ACUTE RENAL FAILURE. Academic Half Day February 9, 2012. Objectives. To review: the etiologies of acute kidney injury (AKI) in the pediatric population the work-up/diagnosis of AKI the management of AKI What is AKIs? “abrupt reduction in kidney function as measured
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Academic Half Day
February 9, 2012
“abrupt reduction in kidney function as measured
by a rapid decline in GFR”
<0.5cc/kg/h x 8h
eCCl dec 25%
eCCl dec 50%
<0.5cc/kg/h x 16h
eCCl dec 75%/
<0.3cc/kg/h x 24h/
Anuric x 12h
Persistent failure >4wks
Failure > 3 months
Incidence (US): 0.8/100 000; ~1/10 in ICU
Independent risk factor for ICU mortality
Increases length of hospital stay
May lead to chronic renal failure (40-50% ICU)
Though likely multifactorial, can be divided into:
Diabetes - DM, DI
Kidney sees less volume:
Vascular - also consider in renal
Takayasu, PAN, KD
ARBsPre-renal causes:Any cause which results from kidney seeing to little blood flow
Tubulo/Interstitial:Acute tubular necrosis -secondary to nephrotoxic insults or poor perfusion
Acute interstitial nephritis -drugs -infxn
Cortical dysplasia -hypoxia/ischemia->infarct -toxins/severe HUS
?Sepsis inflamm, not all volume related
History of Ecoli, Shigella, shiga-toxin…
Atypical (non-diarrhea, non-shiga-toxin)
Hemolytic anemia with fragmented RBCs
CNS, liver, pancreas can also be affected
Occurs in ages 5-12, post-GAS.
Presentation can be asymptomatic to nephritis complete with gross hematuria, proteinuria, HTN, edema
Labs: abnormal urinalysis, low complement
Prognosis: most make complete recovery.
-Causes renal issues d/t IgA deposition.
-A/W palpable purpura, arthritis, abdo pain.
-Renal more likely to be an issue in older kids
-Rx: if crescenteric, GN - steroids.
-prognosis: often relapses. Can have late deterioration even if full recovery. 10-30% adults go on to have end-stage disease.
Describes an end effect of tubular damage…
Change in blood flow, obstruction and passive filtrate backflow into tubular cells can cause a cycle leading to further death…
Drugs (71%) - 1/3 antibiotics
Tubulointersitial nephritis and uveitis (5%)
Autoimmune: SLE, Sjogren’s
Two kidneys - distal or bilateral proximal obstruction
Single kidney - obstruction anywhere
Post-renal: palpable bladder?
BUN, Cr, lytes, fractional excretion of sodium
-pre-renal (may be concentrated)
casts = ATN
-red cell casts =
-proteinuria = glomerular
-pyuria, white cell casts = UTI
or glomerulonephritis (post-
-hematuria = AIN, vasculitis,
infarction, obstructionOn labs…
Everyone gets a urinalysis…
Often low, especially given criteria for AKI.
However, some ATN is non-oliguric
Why? Helps distinguish pre-renal vs ATN…
FENa compensates for the urine output…
UNa x PCr
PNa x UCr
…can also be thought of as
<1% --> pre-renal disease
1-2% --> ??
>2% --> ATN
CBC: look for MAHA, thrombocytopenia
Extended lytes. Renal injury can result in:
Other options, depending on history: ANCA,
ANA, ASOT, complement, drug levels…
Creatinine is usually elevated
Unfortunately, not yet… Some ideas:
Ultrasound - in all children if etiology unclear
Only when diagnosis remains unknown, or
there is a failure to respond to treatment
Generally pediatric nephrology will be involved.
Hyperkalemia - if severe (>7) - C BIG K Die…
AKI is a catabolic state
Ensure adequate calories
- 120kcal/kg/d in infants
- usual maintenance for children
PO -> enteral -> TPN
If fluid balance off with adequate nutrition: RRT
Including making things worse…so no:
Continuous renal replacement therapy
Mortality: 60% (critically ill)
20-25% go on to have some degree of chronic renal issues
Best divided into pre-, renal and post-renal
Urinalysis, ultrasound, bloodwork…
Fluids - close balance
Electrolytes - esp K, PO4, Ca
Dialysis - talk later today
Akcan-Arikan A, Zappitelli M, Loftis L, Washburn K, Jerrerson L, and Goldstein S. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney International; 2007: 71: 1028-35.
Basu R, Devarajan P, Wong H, and Wheeler S. An update and review of acute kidney injury in pediatrics. Pediatric Critical Care Medicine; 2011: 12(3): 339-47.
Imam A. Clinical presentation, evaluation, and diagnosis of acute kidney injury (acute renal failure) in children. Uptodate. Accessed Feb 8, 2012 at http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/clinical-presentation-evaluation-and-diagnosis-of-acute-kidney-injury-acute-renal-failure-in-children?source=search_result&search=acute+kidney+injury&selectedTitle=2~150
Imam A. Prevention and management of acute kidney injury (acute renal failure) in children. Uptodate. Accessed Feb 8, 2012 at http://www.uptodate.com.ezproxy.lib.ucalgary.ca/contents/prevention-and-management-of-acute-kidney-injury-acute-renal-failure-in-children?source=search_result&search=acute+kidney+injury&selectedTitle=1~150
Kliegman R, Stanton B, Geme J, Schor N, and Behrman R. Nelson Textbook of Pediatrics 19th e. Elsevier; 2011: 1814-22.