Acute Renal Failure in Children

Done By : Ma’ad Adnan

Supervised By : Dr.Mahdi Al-Zuhairy

Definition

•A clinical syndrome in which a sudden deterioration in renal function results in the inability of the kidneys to maintain fluid and electrolyte homeostasis.

•Also k/a Acute renal insufficiency

•2-3% of children admitted to pediatric tertiary care centres

•8% of infants in neonatal ICU

•Anuria < 0.5 cc/kg/hour

•Oliguria more than 1 cc/kg/hour‖

•70% Non-oliguric , 30% Oliguric

•Non-oliguric associated with better prognosis and outcome

•―Overall, the critical issue is maintenance of adequate urine output and prevention of further renal injury.‖

Classifications

Pre-renal = in which decrease renal

perfusion 55%

Renal parenchymal (intrinsic)= in

which there is renal paranchymal injury 40%

Post-renal = in which there is obstruction of

renal outflow 5-15%

1.Pre renal

2. Intrinsic Renal

3. Post-renal

Causes of ARF

Pre-renal :vomiting, diarrhea, poor fluid intake, fever, use of diuretics, and heart failure cardiac failure, liver dysfunction, or septic shock

Intrinsic :Interstitial nephritis, acute glomerulonephritis, tubular necrosis, ischemia, toxins

Post-renal :prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders neurogenic bladder bilateral renal calculi, papillary necrosis, coagulated blood, bladder carcinoma, and fungus

Symptoms of ARF1.Decrease urine output (70%)

2.Edema, esp. lower extremity

3.Mental changes

4.Heart failure

5.Nausea, vomiting

6.Pruritus

7.Anemia

8.Tachypenic

9.Cool, pale, moist skin

1.Sunken Fontanels

3.Dry Tongue & Mucous Membranes

3.Loss of skin turgor

4.rritability

5.Feeble Pulses

Sign of Collapse

1.Anorexia

2.Vomiting

3.Nausea

4.Lethargic

5.Hypertension

4.Uremic Encephalopathy

5.Seizure

Sign of uremia

Acute Tubular Necrosis

Renal insults, including •renal ischemia •exposure to exogenous or endogenous nephrotoxins.

The net effect is a rapid decline in renal function that may require a period of dialysis before spontaneous resolution occurs.

Major Causes of Acute Tubular Necrosis

•Renal Ischemia: * Severe prerenal disease from any cause.

•Exposure to Nephrotoxins: * Amphotericin B * Aminoglycosides * Heme Pigments * NSAID's (hemoglobinuria/myoglobinura)

Investigation of ARF

Urine Examination: •Urine Na-- > 20 mEq/l show intrinsic renal < 10 mEq/l show pre-renal •Urine Microscopy---Pus, RBC’s, White Cell Casts

Blood Counts: •Low Hb---blood loss •Leukocytosis---infection •Platelet Counts---low in HUS, Renal Vein Thrombosis

Blood Urea & Creatinine: Raised due to diminished renal function

Serum Calcium, Phosphate, AlkalinePhosphates:•S.Ca low •S.Phosphate raised

Serum Electrolytes & Osmolality: •Na low & K high

C3 Complement Level: Low in Acute Glomerulonephritis, SLE Nephritis

Radiological examination1.ultrasonography:

pelvic ultrasonogrophy may show mass and calculate the residual urine.it is useful for guiding needle for renal biopsy or aspiration of perirenal collection.

Doppler flow imaging of the renal vessels may help in diagnosis of renal artery occlusion or stenosis , renal vein thrombosis and kidney transplant rejection.

2.plain abdominal x-ray (KUB):(kidney,ureter,bladder)may show a.stonesb.calcification of the kidney ,urinary bladder, seminal vesicles.c.renal contour and soft tissue shadow

3.Intravenous urography (IVU): shows any mass ,stones ,back pressure changes and also demonstrates kidney function and obstruction. It should be done in the light of renal function .

4.angiography: this includes a.renal arteriography It is mainly indicated for

diagnosis of renovascular hypertension or persistent haematuria following trauma.

b. renal venography. This is indicated for diagnosis of renal vein thrombosis.

5.Computerized tomography (CT):it is strongly indicated in patients with obstructive uropathy with non-evident cause.

6.Magnetic resonance imaging (MRI)helpful in studying malignancies of the urinary tract and assessment of renal vessels by MRI angiography.

Kidney biopsy

•It shows the pathology of the underlying renal disease.

•The biopsy should be examined by light microscope (LM) ,electronic microscope (EM) and immunofluorescentmicroscope (IF)

•Very helpful in diagnosing, prognosis and therapeutic guidance.

cystoscopy, ureteroscopy

Diagnostic :of bladder disease , (tumour)by direct vision or biopsy.

Therapeutic:ureteric catheter: also , ascending pyelography , differential

renal function.

General Measures

Management

1.IV secure. 2.Take blood samples. 3.Collect urine sample. 4.Catheterize if bladder is palpable.5.Record blood pressure. 6.Careful intake and output record. 7.Daily weight measurement. 8.Daily investigations.

.Urea

.Creatinine

.Serum electrolytes

.Blood gases

.ECG(to detect Hyperkalemia)

•Water and sodium restriction

•Protein restriction

•Potassium and phosphate

restriction

•Adjust medication dosages

•Avoidance of further insults

–BP support

–Nephrotoxins

.

