A 73-year-old man comes to the clinic with 6 weeks of worsening hesitancy, a stream that has slowed to a trickle, and straining to empty his bladder. For the past 2 weeks he has leaked small amounts of urine almost constantly, has woken several times to a wet bed, and now soaks through several pads a day. He has had nocturia and a slow stream for several years. He takes omeprazole, started 3 months ago for reflux, and no other medications. Temperature is 37.0 C (98.6 F), blood pressure is 152/88 mm Hg, and pulse is 84/min. A bedside bladder scan shows about 1,100 mL of urine. Serum creatinine is 2.8 mg/dL (1.1 mg/dL six months ago) and BUN is 42 mg/dL. Urine specific gravity is 1.010 and fractional excretion of sodium (FENa) is 2.4%. Urinalysis shows no protein or blood, 0-2 white blood cells per high-power field, and no casts. Which of the following best explains this patient's acute kidney injury?
- APrerenal kidney injury
- BAcute tubular necrosis
- CObstructive nephropathy
- DInterstitial nephritis
Reveal answer & full explanation
Correct answer: C — Obstructive nephropathy
- APrerenal kidney injury
- BAcute tubular necrosis
- CObstructive nephropathy✓
- DInterstitial nephritis
Why Obstructive nephropathy is correct
- A bladder holding about 1,100 mL, far more than a normal bladder holds, in a man who leaks urine almost constantly is not emptying: this is chronic urinary retention. A large bladder volume alone does not prove kidney injury, because low-pressure chronic retention usually leaves renal function normal. When bladder pressure stays high, it is transmitted back through both ureters to both kidneys, raising intratubular pressure and lowering the net glomerular filtration pressure (postrenal acute kidney injury). New bedwetting in an older adult, hypertension, and a rising creatinine are the classic picture of this high-pressure chronic retention.
- Years of nocturia and a slow stream, now with weeks of hesitancy and straining, point to progressive outlet obstruction from benign prostatic hyperplasia (BPH). No new drug trigger is needed: retention that builds slowly is often painless and may be found only when the bladder volume is measured.
- Near-constant leaking of small amounts, including wetting the bed at night, is overflow incontinence from a bladder that stays full, not adequate output. Partial obstruction often preserves urine flow, and anuria appears only when obstruction is complete, so passing urine does not exclude a postrenal cause.
- Obstruction lasting weeks damages the tubules and impairs sodium reabsorption and concentrating ability, so FENa rises above 1% and specific gravity falls toward 1.010. The indices then resemble acute tubular necrosis (ATN), which is why the measured bladder volume, not the urine chemistry, identifies the cause here.
- Confirm with a renal ultrasound for bilateral hydronephrosis and decompress with a urethral catheter; kidney function often improves after drainage, but long-standing obstruction can leave partial or permanent loss of function.
Why the others are wrong
- Prerenal kidney injury - Prerenal injury from hypoperfusion leaves the tubules intact and sodium-avid, giving FENa <1%, concentrated urine (specific gravity usually >1.020), and often a BUN:creatinine ratio >20:1. Nothing in the history points to volume loss or low cardiac output, he is neither hypotensive nor tachycardic, FENa is 2.4%, the urine is isosthenuric, and the BUN:creatinine ratio is about 15:1 (the trap is reading constant leaking as low output from dehydration).
- Acute tubular necrosis - ATN requires an ischemic or nephrotoxic insult such as sustained hypotension, sepsis, aminoglycosides, or iodinated contrast, and it often shows muddy brown granular casts. FENa >2% and isosthenuria are shared with established obstruction, so they cannot separate the two; here there is no insult, no casts, and a bladder holding about 1,100 mL while he leaks urine, which explains the injury (the trap is letting urine indices override the bladder scan).
- Interstitial nephritis - Proton pump inhibitors are a recognized cause of drug-induced acute interstitial nephritis (AIN); in a systematic review of 60 cases the mean time on the drug before diagnosis was about 13 weeks, so his omeprazole makes AIN worth weighing. Its urine findings are inconsistent: most patients have low-grade proteinuria, sterile pyuria is present in about one-half to three-quarters of cases and hematuria in about half, and about 20% have a bland sediment, so this clean urinalysis lowers the likelihood of AIN without excluding it. FENa does not help, because it can be high or low in AIN. The deciding point is that retention with a very large bladder volume is documented and, with new bedwetting and hypertension, fits high-pressure chronic retention, which explains the injury; reconsider AIN, for which kidney biopsy is the diagnostic gold standard, if creatinine fails to improve after drainage (the trap is assuming that any drug plus AKI means AIN).
Additional high-yield points
- Renal ultrasound is the imaging test of choice when obstruction is suspected, but it can miss obstruction in the first hours, during volume depletion, or when retroperitoneal fibrosis or tumor encases the ureters.
- FENa is unreliable in obstruction: it can be <1% early, before the tubules are damaged, and rises above 1% as obstruction persists, so urine indices never exclude a postrenal cause.
- For urinary retention from BPH, decompress with a urethral catheter (suprapubic if urethral passage fails). The AUA recommends surgery when BPH has caused renal insufficiency; for uncomplicated acute retention, start an alpha-1 blocker such as tamsulosin before the trial without a catheter.
- After relief of obstruction, watch for post-obstructive diuresis (urine output >200 mL/h for 2 consecutive hours or >3 L in 24 hours), especially with renal impairment or a very large residual volume, and monitor volume status, sodium, and potassium.
- Other postrenal causes include bilateral ureteral obstruction (pelvic malignancy, retroperitoneal fibrosis, bilateral stones), obstruction of a solitary functioning kidney, neurogenic bladder, urethral stricture, and a blocked indwelling catheter; in a catheterized patient with sudden oliguria, flush or replace the catheter first.