Acute Renal
failure
management
Moderator
Dr Sudha Rudrappa
Dr. Vinayaka hegde
Clinical Approach to AKI:
Pre-, Intra-, and Post-Renal
History
Volume status
Ultrasound
Urinalysis US shows
Hydronephrosis...
Lab Findings
 Anemia : Dilutional or hemolytic eg. SLE, renal vein
thrombosis, HUS
 Leukopenia : SLE, sepsis
 Thrombocy...
 CXR : cardiomegaly, pulmonary congestion (fluid
overload) or pleural effusions.
 Renal USG :
Hydronephrosis /hydrourete...
 Sensitivity and specificity of urine Na of <20 in
differentiating prerenal azotemia from acute
tubular necrosis are 90% ...
 Other biomarkers:
- changes in plasma neutrophil gelatinase-
associated lipocalin (NGAL) and cystatin C
levels
- urinary...
Treatment of AKI
Aims of treatment:
1.Maintenance of Fluid and Electrolyte
Homeostasis
2.Preventing Life-threatening Compl...
 The treatment of AKI divided into:
 Nondialytic therapy
(supportive therapy and medical management)
 Dialytic therapy .
Management
 Catheterization - in newborn with suspected
posterior ureteral valves & nonambulatory
older children.
The nondialytic therapy:
to date the only effective nondialytic treatment of AKI entails:
1. Restoration of adequate renal...
Creatinine clearance, GFR
 CrCl (ml/min/1.73m2)=
K * lengh(cm)/Pcr
K = 0.35 fr preterm/LBW till 1 yr
0.45 fr term ,<1yr
0...
Est Creatinine clearnce
 (U. creatinine/ S.creatinine )Urine vol *
1.73/BSA
in Ml/min/m2
Assessment of the patient for fluid balance

 Weight, BP, heart rate, skin turgor and capillary
refill are each used to ...
If U.O.P. does not increase and azotemia
does not improve after fluid resuscitation,
then catheterization of the blader an...
 2- for fluid overload, fluid restriction or fluid
removal with dialysis or hemofiltration may be
instituted if the child...
Excess losses need to be accounted for as well and
replaced with the appropriate fluid.
In general, glucose containing sol...
7- Nutritional support
 . AKI is associated with marked catabolism &
malnutrition leading to delayed recovery from
AKI
 ...
. In older children a diet of high-
biologic-value protein, low-
phosphorus& low-potassium foods can
be used.
.Infants sho...
If enteral feeding are not possible, then
hyperalimentation, usually through a central
line, with high concentration of
de...
Therapy to Decrease injury and promote
Recovery
 Recovery of Renal function after ATN requires a
complex & not fully unde...
2- Administration of melatonin-stimulating hormone,
thyroxine,
C5a receptor antagonist,
selective inhibitors of inducible ...
 Diuretic therapy :
 Only after the adequate hydration.
 Mannitol (0.5 g/kg) and furosemide (2-4 mg/kg) - as a
single I...
 Hyperkalemia
 Sr K >6 mEq/L - cardiac arrhythmia, cardiac arrest, and
death.
 Earliest ECG change - peaked T waves f/b...
Table : Treatment of Hyperkalemia
Agent Mechanism Dose Onset of effect Complications
Sodium
bicarbonate
Shifts K+ into cel...
 If Sr K >7 mEq/L : emergency measures in
addition to Kayexalate.
 Calcium gluconate 10% solution : 1.0 mL/kg IV,
over 3...
Mild metabolic acidosis:
common in ARF - rarely requires treatment.
If severe (arterial pH < 7.15;
serum bicarbonate < 8 ...
 Hypocalcemia :
- Primarily treated by lowering the serum
phosphorus level.
- Calcium should not be given IV except in
ca...
 Hyponatremia
- most commonly a dilutional
- must be corrected by fluid restriction.
- hypertonic (3%) saline - limited t...
 GI bleeding
 because of uremic platelet dysfunction,
increased stress, and heparin exposure in
hemodialysis.
 Oral or ...
 Hypertension
 Common in ARF patients with acute
glomerulonephritis or HUS.
