Acute Kidney Failure
A Pediatric Experience Over 20 Years
Debra M. Williams, MD; Sue S. Sreedhar, MD; John J. Mi...
   Table 1. Clinical Characteristics of 228 Cases
   of Pediatric Acute Renal Failure
Table 2. Mortality in Acute Renal Failure in Association With Age

1979-1988                                                                   1989-1998

      Streptococcus               ...
P <.05
                                1979-1988        1989-1998
Table 5. Critically Ill Pediatric Patients With Acute Renal Failure*

What This Paper Adds                                  We thank Sung C. Choi, PhD, for statistical support;
22. Norman ME, Asadi FK. A prospective study of acute renal failure in the newborn      32. Struijk DG, Krediet RT, Koomen...
Upcoming SlideShare
Loading in …5

Acute Kidney Failure


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Acute Kidney Failure

  1. 1. ARTICLE Acute Kidney Failure A Pediatric Experience Over 20 Years Debra M. Williams, MD; Sue S. Sreedhar, MD; John J. Mickell, MD; James C. M. Chan, MD Background: Acute kidney failure in children is a cata- service. Sex distribution, ethnicity, and survival statistics strophic, life-threatening event. were unchanged between both decades. The overall sur- vival rate was 73%. One hundred fifty-four patients (68%) Objective: To compare and contrast 2 decades of data, were admitted to the pediatric intensive care unit. The fol- analyzing the underlying causes, associated multiple or- lowing 106 acute extracorporeal procedures were per- gan system failures, outcome of dialysis procedures, and formed on 93 patients (41%): 12 patients received extra- other variables of interest. corporeal membrane oxygenation, 52 patients underwent peritoneal dialysis, 32 underwent hemodialysis, 3 pa- Design: Retrospective examination of clinical data col- tients received continuous venovenous hemofiltration, and lected between January 1, 1979, and December 31, 1998. 7 patients received continuous arteriovenous hemofiltra- tion. Sepsis and burns, other leading causes of acute re- Setting: Regional health care center in the mid- nal failure in the first decade, are replaced in the second Atlantic area. decade by hematologic-oncologic complications and pul- monary failure. Participants: Two hundred twenty-eight patients, aged from 1 day to 18 years, had acute kidney failure and were Conclusions: Acute kidney failure following repair of referred to a pediatric nephrology service. cardiac lesions remains unchanged as a leading risk fac- tor of mortality in both decades. Three organ system fail- Main Outcome Measures: Characteristics, percentage ures were associated with more than a 50% mortality rate. of mortality, intensive care unit admission, procedures, Predialysis low serum albumin concentrations emerged and other variables and causes of acute renal failure. as a significant copredictor of mortality. Results: The total number of cases analyzed represented 7% of all patients presented to the pediatric nephrology Arch Pediatr Adolesc Med. 2002;156:893-900 A CUTE KIDNEY failure is an natology. This study will analyze the abrupt cessation of kid- underlying diseases leading to acute kid- ney function, with life- ney failure, the outcome of MOSFs, and threatening consequences other variables associated with mortality in children worldwide.1 in the first decade compared with the sec- Given the fact that acute kidney failure is ond decade. Recently, hypoalbuminemia From the Departments of sometimes associated with significant mul- has been shown to be a singular predic- Pediatrics (Drs Williams, tiple organ system failure (MOSF)2 and tor of nutrition failure and presence of sys- Sreedhar, Mickell, and Chan) constitutes an important population ad- temic disease in children receiving chronic and Biochemistry Molecular mitted to pediatric intensive care units renal replacement therapy.4 We will ex- Biophysics (Dr Chan), Virginia (ICUs),3 it seems logical that the various amine whether it is also a co-mortality risk Commonwealth University, risk factors of this catastrophic event are factor in acute kidney failure. Richmond. Dr Chan is now with issues of great importance in terms of tan- This study has particular relevance in The Barbara Bush Children’s Hospital, Maine Medical gible and intangible costs to the well- the light of advancing technology, includ- Center, Portland, and the being of patients and their families. We ing the increase of extracorporeal mem- Department of Pediatrics, share a 20-year experience at a single cen- brane oxygenation in neonates,5 and the University of Vermont College ter with care provided by the same attend- widespread and earlier use of acute renal of Medicine, Burlington. ings in critical care, nephrology, and neo- replacement therapy.6 (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 893 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  2. 