pediatria

1. 890
HASIL PENELITIAN
CDK-211/ vol. 40 no. 12, th. 2013
INTRODUCTION
Acute renal failure (ARF) is defined as a rapid
decline in glomerular filtration rate (GFR),
Alamat korespondensi email: hexin_01@yahoo.com
resulting in disturbance of physiological
renal functions including impairment of
nitrogenous waste product excretion, loss of
water and electrolyte regulation and loss of
acid-base regulation. Although the incidence
of ARF varies with geographical localization
Acute Kidney Injury in Critically Ill Children at
Pediatric Intensive Care Unit
Husein Albar
Department of Child Health, Faculty of Medicine, Hasanuddin University/
Wahidin Sudirohusodo Hospital, Makassar, South Sulawesi, Indonesia
ABSTRACT
Background: Recognition of acute kidney injury (AKI) requires use and selection of easily measured criteria that can be applied widely across
age groups and clinical situations. Modified pediatric RIFLE (pRIFLE) has been used for diagnosis and grading of AKI (acute kidney injury) in
children. Objective: To investigate AKI in children aged 1-14 years hospitalized at PICU (pediatric intensive care unit), Wahidin Sudirohusodo
Hospital, Makassar. Methods: A cross-sectional study was done based on medical records from 2009 until 2011. The records were screened
for demographic data, serum creatinine level and estimated creatinine clearance by Schwartz formula. AKI was grouped according to pRIFLE
formula. Results: There were 77 patients, 58.4% boys and 41.6% girls. Majority were above 5 year-old (76.6%), have increased serum creatinine
level (80.05%) and decreased eCC/estimated creatinine clearance (80.05%). Underlying diseases as the cause of AKI consists of AGN/acute
glomerulonephritis (41.6%), NS/nephrotic syndrome (9.1%), UTI/urinary tract infections (9.1%), and others (40.3%) including DSS (dengue shock
syndrome), dehydration due to diarrhea, and septic shock. pRIFLE-R was more frequent in patients above five years old (33.8%), in boys (27.3%),
well-nourished patients (13.0%), and in patients with increased creatinine serum level or decreased eCC (49.9%) compared to pRIFLE-I and
pRIFLE-F groups. No significant difference of pRIFLE grading in different groups of underlying diseases (p=0.126), age (p=0.075), sex (p=0.817),
and nutritional status (p=0.102). The difference of creatinine serum level and eCC was significant (p <0.001) among different pRIFLE grading.
Conclusion: Early diagnosis of AKI should be based on pRIFLE grading and adequate preventive measures should be instituted as early as
possible to reduce the morbidity and mortality rates at PICU.
Key words: children, acute kidney injury, pRIFLE
ABSTRAK
Latar belakang: Diagnosis gangguan ginjal akut memerlukan kriteria diagnostik yang mudah diterapkan pada semua kelompok umur pasien
dengan risiko gangguan ginjal akut (acutekidneyinjury,AKI). Modifikasi pRIFLE telah digunakan untuk diagnosis dan penentuan gangguan ginjal
akut pada anak. Tujuan: Mengevaluasi gangguan ginjal akut pada anak yang dirawat di Unit Rawat Intensif Anak RS Wahidin Sudirohusodo
Makassar. Metode: Telah dilakukan penelitian retrospektif potong-silang dari catatan medik pasien anak 1-14 tahun yang dirawat di RS Wahidin
Sudirohusodo Makassar periode 2009 - 2011. Analisis data demografi, kadar kreatinin serum dan estimasi kliren kreatinin dengan rumus
Schwartz dari catatan medik pasien. Gangguan ginjal akut dikelompokkan dalam derajat pRIFLE-R, pRIFLE-I, pRIFLE-F, pRIFLE-L, dan pRIFLE-E.
