Renal failure

1. Acute Renal Failure in Children

2. Definition
•A clinical syndrome in which a sudden
deterioration in renal function results in the
inability of the kidneys to maintain fluid
and electrolyte homeostasis.
•Also k/a Acute renal insufficiency
•2-3% of children admitted to pediatric
tertiary care centres
•8% of infants in neonatal ICU

3. •Anuria< 0.5 cc/kg/hour
• Oliguria more than 1 cc/kg/hour
•70% Non-oliguric , 30% Oliguric
•Non-oliguric associated with better
prognosis and outcome
•―Overall, the critical issue is maintenance
of adequate urine output and prevention of
further renal injury.

4. Classifications
Pre-renal = in which decrease renal
perfusion 55%
Renal parenchymal (intrinsic)= in
which there is renal paranchymal injury 40%
Post-renal = in which there is obstruction
of renal outflow 5-15%

5. 1.Pre
renal
2. Intrinsic
Renal
3. Post-
renal

6. Causes ofARF
Pre-renal :
vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
cardiac failure, liver dysfunction, or septic shock
Intrinsic :
Interstitial nephritis, acute glomerulonephritis,
tubular necrosis, ischemia, toxins
Post-renal :
prostatic hypertrophy, cancer of the prostate or
cervix, or retroperitoneal disorders
neurogenic bladder bilateral renal calculi, papillary
necrosis, coagulated blood, bladder carcinoma,
and fungus

7. Symptoms ofARF
1.Decrease urine output (70%)
2.Edema, esp. lower extremity
3.Mental changes
4.Heart failure
5.Nausea, vomiting
6.Pruritus
7.Anemia
8.Tachypenic
9.Cool, pale, moist skin

8. 1.Sunken Fontanels
3.Dry Tongue &
Mucous Membranes
3.Loss of skin
turgor
4.rritability
5.Feeble Pulses
Sign ofCollapse
2.Vomiting
3.Nausea
4.Lethargic
5.Hypertension
4.Uremic Encephalopathy
5.Seizure
Sign of uremia
1.Anorexia

9. AcuteTubular Necrosis
Renal insults, including
•renal ischemia
•exposure to exogenous or endogenous
nephrotoxins.
The net effect is a rapid decline in renal
function that may require a period of dialysis
before spontaneous resolution occurs.

10. Major Causes of Acute Tubular Necrosis
• Renal Ischemia:
* Severe prerenal disease from any
cause.
• Exposure to Nephrotoxins:
* Amphotericin B
*Aminoglycosides * Heme Pigments *
NSAID's (hemoglobinuria/myoglobinura)

11. Investigation ofARF
Urine Examination:
•Urine Na-- > 20 mEq/l show intrinsic renal
< 10 mEq/l show pre-renal
•Urine Microscopy---Pus, RBC’s, White Cell
Casts
Blood Counts:
•Low Hb---blood loss
•Leukocytosis---infection
•Platelet Counts---low in HUS, Renal
Vein Thrombosis

12. Blood Urea & Creatinine:
Raised due to diminished renal
function
Serum Calcium, Phosphate,
AlkalinePhosphates:
•S.Ca low
•S.Phosphate raised
Serum Electrolytes & Osmolality:
•Na low & K high

13. C3 Complement Level:
Low in Acute Glomerulonephritis, SLE Nephritis
Radiological examination
1.ultrasonography:
pelvic ultrasonogrophy may show mass
and calculate the residual urine.
it is useful for guiding needle for renal
biopsy or aspiration of perirenal collection.
Doppler flow imaging of the renal vessels may
help in diagnosis of renal artery occlusion or
stenosis , renal vein thrombosis and kidney
transplant rejection.

14. 2.plain abdominal x-ray (KUB):(kidney,ureter,bladder)may show
a.stones
b.calcification of the kidney ,urinary bladder, seminal vesicles.
c.renal contour and soft tissue shadow
3.Intravenous urography (IVU): shows any mass ,stones
,back pressure changes and also demonstrates kidney function
and obstruction. It should be done in the light of renal function
.
4.angiography: this includes
a.renal arteriography It is mainly indicated for
diagnosis of renovascular hypertension or persistent
haematuria following trauma.
b. renal venography. This is indicated for diagnosis of
renal vein thrombosis.
5.Computerized tomography (CT):it is strongly indicated in
patients with obstructive uropathy with non-evident cause.
6.Magnetic resonance imaging (MRI)
helpful in studying malignancies of the urinary tract and
assessment of renal vessels by MRI angiography.

15. Kidney biopsy
It shows the pathology of the underlying renal disease.
The biopsy should be examined by light microscope
(LM)
,electronic microscope (EM) and immunofluorescent
microscope(IF)
Very helpful in diagnosing, prognosis and
therapeutic guidance.
cystoscopy, ureteroscopy
Diagnostic :
of bladder disease , (tumour)by direct vision or biopsy.
Therapeutic:
ureteric catheter: also , ascending pyelography ,
differential renal function.