 Salt and water restriction, diuretics
 Is...
 Neurologic symptoms
 Headache, seizures, lethargy, and confusion
(encephalopathy).
 Potential etiologic factors - hypo...
 Anemia of ARF
 generally mild
 packed red blood cells if Hb < 7 g/dL
 Slow (4-6 hr) transfusion with packed red
blood...
 Nutrition
 In most cases, sodium, potassium, and
phosphorus should be restricted.
 Protein – restricted & caloric inta...
 Protein :
 enough protein for growth - limiting high protein intake.
 Protein needs increase on dialysis.
 Foods with...
 Sodium.
 Depend on stage of their kidney disease,
their age, and sometimes other factors.
 Foods high in sodium includ...
Potassium.Low-potassium High-potassium
- Apples
––cranberries
––strawberries
––blueberries
––raspberries
––pineapple
––cab...
Dialysis
Indications
 Volume overload with evidence of hypertension or
pulmonary edema refractory to diuretic therapy
 ...
Types of Dialysis
 Peritoneal dialysis
 Intermittent hemodialysis
 Continuous renal replacement therapy
Choice of procedure
depends on
 1. Age &size
 2. Cardiovascular status
 3. Availability of vascular acess
 4. Integrit...
Take Home Points
 Management of a patient with ARF involves:
 Treating potentially life-threatening complications
 Reve...
Referances
 Nelson Textbook of pediatrics 19 th edition
 Treatment Methods for Kidney Failure in
Children (National inst...
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
Acuterenalfailure management in children
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Acuterenalfailure management in children

  1. 1. Acute Renal failure management Moderator Dr Sudha Rudrappa Dr. Vinayaka hegde
  2. 2. Clinical Approach to AKI: Pre-, Intra-, and Post-Renal History Volume status Ultrasound Urinalysis US shows Hydronephrosis Post-Renal Urinalysis Normal Urinalysis Abnormal Tubulointerstial Disorders Glomerular and Vascular Disorders Pre-renal
  3. 3. Lab Findings  Anemia : Dilutional or hemolytic eg. SLE, renal vein thrombosis, HUS  Leukopenia : SLE, sepsis  Thrombocytopenia :SLE, renal vein thrombosis, sepsis, HUS  Hyponatremia : dilutional  Metabolic acidosis  Elevated BUN, creatinine, uric acid, potassium, and phosphate (diminished renal function); and hypocalcemia (hyperphosphatemia).
  4. 4.  CXR : cardiomegaly, pulmonary congestion (fluid overload) or pleural effusions.  Renal USG : Hydronephrosis /hydroureter, Nephromegaly- s/o intrinsic renal disease. Small kidney - Nephrosclerosis , CRF  Renal biopsy : who do not have clearly defined prerenal or postrenal ARF
  5. 5.  Sensitivity and specificity of urine Na of <20 in differentiating prerenal azotemia from acute tubular necrosis are 90% and 82%, respectively.  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)
  6. 6.  Other biomarkers: - changes in plasma neutrophil gelatinase- associated lipocalin (NGAL) and cystatin C levels - urinary changes in NGAL, interleukin-18 (IL-18), and kidney injury molecule-1 (KIM-1).
  7. 7. Treatment of AKI Aims of treatment: 1.Maintenance of Fluid and Electrolyte Homeostasis 2.Preventing Life-threatening Complications 3.Avoiding Further Kidney Injury 4.Providing Appropriate Nutrition 5.RRT in most severe forms of AKI
  8. 8.  The treatment of AKI divided into:  Nondialytic therapy (supportive therapy and medical management)  Dialytic therapy .
  9. 9. Management  Catheterization - in newborn with suspected posterior ureteral valves & nonambulatory older children.
  10. 10. The nondialytic therapy: to date the only effective nondialytic treatment of AKI entails: 1. Restoration of adequate renal blood flow 2. Avoidance of nephrotoxic medications or those that interfere with renal compensatory mechanisms 3. Assurance that renal perfusion has been maximized before exposure to nephrotoxic agents.