•Catheterization - in newborn with suspected

posterior ureteral valves & nonambulatory older children.

•If there is no evidence of volume overload or

cardiac failure, intravenous administration of isotonic saline, 20 mL/kg over 30 min.

•hypovolemic patients generally void within 2 hr

after bolus; failure points to intrinsic or

postrenal ARF.

•Hypotension due to sepsis - vigorous fluid

resuscitation f/b continuous infusion of norepinephrine

Diuretic therapy :

1.only after the adequate hydration.

2.Mannitol (0.5 g/kg) and furosemide (2-4 mg/kg) - as a

single IV dose. [Mannitol - effective in pigment (myoglobin,

hemoglobin)-induced renal failure.]

3.Bumetanide (0.1 mg/kg)- an alternative to furosemide.

If urine output is not improved - continuous diuretic

infusion may be considered.

1. Consider Dopamine (2-3 µg/kg/min) in conjunction with

diuretic therapy.

2.There is little evidence that diuretics or dopamine can prevent ARF or hasten recovery

1.Hyperkalemia

Symptoms

•Weakness•Lethargy•Muscle cramps•Paresthesias•Dysrhythmias

Hyperkalemia & EKG

•K > 5.5 -6

•Tall, peaked T’s

•Wide QRS

•Prolong PR

•Diminished P

•Prolonged QT

•QRS-T merge – sine wave

Management of Complications

Hyperkalemia Treatment

•Calcium gluconate (carbonate)

•Sodium Bicarbonate

•Insulin/glucose

•Kayexalate (sodium polystyrene sulfonate)

•Lasix

•Albuterol

•Hemodialysis

2. ACIDOSIS: Correct acidosis by NaHCO3 Total calculated dose divide in 3 doses; •One part given start •2nd part after 8 hrs •3rd part discard

3. HYPOCALCEMIA Can present as tetany or convulsions.

•iv calcium gluconate slow and diluted in 5 to 10

mints under cardiac monitoring.

•Treatment primarily involves efforts to lower the

serum phosphorous level.

•Calcium Carbonate (phosphate binder) help to

decrease the absorption of phosphorous & help its

excretion.

4. Hyponatremia: •Due to fluid overload or hypotonic fluid administration.

require correction with hypertonic sodium chloride

• In Hypertension due to fluid over load, contraindicated

to give Hypertonic Saline

•Do Dialysis to correct hyponatremia

5. Seizures: •Due to primary renal disease, uremia,

hyponatremia, hypocalcaemia & hypertension

•Inj.Diazepam

6. Infections: •Due to bladder catheterization or peritoneal dialysis

•Broad Spectrum Antibiotics (B.Pencillin or Ceftrixone)

given.

•Nephrotoxic (Amikacin, Erythromycin) drugs avoided.

7. Anemia: Due to volume expansion

•If Hb < 7 g/dl, blood should be given very slowly in 4

to 6 hrs.

Dialysis

Indications for dialysis

•Hyperkalemia unresponsive to medical therapy.

•Acidosis unresponsive to medical therapy.

•Fluid overload unresponsive to fluid restriction

or to diuretics.

•Symptoms & Signs of uremia.

•Hypertension & CCF not responding to medical

therapy.

•Blood urea N greater than 100-150mg/dl

•Mental status change

Types Of Dialysis

•Peritoneal Dialysis

•Acute Intermittent Hemodialysis

•Continuous Hemofiltration

Peritoneal dialysis

1.Simple to set up & perform

2.Easy to use in infants

3.Hemodynamic stability

4.No anti-coagulation

5.Bedside peritoneal access

6.Treat severe hypothermia or

hyperthermia

Advantages Disadvantages

1.Unreliable ultrafiltration

2.Slow fluid & solute removal

3.Drainage failure & leakage

4.Catheter obstruction

5.Respiratory compromise

6.Hyperglycemia

7.Peritonitis

8.Not good for

hyperammonemia or

intoxication with dialyzable

poisons

Intermittent Hemodialysis

•Maximum solute

clearance of 3 modalities

•Best therapy for severe

hyperkalemia

•Limited anti-coagulation

time

•Bedside vascular

access can be used

•Hemodynamic instability

•Hypoxemia

•Rapid fluid and electrolyte

shifts

•Complex equipment

•Specialized personnel

•Difficult in small infants

Advantages Disadvantages

Continuous Hemofiltration

•Easy to use in PICU

•Rapid electrolyte correction

•Excellent solute clearances

•Rapid acid/base correction

•Controllable fluid balance

•Tolerated by unstable pts.

•Early use of TPN

•Bedside vascular access

routine

•Systemic anticoagulation

(except citrate)

•Frequent filter clotting

•Vascular access in

infants

Advantages Disadvantages

Depends upon cause. 90 % complete remission in; •ATN (Acute Tubular Necrosis)•HUS (Hemolytic-uremic Syndrome) Other Causes of pre-renal failure

Poor Prognosis when renal failure due to; •RPGN (Rapidly Progressive Glomerulonephritis)•Bilateral Renal Vein Thrombosis •Bilateral Cortical Necrosis

Prognosis

THE END

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