Hasil: Dari tujuh puluh tujuh pasien yang dianalisis didapatkan 58,4% laki-laki dan 41,6% perempuan. Rerata usia 8,483 tahun, dari usia 1
tahun 10 bulan – 14 tahun. Kebanyakan pasien berusia di atas lima tahun (76,6%), status gizi kurang (53,2%), kadar kreatinin serum tinggi dan
estimasi bersihan kreatinin rendah (80,05%). Penyebab gangguan ginjal akut pada penelitian ini adalah glomerulonefritis akut (41,6%), sindrom
nefrotik (9,1%), infeksi saluran kemih (9,1%), dan penyakit lain (40,3%) meliputi demam berdarah renjatan, diare dehidrasi, dan renjatan septik.
pRIFLE-R lebih sering ditemukan pada pasien umur di atas lima tahun (33,8%), pada anak lelaki (27,3%), pasien gizi baik (13,0%), dan pasien
dengan kadar kreatinin serum tinggi dan estimasi bersihan kreatinin rendah (49,9%) dibandingkan dengan kelompok pRIFLE-I dan pRIFLE-F.
Tidak ditemukan perbedaan bermakna di antara derajat pRIFLE dan penyakit penyebab gangguan ginjal akut (p=0,126) dan di antara derajat
pRIFLE dan distribusi umur (p=0,075), jenis kelamin (p=0,817), dan status gizi (p=0,102). Perbedaan bermakna ditemukan di antara derajat
pRIFLE dan distribusi kadar kreatinin serum (p <0,001) dan estimasi bersihan kreatinin (p <0,001). Simpulan: Diagnosis dini gangguan ginjal
akut berdasarkan derajat pRIFLE seyogyanya dilakukan pada semua pasien di Unit Rawat Intensif Anak sehingga pencegahan adekuat dapat
segera diberikan untuk mengurangi angka morbiditas dan mortalitas akibat gangguan ginjal akut. Husein Albar.Gangguan Ginjal Akut pada
Anak Sakit Kritis yang Dirawat di Unit Rawat Intensif.
Kata kunci: anak, gangguan ginjal akut, pRIFLE

2. 891
HASIL PENELITIAN
CDK-211/ vol. 40 no. 12, th. 2013
and countries, it has been reported in 2-5%
of hospitalized children and in 4.5-30% of
children in pediatric intensive care units (
PICU). Mortality rates of 35 to 80% have been
reported in patients developing ARF.1-3
An
acute decline of kidney function is secondary
to tubular (or more extensive) injury that
leads to functional or structural damage in
the kidney. ARF actually includes a spectrum
of conditions, the term acute kidney injury
(AKI) has been recently proposed to reflect
the entire spectrum of the syndrome.4-6
The exact incidence and causes of AKI in
children is unknown; recent studies suggest
that incidence of AKI in hospitalized children
is increasing. Previous studies in Nigeria
and North India showed 11.7 and 20 AKI
cases admitted per year per 1000 pediatric
admissions, respectively7
and in New Zealand
children, 4.0 per 100 000 total population
under 15 year of age.8
No study reported
incidence of AKI in Indonesia.
This study retrospectively investigated AKI
in children hospitalized at PICU in Wahidin
Sudirohusodo Hospital, Makassar.
METHOD
This survey was a retrospective cross-sectional
studytoinvestigateAKIinhospitalizedchildren
at Wahidin Sudirohusodo Hospital Makassar.
Data were based on a review of standard
medical records of all patients aged 1-14 years
hospitalized at PICU of Wahidin Sudirohusodo
Hospital, Makassar from 2009 until 2011.
Study approval was obtained from the Ethical
CommitteeofWahidinSudirohusodoHospital,
Makassar.
