretory apparatus of the kidneys; 2) A. as a result of compression of the renal parenchyma that cannot drain urine; 3) A. as a result of a nervous reflex on a healthy kidney from the side of the other, diseased kidney (reno-renal reflex), from the side of the urinary tract undergoing irritation, or finally from the side of irritated peritoneum; 4) A. as a result of even brief compression or obstruction of the renal arteries or renal veins; 5) A. as a result of traumatic injury to the kidneys. The first group of diseases, sometimes accompanied by A., includes acute diffuse glomerulonephritis, severe necrotic nephroses (especially in poisonings), and the terminal stages of chronic nephritis. Here, lesions of the glomeruli play the main role, but to some extent, perhaps, also the obstruction of the renal tubules by cylinders - in acute diseases. The obstruction of renal tubules by cylinders is also attributed to A., observed in severe burns and yellow fever. A., especially in women, is observed in intra-abdominal tumors compressing the ureters. A. in cholera, some authors consider a consequence of the body's depletion of fluid, others - degeneration and desquamation of the renal epithelium, still others - nervous shock. Excretory A. arises due to a mechanical obstacle along the urinary tract. It occurs particularly easily in patients either with a single congenital kidney, or those who have lost a kidney through previous nephrectomy, finally in persons in whom one of the kidneys is destroyed by a deep process and is in a state of inactivity. With two functioning kidneys, the conditions for the onset of excretory anuria are less favorable, and their ureters are usually obstructed at different times. The cessation of outflow can be caused either by an obstacle in the lumen of the ureter itself or by external compression of the ureter. Rubritius collected from the literature 324 cases of excretory A. In 298 cases, the obstacle was found in the lumen of the ureter and only in 26 cases the ureters were compressed from the outside. In 88 cases out of 298, the obstruction was bilateral, in 113 cases the patients had one kidney, in 44 cases the inactivity of the second kidney was proven. The most common cause of excretory A. is stone disease. But obstruction of the ureter lumen can also be caused by blood or pus clots. Among the causes causing compression of the ureters from the outside, uterine cancer, prostate cancer, tumors of the bladder, and finally, rectal cancer are most frequently observed. Excretory A. can occur if during surgical intervention - usually gynecological - both ureters are mistakenly ligated, or, with one kidney, the only available ureter. Excretory A. also occurs as a result of erroneous removal of the only kidney. Obstruction by stones rarely occurs simultaneously on both sides. Usually, outflow ceases first on one side, and after some time suddenly on the other side, with the appearance of a clinical picture of A. The obstruction can occur either at the point where the pelvis transitions into the ureter - by a kidney stone (the stone acts as a valve), or somewhere along the course of the ureter - by a ureteral stone. According to collective statistics by Donnadie, out of 61 cases of excretory A., in 34 cases the stone was in the upper third, in 16 cases - in the lower third, and in 6 cases - in the middle third of the ureter. Obstruction is caused by both single stones and small multiple ones, and finally sometimes even by renal sand. In excretory A. caused not by stones but by other mechanical causes (bladder cancer, uterine cancer, etc.), the symptoms of A. do not appear suddenly, as in calculosis, but develop gradually from a state of previous oliguria. The clinical picture in excretory A. caused by stones is very diverse. Sometimes it is preceded by severe attacks of renal colic, while in other cases A. occurs without any noticeable symptoms, and the patient only notices the absence of urges to urinate. Despite the fact that A. represents the highest stage of functional insufficiency of the kidneys, its forms not associated with acute nephroses or nephritis do not cause severe painful phenomena in the first days. Only on the 5th-6th day or later do the first precursors of uremia appear, consisting in physical and mental depression, indifference and drowsiness, which quickly pass into clearly expressed uremia of the chronic azotemia type (see Uremia), and only very rarely - into eclamptic. Another feature of these A. is the late appearance of slight edema. Both of these features are of great importance for the theory of kidney diseases. Reflex anuria often develops. Kümmel distinguishes reflex A. - peripheral and renal. In peripheral reflex A., both kidneys cease their secretory activity under the influence of peripheral irritations. Reflex A. has been described after falling into cold water, after instillations of a solution of lunar caustic into the neck of the bladder, after lithotripsy, after sounding the urethra, after catheterization of the ureters, after rapid emptying of the distended bladder by a catheter, in injuries to the abdominal area, after laparotomy. Reflex renal A. is called such a condition when a healthy kidney