A minor fault may lead to a major complication

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.