4. 14,220 children from 24 studies worldwide
from 2004 to 2012
Studies used KDIGO definition for AKI
Most studies originated from N America,
Europe, and East Asia, from high income
countries and from nations that spent ≥5% of
the gross domestic product on total health
expenditure
5. Pooled incidence of AKI was 33.7% in
hospitalized children (95% CI 26.9-41.3)
6. DEFINITIONS
Abrupt loss of kidney function(GFR): An
elevated or a rise in serum creatinine from
baseline
Retention of urea and other nitrogenous waste
products.
Dysregulation of extracellular volume and
electrolytes.
8. AKIN classification of AKI
Serum creatinine criteria Urine output criteria
Stage 1 Increase in serum creatinine ≥0.3
mg/dL (≥26.4 umol/L) or
increase to ≥150-200% (1.5-2
fold) from baseline
<0.5 ml/kg/hour for 6
hours
Stage 2 Increase to >200-300% (>3 fold)
from baseline
<0.5 ml/kg/hour for 12
hours
Stage 3 Increase in serum creatinine to
>300% (>3 fold) from baseline
or serum creatinine ≥4 mg/dL
(≥354 umol/L) with acute
increase of at least 0.5 mg/dL
(45.5 umol/L)
<0.3 ml/kg/hour for 24
hours or anuria for 12
hours
9. Criteria for the Kidney Disease Improving
Global Outcomes (KDIGO) AKI in children
Serum creatinine Urine output
Stage 1 Increase to 1.5-1.9 times baseline within
the prior 7 days OR
Increase of serum creatinine ≥0.3 mg/dL
(≥26.5 umol/L) within 48 hours
<0.5 ml/kg/hour
for 6-12 hours
Stage 2 Increase to 2-2.9 times baseline <0.5 ml/kg/hour
for ≥12 hours
Stage 3 Increase >3 times baseline OR
Serum creatinine ≥4 mg/dL (≥353.6
umol/L) OR
Initiation of renal replacement therapy
OR
eGFR <35 ml/min/1.73m2 (<18 years)
<0.3 ml/kg/hour
for 24 hours or
anuria for 12 hours
10. The 3 different criteria resulted in
different incidences and staging
26.9
13.4
10.8
48.9
Stage 1 Stage 2
Stage 3 No AKI
19.4
11.2
6.7
62.7
18.2
10.4
11.7
59.7
Stage 1
Stage 2
Stage 3
No AKI
pRIFLE AKIN KDIGO
11. All 3 definitions correlate highly with outcomes
in terms of mortality and length of stay
1720
6
5406
427
15
3
0
0
pRIFLE
KDIGO
AKI
N
n Mortality LOS
AKI by all three 5406 2.7% 10 (5-21)
No AKI any 6146 0.8% 4 (2-6)
AKI pRIFLE 1720 1.5% 5 (3-9)
AKI AKIN 0 n/a n/a
AKI KDIGO 6 0 6 (3-8)
Not diagnosed
by pRIFLE
153 0 5 (4-8)
Not diagnosed
by AKIN
427 0.7% 12 (7-18)
Not diagnosed
by KDGIO
0 0 n/a
12. CLASSIFICATION
URINE OUTPUT
Anuria no urine output
Oliguria Infant: <1 mL/kg per hour
Children and adults: <0.5 mL/kg per hour for greater than six
hours
Nonoliguria Infant: >1 mL/kg per hour for greater than six hours
Children and adults: >0.5 mL/kg per hour for greater than six
hours
Polyuria Urine output of greater than 3 mL/kg per hour
Less frequently use
21. Using serum creatinine, diagnosis of AKI is made 24-72 hours
following the event that precipitated the reduction in GFR
long past the window of potential reversibility
22.
23. Tests to distinguish between
prerenal and intrinsic ATN ?
Fractional excretion of sodium
UNa x SCr
FENa, percent = ——————— x 100
SNa x Ucr
- A FENa < 1% suggests prerenal AKI
- A FENa > 2% suggests ATN
Limitations
- Previous fluid administration
- Diuretic therapy
- AKI due to contrast nephropathy
24. Tests to distinguish between
prerenal and intrinsic ATN ?
Diagnostic fluid challenge
- Infuse 10 to 20 mL/kg of normal saline
Indications
- Suspected prerenal AKI but the duration is unknown.
- An increase in serum creatinine with unclear cause.
Contraindicated in patients with obvious volume overload
or heart failure.
25. MANAGEMENT OF AKI
- Specific treatment of the underlying cause
- Fluid management
- Electrolyte management
- Nutritional support
- Adjustment of drug dosing
- Renal replacement therapy
- Specific pharmacologic therapies
26. FLUID MANAGEMENT
Hypovolemia clinical history and physical exam
- Normal saline bolus (10 to 20 mL/kg over 30 minutes,
repeated twice as needed)
Euvolemia
- Ongoing fluid losses (insensible fluid [300 to
500 mL/m2 per day], urine, and gastrointestinal losses)
Hypervolemia
- Furosemide
- A single high-dose bolus (2 to 5 mg/kg/dose) (oliguria of less than
24 hours’ duration),
If effective, then a continuous infusion of furosemide (0.1 to
0.3 mg/kg per hour)
If not response within 2 hours, should be promptly discontinued
28. HYPERTENSION
Nicardipin:
Initial 0.5 to 1 mcg/kg per minute, increased every 15
to 30 minutes; maximum dose: 4 to 5 mcg/kg per
minute
Labetatol:
Initial bolus of 0.2 to 1 mg/kg per dose (maximum
dose: 40 mg) followed by an infusion of 0.25 to
3 mg/kg per hour
30. DRUG MANAGEMENT
Avoidance of nephrotoxic drugs
Dosing adjustment of renally excreted drugs
- if AKI is in an early stage and Cr is rising ( Injury), assume GFR is
<10 mL/min 1.73 m2.
Drug levels should be routinely monitored
- Vancomycin
- Digoxin
38. AKI PREVENTION
Nephrotoxin management
- CONTRAST INDUCED AKI: defined as
- A rise in SCr of X 0.5 mg/dl (X44 mmol/l) or
- A 25% increase from baseline value
Assessed at 48 hours after a radiological procedure.
40. AKI PREVENTION
Nephrotoxin management
- Contrast induced AKI prevention
-Isotonic crystaloid fluid should be started 3 hours and
continued 6 hours after contrast-media administration at the
dose of 1.5-3 ml/kg/h, to maintain UO at least 150 ml/h.
