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Management Of Acute Renal Injury In Pediatrics
ProfSonia Elsharkawy
Head of pediatric departmentSuez canal university
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Objectives
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Acute renal failure.•
•Definition of ARF.Definition of ARF.
• Classification of ARF.
• Causes of ARF.
• Symptoms & sings Of ARF.• Diagnosis Of ARF.& prevention
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Indications and goals for acute renal replacement therapy
• Modalities for renal replacement therapy– Peritoneal dialysis– Intermittent hemodialysis– Continuous renal replacement therapy
(CRRT)
Special issues related to the infant
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The Problematic Definition of The Problematic Definition of ARFARF
• The Conceptual Definition of Acute Renal Failure:
– “Sudden loss of renal function resulting in the loss of the kidneys’ ability to regulate electrolyte and fluid homeostasis”
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The Problematic Definition of The Problematic Definition of ARFARF
• Pediatric AKI definition: a moving target
• Infants– Cr in the first few weeks of life may reflect
maternal values
• Children– Low baseline Cr makes 0.2-0.3 changes in Cr
significant– Varying muscle mass
• Adolescents– Similar to adults
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ARF• Pre renal (functional)
• Renal-intrinsic (structural)
• Post renal (obstruction)
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ARF Pirouz Daeihagh, M.D.Internal medicine/Nephrology Wake Forest University School of Medicine. Downloaded 4.6.09
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Causes of ARF
Pre-renal Renal Post-renal Absolute hypovolaemia
Glomerular (RPGN)
Pelvi-calyceal
Relative hypovolaemia
Tubular (ATN)
Ureteric
Reduced cardiac output
Interstitial (AIN)
VUJ-bladder
Reno-vascular occlusion
Vascular (atheroemboli)
Bladder neck-urethra
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ARF Pre renal
•Decreased renal perfusion without cellular injury
– 70% of community acquired cases– 30% hospital acquired cases
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ARF Intrinsic• Acute tubular necrosis (ATN)
– Ischaemia
– Toxin
– Tubular factors
• Acute interstitial Necrosis (AIN)– Inflammation
– oedema
• Glomerulonephritis (GN)
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ARF Post renal
• Post renal obstruction
• Obstruction to the urinary outflow tract
Blocked catheter– Malignancy
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Contrast-Induced ARF
• Prevalence• Less than 1% in patients with normal
renal function
• Increases significantly with renal insufficiency
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Contrast-Induced ARF• Risk Factors
• Renal insufficiency
• Diabetes mellitus
• Multiple myeloma
• High osmolar (ionic) contrast media
• Contrast medium volume
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Contrast-induced ARF
Clinical Characteristics
• Onset - 24 to 48 hrs. after exposure
• Duration - 5 to 7 days
• Non-oliguric (majority)
• Dialysis - rarely needed
• Urinary sediment - variable
• Low fractional excretion of Na
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Contrast-induced ARFProphylactic Strategies
• Use I.V. contrast only when necessary
• Hydration
• Minimize contrast volume
• Low-osmolar (nonionic) contrast media
• N-acetylcysteine.
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Pediatric Modified RIFLE--Pediatric Modified RIFLE--definitiondefinition
Ackan-Arikan et al: Kid Int 2010
Pediatric Modified RIFLE Criteria
CrCl Urine output
Risk GFR decrease by 25% <0.5ml/kg/hour for 8 hours
Injury GFR decrease by 50% <0.5ml/kg/hour for 16 hours
Failure GFR decrease by 75% or GFR<35ml/min/1.73m 2
<0.3 ml/kg/hour for 24 hours or anuric for 12 hours
Loss Persistent ARF > 4 weeks
End stage
End Stage Renal Disease (>3 months)
GFR per Schwartz equation: GFR= Ht (cm) X constant / serum creat (mg/dl)
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Acute Kidney Injury
AKI can be prevented by early recognition and treatment of the underlying cause, for example:
-Early treatment of infections/sepsis– Early treatment/prevention of dehydration– Correcting hypovolaemia
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Monitoring use of drugs such as NSAIDs and ACE inhibitors, especially if a patient is acutely unwell
• Taking care with at-risk patients who need iodinated contrast agents with scans
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BIOMARKERS
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Biomarkers for Acute Kidney InjuryBiomarkers for Acute Kidney Injury
• Ideally AKI would have a biomarkers like myocardial infarction (i.e. troponin-1)
• Currently no Troponin-I like marker to identify the site or severity of injury, although various markers are being evaluated
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– Kidney Injury Molecule (KIM-1)
– Neutrophil gelatinase-associated lipocalcin (NGAL)
– IL-18
– Cystatin C
(Changes in SCr may be a very late indicator of renal injury)
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AKI in the ICU
• Treatment of acute kidney injury (AKI) is principally supportive -- renal replacement therapy (RRT) indicated in patients with severe kidney injury.
• Goal: optimization of fluid & electrolyte balance
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Use an early warning score
that recognises and responds to
deterioration and acute illness
Staff should have competencies in:
• Monitoring • Measurement• Interpretation
Observations and assessment
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Neonatal Renal Failure
In term neonates, renal failure is suspected when the plasma creatinine concentration is greater than 15 mg/L, for at least twenty four to forty eight hours, while maternal renal function is normal
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Incidence
Precise incidence and prevalence of ARF in the newborn is
unknown , 6%- 24% (Andreoli, 2013).
In developing countries, the incidence and epidemiology of
acute renal failure in newborns was 3.9% of 1.000 live births
and 34.5% of 1.000 newborns admitted to the neonatal unit
(Andreoli, 2013).
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The mortality of acute renal failure is still very high (30%-
60%) (Drukker & Guingard, 2012).
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Etiology
Variety of congenital, developmental, and acquired conditions
(Mercado-Deane et al, 2012).
