Acute Renal failure
Dr. Abhijeet Deshmukh
Dept. of Pediatrics
Pushpagiri Medical College & RC
• A clinical syndrome in which a sudden
deterioration in renal function results in the
inability of the kidneys to maintain fluid and
• Also k/a Acute renal insufficiency
• 2-3% of children admitted to pediatric tertiary
• 8% of infants in neonatal ICU.
• Sensitivity and specificity of urine Na of <20
in differentiating prerenal azotemia from
acute tubular necrosis are 90% and 82%,
• Fractional excretion of sodium
= urine:plasma (U/P) ratio of sodium divided
by U/P of creatinine × 100.
(sensitivity and specificity of fractional excretion of
sodium of <1% in differentiating prerenal
azotemia from acute tubular necrosis are 96%
and 95%, respectively)
• CXR : cardiomegaly, pulmonary
congestion (fluid overload) or pleural
• Renal USG :
Nephromegaly- s/o intrinsic renal disease.
• Renal biopsy : who do not have clearly
defined prerenal or postrenal ARF
• Other biomarkers:
- changes in plasma neutrophil
gelatinase-associated lipocalin (NGAL)
and cystatin C levels
- urinary changes in NGAL, interleukin18 (IL-18), and kidney injury molecule-1
• 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
• Diuretic therapy :
only after the adequate hydration.
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.]
Bumetanide (0.1 mg/kg)- an alternative to furosemide.
If urine output is not improved - continuous diuretic
infusion may be considered.
Consider Dopamine (2-3 µg/kg/min) in conjunction
with diuretic therapy.
There is little evidence that diuretics or dopamine can
prevent ARF or hasten recovery.
• Sr K >6 mEq/L - cardiac arrhythmia, cardiac arrest, and death.
• Earliest ECG change - peaked T waves f/b widening of the QRS
intervals, ST segment depression, ventricular arrhythmias, and
• Exogenous sources of K : dietary, intravenous fluids, total parenteral
nutrition) should be eliminated.
• Sodium polystyrene sulfonate resin (Kayexalate) : (1 g/kg) - orally or
by retention enema when Sr K>6 mEq/L
- exchanges sodium for potassium
- can take several hours to take effect. A single dose of 1 g/kg
can lower the sr K level by about 1 mEq/L.
- Resin therapy may be repeated every 2 hr, the frequency
being limited primarily by the risk of sodium overload.
• If Sr K >7 mEq/L : emergency measures in
addition to Kayexalate.
Calcium gluconate 10% solution :
1.0 mL/kg IV, over 3-5 min
Sodium bicarbonate :1-2 mEq/kg IV, over
Regular insulin : 0.1 U/kg, with glucose
50% solution, 1 mL/kg, over 1 hr
• Mild metabolic acidosis:
common in ARF - rarely requires
If severe (arterial pH < 7.15; serum
bicarbonate < 8 mEq/L) or contributes to
hyperkalemia it should be corrected.
• Hypocalcemia :
- Primarily treated by lowering the serum
- Calcium should not be given IV except
in cases of tetany, to avoid deposition of
calcium salts into tissues.
- Follow a low-phosphorus diet,
- most commonly a dilutional
- must be corrected by fluid restriction.
- hypertonic (3%) saline - limited to
(seizures, lethargy) or those with a serum
sodium level <120 mEq/L.
• GI bleeding
because of uremic platelet
dysfunction, increased stress, and heparin
exposure in hemodialysis.
Oral or intravenous H2 blockerRanitidine.
Common in ARF patients with acute
glomerulonephritis or HUS.
Salt and water restriction, diuretics
Isradipine (0.05-0.15 mg/kg/dose,
amlodipine, 0.1-0.6 mg/kg/24 hr qd or divided bid
propranolol, 0.5-8 mg/kg/24 hr divided bid or tid;
labetalol, 4-40 mg/kg/24 hr divided bid or tid
severe symptomatic hypertension - continuous
infusions of sodium nitroprusside or esmolol
• Neurologic symptoms
Headache, seizures, lethargy, and confusion
Potential etiologic factors - hyponatremia,
hypocalcemia, hypertension, cerebral
hemorrhage, cerebral vasculitis, and the
Diazepam - most effective in controlling
Treat the underlying cause.
• Anemia of ARF
packed red blood cells if Hb < 7 g/dL
Slow (4-6 hr) transfusion with packed red
blood cells (10 mL/kg) diminishes the risk
In most cases, sodium, potassium, and
phosphorus should be restricted.
Protein – restricted & caloric intake
maximised to minimize the accumulation
of nitrogenous wastes.
Critically ill patients with ARF - parenteral
essential amino acids given
• Protein :
enough protein for growth - limiting high protein intake.
Protein needs increase on dialysis.
Foods with protein include
Depend on stage of their kidney disease, their
age, and sometimes other factors.
Foods high in sodium include
• canned foods
• some frozen foods
• most processed foods
• some snack foods, such as chips