  11. 11. Creatinine clearance, GFR  CrCl (ml/min/1.73m2)= K * lengh(cm)/Pcr K = 0.35 fr preterm/LBW till 1 yr 0.45 fr term ,<1yr 0.55 fr children & adolescent girls 0.70 fr adolescent boys
  12. 12. Est Creatinine clearnce  (U. creatinine/ S.creatinine )Urine vol * 1.73/BSA in Ml/min/m2
  13. 13. Assessment of the patient for fluid balance   Weight, BP, heart rate, skin turgor and capillary refill are each used to assess the intravascular volume.  1- in children who are intravascular volume depleted, 10-20 ml / kg of normal saline can be infused to re-establish intravascular volume (dehydrated pt. generally void with in 2 hours) .
  14. 14. If U.O.P. does not increase and azotemia does not improve after fluid resuscitation, then catheterization of the blader and central venous pressure monitoring may be necessary to further guide fluid therapy. the CVP normally between 2 and 12 cm H2O. If clinical and laboratory evaluations show that the patient is adequately hydrated, then aggressive diuretic therapy may be considered
  15. 15.  2- for fluid overload, fluid restriction or fluid removal with dialysis or hemofiltration may be instituted if the child does not respond to diuretic therapy.  When intravascular volume normalized, euvoluemia can be maintained by providing the child with fluid to replace normal water losses from the skin, respiratory tract, and GIT (insensible losses, 400 ml / m2 / 24hr. + UOP)
  16. 16. Excess losses need to be accounted for as well and replaced with the appropriate fluid. In general, glucose containing solutions (10- 30%) with out electrolytes are used as maintenance fluids . The composition of the fluid may be modified in accordance with the state of electrolyte balance. Daily weight measurements, BP, accurate fluid input & output records, physical examination and nutritional needs of the child guide on going fluid therapy.
  17. 17. 7- Nutritional support  . AKI is associated with marked catabolism & malnutrition leading to delayed recovery from AKI  . if GIT is intact and functional, enteral feedings with formula (similac PM 60/40 for Newborns & infants) should be instituted .  . Dilute formula should be given initially and then feedings can be increase and concentrated to achieve optimal calories intake.
  18. 18. . In older children a diet of high- biologic-value protein, low- phosphorus& low-potassium foods can be used. .Infants should receive maintenance calories (120 Kcal/kg/day) and older children appropriate maintenance calories plus 20% extra calories due to the catabolic state and malnutrition.
  19. 19. If enteral feeding are not possible, then hyperalimentation, usually through a central line, with high concentration of dextrose (25%), lipids (10-20%), and protein (0.5-1.25g/kg/day) should be instituted . If the child is oliguric or anuric and sufficient caloric intake cannot be achieved while appropriate fluid balance is maintained, dialysis should be initiated earlier than in the usual case.
  20. 20. Therapy to Decrease injury and promote Recovery  Recovery of Renal function after ATN requires a complex & not fully understood set of events that leads to restoration of renal blood flow and regeneration of renal tubular epithelial cells  1- Post-ischemic infusion of growth factors including  IGF-1, epidermal GF & hepatocyte GF → accelerate recovery of renal impairment .
  21. 21. 2- Administration of melatonin-stimulating hormone, thyroxine, C5a receptor antagonist, selective inhibitors of inducible nitric oxide synthase, statins & Novel inhibitor of the Na / H exchange subtype 3 as well as inhibition of monocyte chemoattractant protein 1 by gene therapy has been shown to ameliorate AKI 3- Other studies demonstrate that anti-adhesion molecule therapy markedly decrease ischemic renal injury by preventing adhesion of activated neutrophils to renal cells.
  22. 22.  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.
  23. 23.  Hyperkalemia  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 cardiac arrest.  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.