2. RESULTS Table 1. Clinical Characteristics of 228 Cases of Pediatric Acute Renal Failure The 228 patients with acute kidney failure represented 7% of all inpatient and outpatient referrals made to the First Decade Second Decade Combined Decades (1979-1988) (1989-1998) (1979-1998) pediatric nephrology service over these 2 decades.9 The No. (%) No. (%) No. (%) clinical characteristics were as follows: slightly more male of Patients of Patients of Patients than female patients (60% vs 40% and 57% vs 43%, Sex respectively). Comparing the first (1979-1988) and sec- Male 62 (60) 71 (57) 133 (58) ond (1989-1998) decades, the ethnic distribution was, Female 41 (40) 54 (43) 95 (42) respectively, 53% and 54% white; 38% and 33% black; Ethnicity and 9% and 13% others. No statistically significant dif- White 55 (53) 67 (54) 122 (54) ferences were noted between the first and the second de- Black 39 (38) 41 (33) 80 (35) Other 9 (9) 17 (13) 26 (11) cade in these patient characteristics as given in Table 1. Age Between the 2 decades, patient survival was 71% and 1 d-1 y 43 (42) 46 (37) 89 (39) 74%, respectively, for an overall survival rate of 73%. The 2-4 y 22 (21) 25 (20) 47 (21) mortality rates between the 2 decades were not signifi- 5- 15 y 38 (37) 54 (43) 92 (40) cantly different as well, at 29% and 26%, respectively Outcome (Table 1). Table 2 lists the age of patients in relation- Total 103 125 228 Nonsurvivors 30 (29) 32 (26) 62 (27) ship to mortality. Survivors 73 (71) 93 (74) 166 (73) Among the survivors, the order of underlying causes for acute kidney failure hardly change between the 2 de- cades. (Table 3) Hemolytic uremic syndrome (HUS)9 in the survivors was the leading cause of acute kidney failure PATIENTS AND METHODS in both decades, 38% and 22%, respectively. There was 1 death from HUS in the 2 decades, of a total of 49 patients, Between January 1979 and December 1998, 228 consecutive making the mortality rate 2% for this condition. Twenty- pediatric cases of acute renal failure were diagnosed and treated one percent and 57% of these patients required dialysis in at the Medical College of Virginia Hospital, Richmond, a re- their respective decades. gional health care center in the mid-Atlantic area. All medical data were entered prospectively each day on standard forms Postcardiac surgery remained the leading cause of (“the yellow sheets” advocated by Frederic C. Bartter, MD*) acute kidney failure among the nonsurvivors in both de- under direction of the same pediatric nephrologist (J.C.M.C.). cades. However, sepsis as a cause of acute kidney failure These forms remained unchanged in the 2 decades of the dropped significantly from 23% (1979-1988) to 3% (1989- study and were intended for future review as well as for clini- 1998) (P .001). Figure 1 shows the organisms respon- cal use as a flow sheet. We obtained institutional review board sible for sepsis in each decade. Also, extensive burns pre- approval for this study. cipitating acute kidney failure accounted for 13% of acute The diagnosis of acute kidney failure was made by the kidney failure in the first decade, but dropped signifi- same attending nephrologist (J.C.M.C.) using the following cantly to 0% in the second decade. Pulmonary causes of criteria: a sudden cessation of kidney function characterized acute kidney failure among the nonsurvivors increased by oliguria, less than 0.5 mL/kg per hour, confirmed by rising levels of serum urea nitrogen and creatinine to double that of between the 2 decades, 7% to 12%, but this did not reach normal for age.1,6 Patients with preexisting chronic kidney statistical significance. Hematologic-oncologic causes of diseases4 were excluded. The criteria for admission to the ICU acute kidney failure among the nonsurvivors also in- was determined by the same 2 attendings (S.S.S. and J.J.M.), creased from 10% in the first decade to 22% in the sec- and were as follows: (1) the requirement of close monitoring ond decade, in association with bone marrow trans- of critically ill patients, such as those who were recovering plant rejections, leukemia, tumor lysis, hyperuricemia, from postcardiac surgery; (2) patients requiring invasive and other complications (Figure 2). While tumor lysis monitoring, that is, arterial lines, ventriculostomies, and oth- was an important cause of death in the first decade (Fig- ers; (3) those in congestive heart failure or respiratory failure ure 2), it was not so in the second, where the mortality requiring intubation; and (4) patients with MOSFs7 requiring rate from this cause was 0%. “Anticipatory” interven- invasive monitoring. The established criteria for MOSF were adjusted for age.7,8 The race, age, and other clinical character- tion is prevalent and the improved results may be attrib- istics of the children are summarized in Table 1. uted to this. The use of peritoneal dialysis (PD) dropped In the patients described herein, univariant analysis was from 60% of all acute renal replacement therapy in the used on all