ACUTE RENAL FAILURE IN THE NEONATEBackground Acute renal failure requiring treatment occurs rarely in the neonatalperiod. It is usually diagnosed after a period (<24 hours) of anuria. Therapyshould be directed towards treating the underlying cause and coexistinghyperkalaemia, oedema and acidosis. The following options should beconsidered (after discussion with a consultant):For anuria a fluid bolus (20ml/kg saline) with 2mg/kg frusemide stat. If nourine output afterwards, restrict fluids to 60ml/kg/day. Ensure that blood sugarremains in normal range.For hyperkalaemia if true serum potassium above 7.5 mmol/l or ecgabnormalities (peaked t waves, prolonged qrs segments or arrythmia)administer salbutamol intravascularly (see formulary for dose). If potassiumremains raised or recurrent ecg abnormalities repeat salbutamol and considerglucose and insulin infusion (see formulary for dose) and consider whetherdialysis would be appropriate. Correct coexisting acidosis (see below) andconsider calcium gluconate to stabilise membrane excitability. (correction ofhyperkalaemia is only a holding measure prior to possible earlyrecovery or commencement of dialysis)For acidosis Treat with NaHCO3 intravenously (after correcting for lowcalcium if present). If persists, consider dialysis.For oedema Fluid restrict as above and consider dialysis.General Avoid nephrotoxic drugs and consider whether doses ofother medication needs to be modified.If dialysis is being considered – involve renal physicians early in order thatthey can organise their commitments appropriately. Prior to dialysis order arenal ultrasound and clotting studies.PERITONEAL DIALYSISEQUIPMENT• Catheter – usually brought by renal team from AHCH• Paediatric PD set (LL225) with warming bag• Fenwall blood warmer• Dialysis fluid – Intraneal fluid nos. 1, 2, 3.• Prescription sheet
• PD fluid balance chart• Dressing pack and trolleyPROCEDUREParents should be spoken to by one of the neonatal or renal consultants priorto commencing dialysis.The PD set comes together in one pack. The bags of fluid (kept in pharmacyroom) are attached to the PD set; the renal team from Alder Hey will insert thecatheter, attach the set and commence the first cycle. This procedure is asterile procedure. The dialysis fluids should be prescribed on a separatewhite/blue fluid prescription sheet – not on the same one as any IV fluids.If possible, when PD starts care should be provided by a nurse with no otherresponsibilities for that shift. Before the doctor leaves ensure that the numberand length of cycles that they want the infant to initially have is clearlydocumented. Any future changes should be made by the renal team, this maybe via telephone, and documented on the prescription chart.Completion of cycleExample of prescription might be:1 cycle of 20mls of fluid 1, followed by two cycles of 20mls of fluid 2 – 30minute cycles – 15 minutes dwelling time.(Refer to diagram of PD set)• 10:00 Open clamp A on solution 1 and run 20mls into the burette.• Close clamp and check clamp C is closed• Open clamp B and allow fluid to run out of the burette, through the warmer into the baby.• Leave for 15 minutes (dwelling time)• Open clamp C and allow fluid to run out of baby into the accurate measuring container.• Close clamp C.• 10:25 Measure the amount of fluid in the container, document in the “out” column and turn clamp D down to allow fluid to run into the 24 hr bag.• 10:30 Repeat procedure with fluid 2 and continue cycles following prescription.Observations and investigationsInfants receiving PD should have continuous monitoring of heart rate, oxygensaturation and if possible blood pressure. If there is no invasive BP available amanual BP reading should be taken at least every 2 hrs.The infant should be weighed at least daily.The skin around the catheter site should be checked regularly and kept cleanand dry. If there is any leakage the gauze swabs around the site should beweighed to assess amount of loss.
Regular blood gases and U&E’s should be carried out.Send PD sample daily for microscopy and culture.DocumentationAn accurate fluid balance is essential for any infant on PD. The PD fluidbalance chart should be accurately completed with an hourly fluid balancethat is totalled at midnight. Any leakage from around the catheter should beincluded in the total output.Any advice given over the phone by the renal team should be recorded in theinfant notes by the person who received the information.COMMUNICATIONDaily update to the renal physician involved at Alder Hey. Contact PD sister orrenal nurse practitioner regarding procedure following any possiblecontamination of the PD circuit.ReferencesAndreoli SP Acute renal failure in the newborn. Semin Perinatol.2004;28(2):112-23Haycock GB. Management of acute and chronic renal failure in the newbornSemin Neonatol. 2003;8(4):325-34This guideline is a working guideline pendingdiscussion with the manufacturers about newperitoneal dialysis equipment22nd December 2009 (version 2-NICU54)
Fluid bags A Burette B Warmer To baby C From babyAccuratemeasure 24 Hr bag D E