suddenly stops functioning after the activity of the diseased kidney ceases due to obstruction of the ureter by a stone. Most authors explain this form of reflex A. by the reno-renal reflex. Some authors, however, including Fedorov and Legueu, completely deny the possibility of the existence of the renal form of reflex A. In such cases, in their opinion, the kidney, supposedly reflexively ceasing its function, was previously deeply affected by some pathological process and was functioning poorly. The reno-renal reflex is explained by the presence of a direct anatomical connection between the nerve plexuses of the splanchnici of both kidneys, or arises by a circular path through the ganglia coeliaca. The reflex transmitted to the healthy kidney causes spastic contraction of the renal vessels and cessation of the excretory function of the kidney. Neu-wirth succeeded in one case to stop reflex A. by means of anesthesia of the splanchnici according to Kappis, by interrupting the reflex arc. In A., it is first necessary to determine its nature. Secretory A. can be easily excluded on the basis of the history and previous course. It is difficult to differentiate excretory and reflex A. and it can only be done by instrumental (cystoscopy and catheterization of the ureters) and X-ray examinations. These methods make it possible, first, to determine the aplasia of one kidney, and second, to determine the cause of A. and the location of the obstacle. By introducing a ureteral catheter, it is possible to establish the presence and location of the obstacle. In A. caused by stones, it is essential to determine on which side the obstruction occurred later. The data from the history, palpation (enlarged and painful kidney, tension of the abdominal wall, etc.) and cystoscopy (edematous orifice) help in some cases to answer this question. The prognosis and treatment of A. are determined by the underlying disease. In the treatment of reflex A., it is necessary to eliminate the cause that caused A. on the diseased side. In addition, one can apply paravertebral anesthesia according to Kappis and try intravenous injection of 0.24 Euphyllin. Haim observed in one case of reflex A. favorable results with the use of the latter method. Measures to restore patency should be, first of all, directed to the side where the obstacle arose later. The degree of activity of intervention depends on the condition of the patient. In the period of endurance, attempts at instrumental transvesical treatment are permissible. In the period of intoxication, measures should be more accelerated and decisive. If the stone is visible during cystoscopy protruding into the ureteral orifice, it can be removed or displaced either with the end of a ureteral catheter or with special grasping instruments. If the stone is located higher, an attempt is made to displace it or to pass a ureteral catheter past it. Often these manipulations are sufficient to restore the patency of the ureter. If endovesical methods remain ineffective, it is necessary to resort to surgical treatment. Under these circumstances, it is extremely important to determine which side should be operated on first. Most authors advise operating on the side where the obstruction occurred later and where one can assume lesser changes in the renal parenchyma. Fedorov advises operating on both sides simultaneously, since it appears very difficult to decide on the degree of damage to the function of each kidney separately and on the time of their obstruction. The earlier the operation is performed, the more favorable the results.

According to statistical data by Legueu, mortality from operations performed within the first 5 days from the onset of excretory A. is 22%, and after 5 days - 40%. In view of the impairment of renal function and weakening of cardiac activity in these patients, extreme caution is necessary during anesthesia. Chloroform should especially be avoided. Local anesthesia is preferable. The nature of the surgical intervention in excretory A. depends, further, on the cause of the obstruction (stone, tumor compressing the ureter, etc.) and its location. If the stone is located in the ureter, in an easily accessible part of it, it is necessary to perform ureterolithotomy. With the stone located in the pelvis - pyelotomy. In A. caused by compression of the ureters by a tumor located in the pelvic cavity (cancer of the bladder, uterus, etc.), it is best to perform ureterostomy for the purpose of diverting urine above the point of obstruction. If, finally, it is not possible to determine the cause and location of the obstruction or the patient is in a serious condition, it is necessary to perform nephrostomy. To improve the patient's subjective condition, morphine or warm baths are prescribed. Diuretics should not be given in any case. In traumatic kidney injuries accompanied by A., surgical intervention is necessary. Lit.: Fedorov S.P., Surgery of the Kidneys and Ureters, M.-L., 1925; Israel J. u. W., Chirurgie der Niere und des Harnleiters. Lpz., 1925; Legueu F., Encyclopedie francaise d'urologie, v. II, P., 1914; Rubritius H., Die reflekt. Anurie. Verhandlungen der Deutschen Gesellschaft fur Urologie, VII Kongress in Wien, Lpz., 1927.