Submitted: 19 Apr 2017
Accepted: 15 Aug 2017
First published online: 30 Aug 2017
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J Renal Inj Prev. 2018;7(3):116-118.
doi: 10.15171/jrip.2018.27

Scopus id: 85050083990
  Abstract View: 266
  PDF Download: 201

Case Report

A minor fault may lead to a major complication 

Seyed Majid Mousavi Movahhed 1, Leila Sabetnia 2, Mohammad Javad Alemzadeh-Ansari 3, Shahla Ahmadi Halili 2 * , Seyed Seifollah Beladi Mousavi 2

1 Department of Internal Medicine, Tehran University of Medical Sciences, Tehran, Iran
2 Chronic Renal Failure Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
3 Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
*Corresponding author: Shahla Ahmadi Halili, Email: Email:


Control of intake and urinary output is an important measure in the management of patients with acute renal failure (ARF) and non-correct recordation of urinary output by nurses may cause a severe problem in the management of these patients. The reported case was a 34-yaer-old woman who developed ARF and anuria after hysterectomy during emergency cesarean section. Computed tomography and serial ultrasonography of kidneys and urinary tract revealed mild hydronephrosis. Although, our patient had anuria, but recoded urinary output by nurses was 300-350 mL/d because urinary bag has not been emptied at the end of each day. Therefore, we thought that ARF is due to acute tubular necrosis because of severe bleeding during cesarean section. We also interpreted that hydronephrosis is secondary to recent pregnancy. After 10 days, it was detected that the patient has not been any urinary output during this period. Therefore the diagnosis was changed to urinary obstruction because of bilateral ureteral ligation during hysterectomy.

Implication for health policy/practice/research/medical education:

In an approach to a patient with anuria after pelvic operations, urinary tract obstruction must be reminded. Early diagnosing and resolving obstruction may lead to completely return of renal function. However, if neglected, it can lead to non-compensative complications.

Please cite this paper as: Mousavi Movahhed SM, Sabetnia L, Alemzadeh-Ansari MJ, Ahmadi Halili S, Beladi Mousavi SS. A minor fault may lead to a major complication J Renal Inj Prev. 2018;7(3):116-118. doi: 10.15171/jrip.2018.27.

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