variables of interest in survivors and nonsurvivors. first decade to 44% in the second decade (Table 4). The Fisher exact and 2 tests were used to compare data between use of hemodialysis, continuous venovenous hemofil- the 2 decades (ie, decade 1, 1979-1988; decade 2, 1989-1998). tration (CVVH), and continuous arteriovenous hemo- A Kaplan-Meier survival plot for serum albumin concentra- filtration (CAVH) increased to 43% of acute renal re- tions was used. All values were expressed as mean ± SD. P .05 placement therapy in the second decade. Also, the interval denotes statistical significance. between renal consultation for acute kidney failure to the initiation of acute renal replacement therapy was *Frederic C. Bartter, possibly the longest serving branch chief of the 2.0 ± 1.8 days vs 1.9 ± 1.4 days, respectively, between National Heart, Lung, and Blood Institute at the National Institutes of Health, the 2 decades. always advocated the use of the National Institutes of Health’s data forms, referred by generations of clinical associates as “the yellow sheets,” to keep Figure 3 shows the data on mortality in acute kid- patient data and to plan research studies. ney failure in association with other organ failures. In the (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 894 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  3. 3. Table 2. Mortality in Acute Renal Failure in Association With Age First Decade (1979-1988), Second Decade (1989-1998), Total, Patients With Acute Renal Failure by Age No. (%) of Patients No. (%) of Patients No. (%) of Patients Nonsurvivors Neonate-infant, 1 d-1 y 17 (57) 18 (56) 35 (56) Toddler, 2-4 y 4 (13) 3 (9) 7 (11) School age, 5- 15 y 9 (30) 11 (34) 20 (32) Subtotal 30 (100) 32 (100) 62 (100) Survivors Neonate-infant, 1 d-1 y 26 (36) 28 (30) 54 (32) Toddler, 2-4 y 18 (25) 22 (24) 40 (24) School age, 5- 15 y 29 (40) 43 (46) 72 (43) Subtotal 73 (100) 93 (100) 166 (100) All Neonate-infant, 1 d-1 y 43 (42) 46 (37) 89 (39) Toddler, 2-4 y 22 (21) 25 (20) 47 (21) School age, 5- 15 y 38 (37) 54 (43) 92 (40) Total 103 (100) 125 (100) 228 (100) first decade, 27% of the patients died with 2 MOSFs; 3 MOSFs, 57%; and 4 MOSFs, 100%. However, in the sec- Table 3. Underlying Cause and Outcome ond decade of this study, 2 MOSFs had a mortality rate of Pediatric Acute Renal Failure of 13%; 3 MOSFs, 68%; and 4 MOSFs, 88%. First Decade Second Decade Examination of all serum variables on the compre- (1979-1988), (1989-1998), hensive metabolic profile, for example, sodium, potas- No. (%) No. (%) sium, chloride, carbon dioxide, cholesterol, calcium, glu- Variable of Patients of Patients P Value cose, and others, obtained immediately before acute kidney Survivors replacement therapy did not show significant differences HUS* 28 (38) 21 (22) .05 between survivors and nonsurvivors, with the exception Sepsis 15 (21) 18 (19) .05 of the serum albumin concentrations (Figure 4). The se- Hematologic-oncologic 6 (8) 16 (17) .05 rum albumin concentrations were 2.6 ± 0.7 g/dL in non- complications After cardiac surgery 6 (8) 8 (9) .05 survivors vs 3.3 ± 0.9 g/dL in survivors (P .05). Figure 5 Hypovolumenia 3 (4) 6 (7) .05 shows a survival distribution plot for serum albumin con- Others 15 (21) 24 (26) .05 centration. Hypoalbuminemia was significantly associ- Nonsurvivors ated with the nonsurvivors. After cardiac surgery 8 (27) 14 (44) .05 Sepsis 7 (23) 1 (3) .001 COMMENT Burns 4 (13) 0 .001 Pulmonary 2 (7) 4 (12) .05 We reviewed all English-language published reports since Hematologic-oncologic 3 (10) 7 (22) .05 1977 of acute kidney failure with 50 children or more complications Others 6 (20) 6 (19) .05 (Table 5). It was surprising to find a persisting scarcity of published data specifically addressing acute kidney fail- *HUS indicates hemolytic uremic syndrome. ure and its risk factors and morbidity and mortality in the pediatric population. In regard to our patient data on morbidity and mortality and critical illness, our criteria in our study compares favorably with the other pub- for ICU admission were (1) the requirement of close moni- lished series, despite the persistent requirement of ICU toring of critically ill patients, such as those who were admissions for this disease. recovering from cardiac surgery; (2) patients requiring Smoyer et al17 and Zobel et al18 indicated that pediat- invasive monitoring, that is, arterial lines, ventriculos- ric patients with acute kidney failure with MOSF, even when tomies, and others; (3) those in congestive heart failure treated with continuous kidney replacement therapy, sus- or respiratory failure requiring intubation; and (4) pa- tained a 60% to 100% mortality rate. In further review of tients with MOSFs, as established previously, requiring the pediatric literature (Table 5), we noted that few stud- invasive monitoring. Similar criteria for ICU admission ies examined the number of organ failures in relationship were used by Moghal et al7 