  24. 24. Table : Treatment of Hyperkalemia Agent Mechanism Dose Onset of effect Complications Sodium bicarbonate Shifts K+ into cells 0.5-1 mEq/kg IV over 10-30 min. 15-30 min. Hypernatremia Change in ionized calcium level Calcium gluconate (10%) Stabilizes membrane potential 0.5-1 mL/kg over 5-15 min. Immediate Bradycardia Arrhythmias Hypercalcemia Glucose and insulin Stimulates cellular uptake of K+ glucose50% 1ml/kg insulin 0.1 U/kgIV over 60min. 30-120 min. Hypoglycemia β – Agonists (albuterol)a Stimulates cellular uptake of K+ 5-10 mg nebulizer (adult dose) 30 min. Tachycardia Hypertension Sodium polystyrene sulfonate (Kayexalate) Exchanges Na+ for K+ across colonic mucosa 1g/kg PO or PR in sorbitol 30-60 min. Hypernatremia Constipation
  25. 25.  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 5- 10 min  Regular insulin : 0.1 U/kg, with glucose 50% solution, 1 mL/kg, over 1 hr
  26. 26. Mild metabolic acidosis: common in ARF - rarely requires treatment. If severe (arterial pH < 7.15; serum bicarbonate < 8 mEq/L) or contributes to hyperkalemia it should be corrected.
  27. 27.  Hypocalcemia : - Primarily treated by lowering the serum phosphorus level. - Calcium should not be given IV except in cases of tetany, to avoid deposition of calcium salts into tissues. - Follow a low-phosphorus diet,
  28. 28.  Hyponatremia - most commonly a dilutional - must be corrected by fluid restriction. - hypertonic (3%) saline - limited to symptomatic hyponatremia (seizures, lethargy) or those with a serum sodium level <120 mEq/L.
  29. 29.  GI bleeding  because of uremic platelet dysfunction, increased stress, and heparin exposure in hemodialysis.  Oral or intravenous H2 blocker-Ranitidine.
  30. 30.  Hypertension  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
  31. 31.  Neurologic symptoms  Headache, seizures, lethargy, and confusion (encephalopathy).  Potential etiologic factors - hyponatremia, hypocalcemia, hypertension, cerebral hemorrhage, cerebral vasculitis, and the uremic state.  Diazepam - most effective in controlling seizures,  Treat the underlying cause.
  32. 32.  Anemia of ARF  generally mild  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 of hypervolemia.
  33. 33.  Nutrition  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
  34. 34.  Protein :  enough protein for growth - limiting high protein intake.  Protein needs increase on dialysis.  Foods with protein include Eggs Milk Cheese Chicken Fish Red meats Beans Yogurt Cottage cheese
  35. 35.  Sodium.  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
  36. 36. Potassium.Low-potassium High-potassium - Apples ––cranberries ––strawberries ––blueberries ––raspberries ––pineapple ––cabbage ––boiled cauliflower ––mustard greens - Oranges ––melons ––apricots ––bananas ––potatoes ––tomatoes ––sweet potatoes ––cooked spinach
  37. 37. Dialysis Indications  Volume overload with evidence of hypertension or pulmonary edema refractory to diuretic therapy  Persistent hyperkalemia  Severe metabolic acidosis unresponsive to medical management  Neurologic symptoms (altered mental status, seizures)  Blood urea nitrogen >100-150 mg/dL (or lower if rapidly rising)  Calcium:phosphorus imbalance, with hypocalcemic tetany
  38. 38. Types of Dialysis  Peritoneal dialysis  Intermittent hemodialysis  Continuous renal replacement therapy
  39. 39. Choice of procedure depends on  1. Age &size  2. Cardiovascular status  3. Availability of vascular acess  4. Integrity of peritoneal membrane & abdominal cavity  5. Expertise available
  40. 40. Take Home Points  Management of a patient with ARF involves:  Treating potentially life-threatening complications  Reversing pre-renal and post-renal causes  Minimizing further hemodynamic and toxic insults to the kidney stoppage of offending agent  Admission and appropriate consultation in time  Lack of evidence for converting oliguric to non-oliguric ARF  Features of the history and physical examination in addition to relevant lab and radiologic investigations help to determine the most likely cause(s) of ARF in a given patient and appropriate Rx for the same
  41. 41. Referances  Nelson Textbook of pediatrics 19 th edition  Treatment Methods for Kidney Failure in Children (National instt. of Diabetes & Kidney disease)  Bagga’s nephrology
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