When The Pee Stops

When a patient stops producing urine, often the end is near.

Of course, this isn’t always the case.  Lots of people go into renal failure in the hospital for lots of reasons.  They get dialysis and do fine in the end.  Some don’t even stay on dialysis.  So, this isn’t a hard-and-fast rule.  But when a patient suddenly stops making urine and their kidneys are shutting down…frequently the story won’t have a happy ending.

I’m finished with my rural rotation and have been dropped – with a dull plunk - back into the hospital.

Hospital medicine is tough.  Described at least once as a process of “herding cats”, inpatient medicine demands constant attention to seemingly endless, often easily-forgotten details.

Aside from the sheer mental effort generally required to manage complicated hospital patients, drastic outcomes are more common too.  If a guy comes into clinic and says, “Hey doc, this hurts.”  The doctor often shrug and tell them not to do “that”, and to let them know if the pain doesn’t go away.  But in the hospital, what appears to be a vague ache or pain can be life-ending.

One of my first patients today came in with so many problems I felt sick just reading her history.  Renal stones, chronic pancreatitis (if you’re wondering what real pain is like, try that one), severe carotid stenosis (almost no blood gets to the brain), strokes, heart attacks, bowel obstructions.  Yuck, yuck, yuck.

Today, I noticed that two of the best indicators of renal function – BUN and Creatinine – were just barely worse than yesterday.  In talking the problem over with my attending, our assesment was that she probably had some decrease in her renal function because she recently had a CT with contrast (NOT a nice test…contrast is the destroyer of kidneys).  So, some elevation was to be expected.  Besides, the lady was peeing.  This is a big deal.

I once was asked by a prestigious nephrologist, rhetorically, what was the best way to identify severe renal failure.  I futzed and bumbled around, throwing out dimwitted answers about excreted urine sodium compared to plasma sodium and potassium.  After watching me wriggle around uncomfortably for awhile, the gleeful specialist exclaimed, “They’re makin’ PEE!  HAHAHAHA!”

By that, he meant that the patient was generating at least 30cc of urine per hour.  Something around that much and you don’t have too much to worry about.

And this morning, that patient was making almost 50 cc/hour.  I re-checked her urine bag myself because I was surprised that someone so sick could be producing urine so “well”.  Satisfied, I figured she would be improving in short order and soon we would be calling for the wheelchair and home-care nurses.

Instead, I got a page this afternoon notifying me that the patient had produced less than 20cc of urine over the previous 2 hours.  And she was having difficulty breathing not long after that.  And every limb was suddenly swollen and puffy.  And her pain was immense.  And she was febrile and what about that white count that never really came down, doctor?

After checking on her, it became clear that for reasons unclear to us, the woman’s kidney’s were headed for total collapse.  In a younger patient with fewer medical problems, simple dialysis would probably solve the problems.  But this patient is infinitely more complicated.  Her kidneys are shutting down because her body is shutting down.  She can’t breathe because the fluid that she’s supposed to pee out is backing up into her lungs.  And limbs, which causes the swelling.  I can’t explain the pain, but the white cell count is elevated because she likely has disseminated infection that is attacking other organ systems.

In the hospital, things can go from promising to dire in the space of 2 hours, or less.  Some of the more dramatic turns for the worse have occurred when the kidneys throw in the towel.  Although most of us don’t think much about urinating throughout our day, the truth is that when the peeing stops, many times the rest of the body is soon to stop as well.  I don’t know if my patient will make it through this, but I sure had more hope for her this morning – when she was happily peeing – than I do now.

Nice first day back…

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8 responses to “When The Pee Stops

  1. You bet. When those kidneys fail acutely it ain’t good news and the prognosis for recovery is directly proportional to the number of co-morbids conditions. Nice, clear summary of just how much we owe our kidneys for keeping us out of harms way and just how sensitive they are to the rest of the body “shutting down”. I like to say it isn’t the fault of those kidneys; it’s the environment in which they live that’s toxic.

    Good luck! Consult you nephrologist although he/she more than likely has little to offer other than “watch and see, dialyze and wait it out”. When the rest of the body gets better, the kidneys will follow.

  2. I’m at the point now, where I will begin dialysis. Interesting reading! I’m still peeing, but can’t put off much longer. Scares me to think that the rest of my life, I’ll need dialysis to keep me alive. Restricts my activities. How did your patient fair?
    Alice

  3. My dad has been on dialysis for 9 months and we just found out he can’t pee what will happen we are scared?

  4. Mel,

    The above blog describes when the kidneys shut down ACUTELY, which is much different from an instance when they shut down CHRONICALLY over time.

    In an acute environment, renal function is closely tied to overall survival. While this doesn’t mean your Dad is out of the woods – lots of things may need to be evaluated if he has had a change in renal function status – it does not bode as ominously that he can’t pee after 9 months on dialysis.

    One of the “benefits” of dialysis is that it does make urination a bit superfluous. In the absence of other clinical symptoms, this change is not a certain signal of something bad. It may simply be a mild advance of his chronic medical problems, and he may be just fine. Too early to worry…just get a good evaluation and go from there.

  5. what are your chances of living when you cant urinate any longer

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  7. Aw, this was a very good post. Taking the time and actual effort to create a
    superb article… but what can I say… I procrastinate a whole lot and don’t seem to get anything done.streetdirectory

  8. I’m on peritoneal dialysis and my life hasn’t come to a screachin halt.If you have a good job & they will let you continue to work then do that.If U don’t look at it as I have it’s an early retirement so enjoy it.I still play sports & have great sex and do all of the things I use too.So it’s what you make it.I stopped peeing about 6mos ago & I wanted to know exactly what is going on inside my body that causes the pee to stop.Seems like they could manufacture something to make the peeing continue since the erg is still there & sometimes a little comes out.It feels like it’s a blockage or a muscle malfunction taking place.I went to see a separate dr about it & he smiled alot & didn’t really answer my questions seeming to be basically blowing me off.I’m an X marine & I have alot of anger issues so sadly the way I deal with people that play stupid on me is to dumb down myself & back down because anything other than total submission could send me into a violent rage …& well that’s not gone help.

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