resulting in 48% of their 227 to mortality rate in acute kidney failure.19-24 Our data children (1984-1991) with acute kidney failure admit- (Figure 3) show that the mortality rate between the 2 de- ted to their ICU compared with the 68% ICU admission cades dropped, even with 4 organs failing. The mortality rate in our present series. If criteria for admission to the rate fell from 100% to 88% in the second decade (1989- ICU are to be taken as life-threateningly ill, our patients 1998), possibly related to advances in antibiotics, earlier can be considered at least as critical as those in the other therapy, and better volume control in the recent decade. series (Table 5). Also, the overall mortality rate of 27% The examination by Shaw et al25 and Meeks and Sims26 ex- (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 895 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  4. 4. 1979-1988 1989-1998 Streptococcus Neisseria meningitidis Streptococcus Neisseria meningitidis Species Species Species 11% 33% 25% 22% Staphylococcus Species 11% Staphylococcus Species 8% Others Others 34% 45% Figure 1. Organisms responsible for sepsis in acute renal failure. Survivors Died Table 4. Need for ECMO, PD, HD, and CVVH* First Decade Second Decade 1979-1988 1989-1998 Procedure (1979-1988) (1989-1998) ECMO 3 (9) 9 (13) Leukemia PD 21 (60) 31 (44) HD 11 (31) 21 (29) CVVH 0 3 (4) Tumor Lysis CAVH 0 7 (10) Total 35 (100) 71 (100) Bone Marrow Transplants *Data are given as the number (total percentage) of the procedure. ECMO indicates extracorporeal membrane oxygenation; PD, peritoneal dialysis; HD, hemodialysis; CVVH, continuous venovenous hemofiltration; Others and CAVH, continuous arteriovenous hemofiltration. 0 1 2 3 0 1 2 3 4 5 6 No. of Patients No. of Patients difference is due to changes in the attending surgeons, in- creased complexity of patients with heart disease in the sec- Figure 2. Hematologic-oncologic complications associated with acute renal failure. ond decade, and differences in techniques. Although mortality from acute kidney failure sec- ondary to an underlying cardiac diagnosis did not amination of 831 children with MOSFs did not provide spe- appear to have changed significantly when data cific data on the 5% of their patients who developed kid- between the 2 decades were compared, there was a shift ney failure. However, our data of 57% to 68% mortality with in other underlying diagnoses. In the first decade, acute 3 MOSFs are lower than the 89% mortality reported by Shaw kidney failure associated with cardiac surgery was the et al25 and Meeks and Sims,26 again verifying that ad- major cause of mortality, followed by sepsis (Table 3), vances in technology appear to have allowed us to im- burns, pulmonary, and hematologic-oncologic compli- prove our management of this particular risk factor. cations. Among nonsurvivors, sepsis-associated acute Despite the tremendous advances in the last decade kidney failure dropped from 23% in the first decade to of both critical care management and kidney replacement 3% in the second decade (P .001) presumably, again, therapy, however, the significant finding in our study was because of advances in antibiotic therapy and better the persistently high mortality rate of critically ill patients management of fluid volume control. Although the after cardiac surgery. Patients frequently developed acute organisms causing sepsis did not change in the 2 kidney failure as a result of poor perfusion and hypoxia sec- decades (Figure 1), there was an increased emergence ondary to prolonged pump time during surgery for con- of methicillin-resistant Staphylococcus aureus in the first genital heart disease, 27% in the first decade, 44% in the decade and of penicillin-resistant Streptococcus pneumo- second decade among the nonsurvivors. The younger the niae in the second decade. Despite these changes in sen- patient, the poorer the prognosis, especially in patients sitivity, we managed to have better outcomes in the sec- younger than 1 year (Table 2). It is also possible that the ond decade. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 896 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  5. 5. P <.05 1979-1988 1989-1998 100 4 Serum Albumin Level, mg/dL Mortality Rate, % 50 2 0 2 3 4 0 No. of Multiple Organ System Failures Nonsurvivors Survivors Figure 3. Mortality in association with multiple organ system failure. Figure 4. Mean ± SD serum albumin concentration obtained before acute renal replacement therapy. Also, in the second decade, the noncardiac causes of 100 death shifted to hematologic-oncologic complications, for example, leukemic-tumor lysis, hyperuricemia, bone mar- row transplantation (Figure 2), and respiratory failure. 80 The incidence of hematologic-oncologic complications Survival Rate, % associated with death in acute kidney failure increased in the second decade possibly because of the increase in aggressive chemotherapy, management, and bone 60 marrow transplantation availability. The latter proce- dure was unavailable in the first decade of this study (Figure 2). 