Prenatal injury/vascular damage: - Maternal
- Congenital renal diseases
Postnatal:
1- Prerenal: - Decreased true intravascular volume
- Decreased effective intravascular volume
2- Intrinsic: -ATN
-Interstitial nephritis
3- Postrenal (obstructive)
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Management
Immediate Measures:Immediate Measures:
1- 1- volume trials.
2- Diuretics
3- Dopaminergic (Vasoactive) Agents
Conservative treatment.Conservative treatment.
Renal replacement therapyRenal replacement therapy
Renal TransplantationRenal Transplantation
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Indications for Renal Replacement
• Volume overload
• Metabolic imbalance
• Toxins (endogenous or exogenous)
• Inability to provide needed daily fluids due to insufficient urinary excretion
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Goals of Renal Replacement
• Restore fluid, electrolyte and metabolic balance
• Remove endogenous or exogenous toxins as rapidly as possible
• Permit needed therapy and nutrition
• Limit complications
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R R T Includes: •Traditional intermittent hemodialysis,
• Peritoneal dialysis
• Variety of other intermittent and continuous therapy,
•Renal transplant
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Indications to start RRT
• Anuria – oliguria(diuresis <200 ml in 12 hr)
• Severe metabolic acidosis(pH<7.10)
• Hyperazotemia(BUN> 80mg/dl) or creatinine >4mg/dl
• Hyperkalemia K >6.5mEq/l
• Clinical signs of uremic toxicity
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• Severe dysnatremia Na<115 or Na>160mEq/l
• Hyperthermia (>40 deg.C without response to medical therapy)
• Anasarca or severe fluid overload
• Multiple organ failure with renal dysfunction and /SIRS, sepsis, or septic shock with renal dysfunction
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BUT• The optimal timing of RRT for AKI is not
defined
• Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis
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Meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08)
In cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001).
• Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL.
Am J Kidney Dis. 2012;52:272–284
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whenInitiate RRT Initiate RRT EEmergentlymergently
Life-threatening changes in fluid
Electrolyte
Acid-base balance
Uremic complications: pericarditis, pleuritis, encephalopathy, coagulopathy
Kidney Disease: Improving Global Outcomes (KDIGO), 2012
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Technique and modalities
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Technique and modalities
• All RRT consist of blood purification by having the blood flow through SPM.
• Blood flow into hollow fibers composed by biocompatible synthetic materials.
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• Wide range of substances( water , urea,and low, middle and high mol.wt. solutes)allow the blood across such membranes by diffusion (solutes) and by convection(solute and water)
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Modalities for Renal Replacement
• Hemodialysis.
• Peritoneal dialysis.
• Continuous renal replacement therapy (CRRT)
• Heamofiltiration.
• Renal replacement.
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Principles of dialysis
• Dialysis = diffusion = passive movement of solutes across a semi-permeable membrane down concentration gradient– Good for small molecules
• (Ultra)filtration = convection = solute + fluid removal across semi-permeable membrane down a pressure gradient (solvent drag)– Better for removal of fluid and
medium-size molecules
Faber. Nursing in Critical Care 2009; 14: 4Foot. Current Anaesthesia and Critical Care 2005; 16:321-329
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Principles of dialysis
Hemodialysis = solute passively diffuses down concentration gradient Dialysate flows countercurrent to blood flow. Urea, creatinine, K move from blood to dialysate Ca and bicarb move from dialysate to blood.
Hemofiltration: uses hydrostatic pressure gradient to induce filtration / convection plasma water + solutes across membrane.
Hemodiafiltration: combination of dialysis and filtration.
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Intermittent hemodialysis (IHD)
• Oldest and most common technique• Primarily diffusive treatment: blood and dialysate are
circulated in countercurrent manner
• Best for removal of small molecules• typically performed 4 hours 3x/wk or daily
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Continuous RRT Introduced in 1980s• involve either dialysis (diffusion-based solute
removal) or filtration (convection-based solute and water removal) treatments in a continuous mode with slower rate of solute or fluid removal
• CRRT includes continuous hemofiltration, hemodialysis and hemodiafiltration, all of which can be performed using arteriovenous or venovenous extracorporeal circuits.
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Peritoneal dialysis
Considerations for Infants
ADVANTAGES
• No vascular access• No extracorporeal
perfusion• Simplicity• ? Preferred modality
for cardiac patients?
DISADVANTAGES• Infectious risk• Leak• ? Respiratory
compromise?
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Intermittent hemodialysis Considerations for Infants
ADVANTAGES
• Rapid particle and fluid removal; most efficient modality
• Does not require anticoagulation 24h/d
DISADVANTAGES
• Vascular access• Complicated• Large extracorporeal
volume• Adapted equipment• ? Poorly tolerated
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Pediatric CRRT: Vicenza, 1984
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CRRT for Infants: A Series of Challenges
• Small patient with small blood volume
• Equipment designed for bigger people
• No specific protocols
• Complications may be magnified
• No clear guidelines
• Limited outcome data
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Potential Complications of Infant CRRT
• Volume related problems
• Biochemical and nutritional problems
• Hemorrhage, infection
• Thermic loss
• Technical problems
• Logistical problems
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Role of RRT in different clinical situations
• Sepsis
• Congestive heart failure
•Miller's Anesthesia, 7th ed. 2009
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RRT in congestive heart failure
• Slow continuous ultrafiltration (SCUF) effective for fluid removal in decompensated CHF..
Costanzo et al J Am Coll Cardiol 2010 49:675-683.
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Discontinuation of RRT
• Until “evidence of recovery of kidney function”– Improved UOP in oliguria– Decreasing creatinine– Creatinine clearance minimum 12 mL/min,
some say 20 mL/min
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Thanks!