16. Management
General Measures
1.IV secure.
2.Take blood samples.
3.Collect urine sample.
4.Catheterize if bladder is palpable.
5.Record blood pressure.
6.Careful intake and output record.
7.Daily weight measurement.
8.Daily investigations.
.Urea
.Creatinine
.Serum electrolytes
.Blood gases
.ECG(to detect Hyperkalemia

17. •Water and sodium restriction
•Protein restriction
•Potassium and phosphate
restriction
•Adjust medication dosages
•Avoidance of further insults
–BP support
–Nephrotoxins

18. •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 of
norepinephrine

19. Diuretic therapy :
1.only after the adequate hydration.
2.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.]
3.Bumetanide (0.1 mg/kg)- an alternative to furosemide.
If urine output is not improved - continuous diuretic
infusion may be considered.
1.Consider Dopamine (2-3 µg/kg/min) in conjunction with
diuretic therapy.
2.There is little evidence that diuretics or dopamine can
prevent ARF or hasten recovery

20. 1.Hyperkalemia
Symptoms
•Weakness
•Lethargy
•Muscle cramps
•Paresthesias
•Dysrhythmias
Management of Complications
• Hyperkalemia & EKG
•K > 5.5 -6
•Tall, peaked T’s
•Wide QRS
•Prolong PR
•Diminished P
•Prolonged QT
•QRS-T merge – sine wave

22. Hyperkalemia Treatment
•Calcium gluconate (carbonate)
•Sodium Bicarbonate
•Insulin/glucose
•Kayexalate (sodium polystyrene sulfonate)
•Lasix
•Albuterol
•Hemodialysis

23. 2.ACIDOSIS:
Correct acidosis by NaHCO3
Total calculated dose divide in 3 doses;
•One part given start
•2nd part after 8 hrs
•3rd part discard
3. HYPOCALCEMIA
Can present as tetany or convulsions.
•iv calcium gluconate slow and diluted in 5 to 10
mints under cardiac monitoring.
•Treatment primarily involves efforts to lower the
serum phosphorous level.
•Calcium Carbonate (phosphate binder) help to
decrease the absorption of phosphorous & help its
excretion.

24. 4. Hyponatremia:
•Due to fluid overload or hypotonic fluid administration.
require correction with hypertonic sodium chloride
•In Hypertension due to fluid over load, contraindicated
to give Hypertonic Saline
•Do Dialysis to correct hyponatremia
5. Seizures:
•Due to primary renal disease, uremia,
hyponatremia, hypocalcaemia & hypertension
•Inj.Diazepam

25. 6. Infections:
•Due to bladder catheterization or peritoneal dialysis
•Broad Spectrum Antibiotics (B.Pencillin or Ceftrixone)
given.
•Nephrotoxic (Amikacin, Erythromycin) drugs avoided.
7. Anemia:
Due to volume expansion
•If Hb < 7 g/dl, blood should be given very slowly in 4
to 6 hrs.

26. Dialysis

27. Indications for dialysis
• Hyperkalemia unresponsive to medical therapy.
•Acidosis unresponsive to medical therapy.
•Fluid overload unresponsive to fluid restriction or to diuretics.
•Symptoms & Signs of uremia.
•Hypertension & CCF not responding to medical therapy.
•Blood urea N greater than 100-150mg/dl
•Mental status change

28. TypesOf Dialysis
•Peritoneal Dialysis
•Acute Intermittent Hemodialysis
•Continuous Hemofiltration

29. Peritoneal dialysis
Advantages
1.Simple to set up & perform
2.Easy to use in infants
3.Hemodynamic stability
4.No anti-coagulation
5.Bedside peritoneal access
6.Treat severe hypothermia or
hyperthermia
Disadvantages
1.Unreliable ultrafiltration
2.Slow fluid & solute remova
3.Drainage failure & leakage
4.Catheter obstruction
5.Respiratory compromise
6.Hyperglycemia
7.Peritonitis
8.Not good for
hyperammonemia or
intoxication with dialyzable
poisons

30. Intermittent Hemodialysis
• Advantages
• Maximum solute clearance of 3
modalities
• Best therapy for severe
hyperkalemia
• Limited anti-coagulation time
• Bedside vascular access
can be used
Disadvantages
•Hemodynamic instability
•Hypoxemia
•Rapid fluid and electrolyte
shifts
•Complex equipment
•Specialized personnel
•Difficult in small infants

31. Continuous Hemofiltration
Advantages
•Easy to use in PICU
•Rapid electrolyte correction
•Excellent solute clearances
•Rapid acid/base correction
•Controllable fluid balance
•Tolerated by unstable pts.
•Early use of TPN
•Bedside vascular access
routine
Disadvantages
•Systemic anticoagulation
(except citrate)
•Frequent filter clotting
•Vascular access in
infants

32. Depends upon cause.
90 % complete remission in;
•ATN (Acute Tubular Necrosis)
•HUS (Hemolytic-uremic
Syndrome) Other Causes of
pre-renal failure
Poor Prognosis when renal failure due to;
•RPGN (Rapidly Progressive
Glomerulonephritis)
•Bilateral Renal Vein Thrombosis
•Bilateral Cortical Necrosis
Prognosis

33. THE END