40 The significant drop in burns as a cause of acute kid- ney failure in the second decade may be partly due to a 0 10 20 30 40 50 60 70 80 90 100 110 120 change in burn care management, as the care of pediatric No. of Days burn patients was taken over by a newly developed burn Figure 5. Hypoalbuminemia as a significant risk factor of mortality. unit independent of the pediatric ICU in the second de- Kaplan-Meier survival curve for serum albumin concentration shows that 20% cade. It would also appear that burn prevention and man- of the patients with hypoalbuminemia died by day 5 and 40% died by day 30. agement have improved to a degree that the hypovolemia of burns is successfully eliminated as a significant cause of acute kidney failure in the second decade. size of the patients. Finally, the higher mortality rate Another important and significant risk factor for in this age group could possibly be due to other asso- mortality was age. The youngest patients showed a ciated congenital anomalies.19-27 higher mortality rate. Most published studies of acute Our data indicated that in the more recent decade kidney failure in early life are small series19-26 of fewer (1989-1998), the use of acute PD had decreased signifi- than 25 patients, yet the mortality rate is high.19-26 In cantly (Table 4). Acute hemodialysis, CVVH, CAVH, our study, neonates and infants, aged 1 day to 1 year, and renal replacement procedures were used more fre- represented 57% of the total nonsurvivor group quently than before, with a corresponding decrease in (Table 2), and they composed a very large part of the the use of PD. This trend of moving away from acute PD postcardiac acute kidney failure group. In addition, in favor of acute hemodialysis, CVVH, or CAVH in re- the 12 patients requiring extracorporeal membrane nal replacement therapy in acute kidney failure was oxygenation were all in the neonatal age group. Extra- first suggested by a questionnaire survey of pediatric corporeal membrane oxygenation, in turn, led to the nephrologists by Warady and Bunchman.28 Our data choice of CVVH or CAVH over PD in all of these over the span of 20 years substantiated this trend. Acute infants because of the availability of dialysis access. PD, of course, will still be done via Tenckhoff cannula, These observations in morbidity and mortality are in especially for our younger patients. However, CVVH and accord with the observations of Gong et al16 that coma, CAVH will probably be preferred, especially whenever hypovolemia, respiratory failure, and acute tubular extracorporeal membrane oxygenation is used with its necrosis in infants younger than 1 year remain signifi- need to limit the risk of infection from PD in this particu- cant mortality risk factors. Acute kidney failure in lar group, as well as dialysis access availability. neonates and infants19-27 also represents a special clini- In addition, acute kidney replacement therapy was cal and technical challenge, because of the tiny body initiated within 1.9 ± 1.4 days in the more recent (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 897 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  6. 6. Table 5. Critically Ill Pediatric Patients With Acute Renal Failure* Total Overall % of Patients Study Year of Sample Mortality Survival Needing Period Publication Source Country Size Rate, % Rate, % Dialysis Age Conclusions 1971-1975 1977 Counahan et al10 UK 70 20 80 63 1.8-11.2 y Close association with adult renal unit an advantage 1968-1977 1978 Hodson et al11 USA 53 45 55 100 1 d-15 y Underlying and/or concomitant disorders have major influence; early dialysis improves survival 1980-1982 1983 Elzouki et al12 Libya 93 8 92 10 1 d-14 y Dehydration ATN major cause of ARF; excellent recovery after fluid replacement 13 1969-1982 1985 Niaudet et al France 125 11 89 98 1 d-16 y Outcome depended primarily on underlying disease 1987-1990 1991 Reznik et al14 USA 50 50 50 100 1 d-15.5 y Acute PD safer than extracorporeal techniques 1978-1990 1993 Gallego et al15 Spain 138 39 61 38 2 d-15 y Assisted ventilation and dialysis are comortality factors 1989-1994 1996 Arora et al1 India 80 43 58 69 15 y Neurological, respiratory, or cardiac complications poor prognostic factors; HUS still significant mortality 1984-1991 1998 Moghal et al7 UK 227 25 75 90 1 d-15 y ARF nearly always secondary event; major mortality factor, surgery for congenital heart disease 1986-1994 2000 Lowrie8 USA 62 89 11 100 1 d-15 y An important goal of renal support in MOSF is prevention of fluid overload; CHDF appears more effective than PD in maintaining fluid balance 1980-1998 2000 Gong et al16 Singapore 66 68 32 91 1 d-19 y Despite increasing use of CHDF over last 3 years, no significant improvement, probably related to patients being more critically ill 1979-1998 2002 Williams USA 228 27 73 38 1 d-18 y CHF with ARF, a significant mortality risk especially in young patient after cardiac surgery *Only includes studies with 50 children or more. UK indicates United Kingdom; USA, United States of America; ATN, acute tubular necrosis; ARF, acute renal failure; PD, peritoneal dialysis; HUS, hemolytic uremic syndrome; MOSF, multiple organ system failure; CHDF, continuous hemodiafiltration; ECMO, extracorporeal membrane oxygenation; and CHF, congestive heart failure. decade (1989-1998) compared with 2.0 ± 1.8 days in by Arora et al,1 late referral resulting in more critically the previous decade (1979-1988) between the renal ill patients was the reason given for the higher mortality consultation and the start of acute kidney dialysis. Our rate. This is understandable with the persistence of data begin with our initial consultation, which naturally significant differences in availability of medical care and affects our initiation of dialysis. Thus, together, our data gross national income between the United States suggest more favorable outcomes with earlier, rather and India. This continuing difference also has a greater than later, time lags of 4.2 to 4.8 days between the onset significant effect on both chronic and acute kidney of kidney failure and the start of dialysis as reported by diseases and the long-term survival of children in Arora et al.1 India. An interesting finding in our analysis was that In long-term dialysis for end-stage kidney HUS29 represented the largest group of survivors, with- disease, 4,31-34 hypoalbuminemia is shown to be an out differences between the 2 decades. There was only 1 index of malnutrition and a predictor of mortality. death in our group of 49 patients with HUS, a 21⁄2-year- Although Obialo et al35 showed that hypoalbuminemia old, resulting in a 2% mortality rate. This conforms to ( 3.5 g/dL) can be a useful predictor of mortality in the decrease in HUS mortality from 40% in the past to adults with acute kidney failure, this had not been 5% in recent years.30 Although we used the same crite- examined in children. Our data (Figure 4) showed ria for initiation of dialysis in acute kidney failure that there is a significantly lower serum albumin pre- throughout the 2 decades, we were more aggressive in dialysis level between nonsurvivors (2.6 ± 0.7 g/dL) using dialysis in the recent decade. For example, we and survivors (3.3 ± 0.9 g/dL) (P .05). In addition, used dialysis in 57% of the patients with HUS in the the cumulative survival data (Figure 5) clearly estab- second decade compared with 21% in the first decade. lished that hypoalbuminemia could discriminate The improved survival in HUS in our study may be between the survivors and the nonsurvivors, with 40% related to our more aggressive dialysis therapy. These dying by day 30. Thus, our data ascertain the efficacy findings contrast with the current 68% mortality rate of using serum albumin concentration as a copredictor in India. In this series of 25 patients with HUS reported of mortality in pediatric acute kidney failure. Obialo et (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 898 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  7. 7. What This Paper Adds We thank Sung C. Choi, PhD, for statistical support; Karl S. Roth, MD, and K. C. Lin, MSc, for review; and Betty Timozek for secretarial assistance. There is a scarcity of up-to-date published data spe- This study was presented as a poster at the World Con- cifically addressing acute kidney failure in children. gress of Nephrology American Society of Nephrology/ Studies involving large numbers of children with this International Society of Nephrology, San Francisco, Calif, disorder are also rare. Because it can be such a cata- strophic, life-threatening event, it is important for October 14-17, 2001. community pediatricians to recognize the clinical fea- Corresponding author and reprints: James C. M. Chan, tures of this disease with regard to morbidity and MD, The Barbara Bush Children’s Hospital, Maine Medi- mortality. We report a 20-year experience of 228 chil- cal Center, 22 Bramhall St, Portland, ME 04102-3175 dren at the same institution with the same intensivists (e-mail: and nephrologist. The results of our analysis suggest that although we have improved in most areas of care and manage- REFERENCES ment, we still fared poorly with our patients in infancy. The data also provided evidence that during 1. Arora P, Kher V, Rai PK, Singhal MK, Gulati S, Gupta A. Prognosis of acute renal the first decade, burns and sepsis were major comor- failure in children: a multivariate analysis. Pediatr Nephrol. 1997;11:153- bid factors, but not so in the second decade. In addi- 155. tion, more CVVH, CAVH, and less PD were done in 2. Wilkinson JD, Pollack MM, Ruttimann UE, Glass NL, Yeh TS. Outcome of pedi- the recent decade compared with the earlier decade. atric patients with multiple organ system failure. Crit Care Med. 1986;14:271- We conclude that acute kidney failure in childhood 274. continues to carry significant mortality risks, espe- 3. Wilkinson JD, Pollack MM, Glass NL, Kanter RK, Katz RW, Steinhart CM. Mor- cially in the presence of other organ failures. Finally tality associated with multiple organ system failure and sepsis in pediatric in- hypoalbuminemia, rather than elevated levels of tensive care unit. J Pediatr. 1987;111:324-328. 4. Gulati S, Stephens D, Balfe JA, Secker D, Harvey E, Balfe JW. Children with hypo- serum urea nitrogen or creatinine, at the start of dialy- albuminemia on continuous peritoneal dialysis are at risk for technique failure. sis is a significant copredictor of mortality. Kidney Int. 2001;59:2361-2367. 5. Swaniker F, Kolla S, Moler F, et al. Extracorporeal life support outcome for 128 pediatric patients with respiratory failure. J Pediatr Surg. 2000;35:197- 202. 6. Gettings LG, Reynolds HN, Scalea T. Outcome in post-traumatic acute renal fail- al35 also suggested that low albumin concentrations in ure when continuous renal replacement therapy is applied early vs late. Inten- adult patients may be correlated with the activation of sive Care Med. 1999:25:805-813. 7. Moghal NE, Brocklebank JT, Meadow SR. A review of acute renal failure inflammatory mediators. Studies on a molecular basis in children: incidence, etiology and outcome. Clin Nephrol. 1998;49:91- of these observations may illuminate new avenues to 95. improve survival in these patients. 8. Lowrie LH. Renal replacement therapies in pediatric multiorgan dysfunction syn- drome. Pediatr Nephrol. 2000;14:6-12. 9. Chan JCM. Lessons from 20 years of leading a pediatric nephrology program. CONCLUSIONS Nephron. 1998;78:378-388. 10. Counahan R, Cameron JS, Ogg CS, et al. Presentation, management, complica- We have seen that postcardiac surgery36 associated tions, and outcome of acute renal failure in childhood: five years’ experience. with acute kidney failure remains the leading mortal- BMJ. 1977;1:599-602. ity risk factor. Hematologic-oncologic complications 11. Hodson EM, Kjellstrand CM, Mauer SM. Acute renal failure in infants and chil- have become a more frequent cause of acute kidney dren: Outcome of 53 patients requiring hemodialysis treatment. J Pediatr. 1978; 93:756-761. failure in the recent decade because of advances in 12. Elzouki AY, Amin F, Jaiswal OP. Prevalence and pattern of renal disease in east- care management. Sepsis as an associated cause of ern Libya. Arch Dis Child. 1983;58:106-109. acute kidney failure dropped from 23% to 3% in the 13. Niaudet P, Haj-Ibrahim M, Gagnadoux MF, Broyer M. Outcome of children with last 2 decades although the organisms responsible for acute renal failure. Kidney Int Suppl. 1985;28:S148-S151. the sepsis did not change. Our data on acute dialysis 14. Reznik VM, Griswold WR, Peterson BM, Rodarte A, Feris ME, Mendoza SA. Peri- toneal dialysis for acute renal failure in children. Pediatr Nephrol. 1991;5:715- indicated less PD being done in the recent decade, a 717. trend previously suggested in a questionnaire survey.28 15. Gallego N, Gallego A, Pascual J, Liano F, Estepa R, Ortuno J. Prognosis of Also, although mortality risks increase significantly children with acute renal failure: a study of 138 cases. Nephron. 1993;64:399- with MOSFs in association with acute kidney failure in 404. 16. Gong WK, Tan TH, Foong PP, Murugasu B, Yap HK. Eighteen years experience adults,37 our data in this study suggest a slightly better in pediatric acute dialysis: analysis of predictors of outcome. Pediatr Nephrol. prognosis in children.38,39 Another significant comor- 2001;16:212-215. bid risk factor is young age (ie, 1 year), combined 17. Smoyer WE, McAdams C, Kaplan BS, Sherbotie JR. Determinants of survival with the need for extracorporeal membrane oxygen- in pediatric continuous hemofiltration. J Am Soc Nephrol. 1995;6:1401- ation due to respiratory failure secondary to problems 1409. 18. Zobel G, Kuttnig M, Ring E, Grubbauer HM. Clinical scoring systems in children in fluid management. Finally, our data suggest that with continuous extracorporeal renal support. Child Nephrol Urol. 1990;10: hypoalbuminemia is a copredictor of mortality in 14-17. pediatric acute kidney failure. 19. Ronco C, Brendolan A, Bragantini L, et al. Treatment of acute renal failure in new- borns by continuous arterio-venous hemofiltration. Kidney Int. 1986;29:908- Accepted for publication April 4, 2002. 915. 20. Grylack L, Medani C, Hultzen C, et al. Nonoliguric acute renal failure in the new- This study was supported by grants T32 DK07761 and born: a prospective evaluation of diagnostic indexes. AJDC. 1982;136:518-520. R01 DK50419 from the National Institutes of Health, 21. Griffin NK, McElnea J, Barratt M. Acute renal failure in early life. Arch Dis Child. Bethesda, Md (Dr Chan). 1976;51:459-462. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 899 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.
  8. 8. 22. Norman ME, Asadi FK. A prospective study of acute renal failure in the newborn 32. Struijk DG, Krediet RT, Koomen GC, Boeschoten EW, Arisz L. The effect of se- infant. Pediatrics. 1979;63:475-479. rum albumin at the start of continuous ambulatory peritoneal dialysis treatment 23. Zobel G, Ring E, Muller W. Continuous arteriovenous hemofiltration in prema- on patient survival. Perit Dial Int. 1994;14:121-126. ture infants. Crit Care Med. 1989;17:534-536. 33. Owen WF Jr, Lew NL, Liu Y, Lowrie EG, Lazarus JM. The urea reduction ratio 24. Aschinberh LC, Zeis PM, Hageman JR, Vidyasagar D. Acute renal failure in the and serum albumin concentration as predictors of mortality in patients under- newborn. Crit Care Med. 1977;5:36-42. going hemodialysis. N Engl J Med. 1993;329:1001-1006. 25. Shaw NJ, Brocklebank JT, Dickinson DF, Wilson N, Walker DR. Long-term out- 34. Teehan BP, Schleifer CR, Brown JM, Sigler MH, Raimondo J. Urea kinetic analy- come for children with acute renal failure following cardiac surgery. Int J Car- sis and clinical outcome on CAPD: a five year longitudinal study. Adv Perit Dial. diol. 1991;31:161-166. 1990;6:181-185. 26. Meeks AC, Sims DG. Treatment of renal failure in neonates. Arch Dis Child. 1988; 35. Obialo CI, Okonofua EC, Nzerue MC, Tayade AS, Riley LJ. Role of hypoalbumin- 63:1372-1376. emia and hypocholesterolemia as copredictors of mortality in acute renal fail- 27. Niaudet B, Haesner M, Precht K. Prognosis of acute dialysis dependent renal fail- ure. Kidney Int. 1999;56:1058-1063. ure [in German]. Z Urol Nephrol. 1990;83:625-628. 36. Picca S, Principato F, Mazzera E, et al. Risks of acute renal failure after cardio- 28. Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: pulmonary bypass surgery in children: a retrospective 10-year case-control study. survey results. Pediatr Nephrol. 2000;15:11-13. Nephrol Dial Transplant. 1995;10:630-636. 29. Tonshoff B, Sammet A, Sanden I, Mehls O, Waldherr R, Scharer K. Outcome and 37. Liano F, Garcia-Martin F, Gallego A, et al. Easy and early prognosis in acute prognostic determinants in hemolytic uremic syndrome in children. Nephron. tubular necrosis: a forward analysis of 228 cases. Nephron. 1989;51:307- 1994;68:63-70. 313. 30. Remuzzi G, Ruggenenti P. The hemolytic uremic syndrome. Kidney Int. 1995; 38. Ellis D, Avner ED, Starzl TE. Renal failure in children with hepatic failure under- 48:2-19. going liver transplantation. J Pediatr. 1986;108:393-398. 31. Blake PG, Flowerdew G, Blake RM, Oreopoulos DG. Serum albumin in patients 39. Hand MM, Alexander SR, Harmon WE. Intensive care. In: Barratt TM, Avner ED, on continuous ambulatory peritoneal dialysis: predictors and correlations with Harmon WE, eds. Pediatric Nephrology. Baltimore, Md: Lippincott Williams & outcomes. J Am Soc Nephrol. 1993;3:1501-1507. Wilkins; 1998:1135-1150. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 156, SEP 2002 WWW.ARCHPEDIATRICS.COM 900 Downloaded from on October 20, 2010 ©2002 American Medical Association. All rights reserved.