We enrolled all patients who had been
hospitalized at PICU of the hospital with
complete medical records. Patient records
were retrospectively analyzed for age, sex,
nutritional status, underlying diseases, whole
blood count, urinary analysis, duration of renal
failure, blood ureum, serum creatinine, and
estimated creatinine clearance (eCC). Systolic
and/or diastolic blood pressure levels equal
or greater than 95 percentile was defined
as hypertension whereas systolic blood
pressure <70 mmHg + 2 x Age(yr) defined
as hypotension.8
Patients with a history of
chronic renal failure and incomplete medical
records were excluded from the study. The
medical records were screened for creatinine
serum level and estimated GFR, and patients
with GFR of 75 ml/min/1.73 m2 or less were
selected for additional analysis. GFR was
assessed by Schwartz formula.9
AKI was
defined according to the modifed pediatric
RIFLE (pRIFLE) and graded into “pRIFLE-R”
(risk for reduced kidney function) ,“pRIFLE-I”
(injury of kidney function), “pRIFLE-F (failure
of kidney)”, “pRIFLE-L”(loss of kidney function),
and “pRIFLE-E” (End Stage Renal Disease).
pRIFLE-L and pRIFLE-E define the outcome of
AKI. pRIFLE grading uses estimated creatinine
clearance estimation (eCC) to assess renal
function based on Schwartz’ formula’s (0.55 x
height (cm) / serum creatinine (mg/dL) in mL/
minute/1.73 m2
)5,6
(Tabel 1).
Baseline of normal eCC used in this study was
120 mL/min/1.73 m2
.6
Underlying diseases
as the cause of AKI were grouped into
acute glomerulonephritis (AGN), nephrotic
syndrome(NS),urinarytractinfection(UTI),and
others including any shock conditions such as
dengue shock syndrome (DSS), dehydration
caused by diarrhea, and any cause of septic
shock. Data were analyzed using SPSS v.15.00
(SPSS, Inc, Chicago). Pearson chi-square was
used to compare characteristic data and p
<0.05 was considered as significant.
RESULTS
There were 77 patients enrolled in this study,
consisting of 58.4% boys and 41.6% girls
with a boy to girl ratio of 1.4:1. Mean age of
subjects was 8.483 years ranging from 1.10 to
13.50 years. Majority of subjects was above
5 years (76.6%) and undernourished (53.2%).
Increased serum creatinine level or decreased
eCC occured in 80.05 % cases (Table 2).
Tabel 2 Characteristics of subjects
Parameters n (77) / (100%)
Age (mean: 8.483 [1.83 - 13.5])
< 5 yr
> 5 yr
Sex
Boy
Girl
Nutritional status
Well-nourished
Undernourished
Serum creatinine (mean: 1.553
[0.410-6.861])
Normal
High
eCC (mean: 40.920 [0.45-127.00])
Normal
Low
18/23.4%
59/76.6%
45/58.4%
32/41.6%
36/46.8%
41/53.2%
15/19.05 %
62/80.05 %
15/19.05 %
62/80.05 %
Table 3 shows that underlying diseases as the
cause of AKI consist of AGN (41.6%), NS (9.1%),
UTI ( 9.1%), or others (40.3%) including DSS,
dehydration due to diarrhea, and septic shock.
Table 1 pRIFLE grading4-6

3. 892
HASIL PENELITIAN
CDK-211/ vol. 40 no. 12, th. 2013
There was no significant difference of pRIFLE
grading among different underlying diseases
(p=0.126). pRIFLE-R was more frequent in
patients aged under and above five years old
(9.1%/33.8%), in boys (27.3%), well-nourished
patients (13.0%), and patients with increased
creatinine serum level and decreased eCC
(49.9%) compared to those with pRIFLE-I and
pRIFLE-F (Table 4).
Table 4 shows no significant differences of
pRIFLE grading among distribution of age
(p=0.075), sex (p=0.817), and nutritional status
(p=0.102) but very significant difference
among different pRIFLE grading, creatinine
serum level (p <0.001) and eCC (p <0.001).
DISCUSSION
AKI is defined as functional or structural
abnormalities or markers of kidney damage
including abnormalities in blood, urine or
tissue tests or imaging studies present for less
than three months. AKI is an abrupt or less
than 48 hours reduction in kidney function
confirmed by an absolute increase in serum
creatinineofeither>0.3mg/dLorapercentage
increase of 50% or reduction in urine output
or documented oliguria of <0.5 mL/kg/hr
for >6 hr.The heterogenous cause of AKI has
been associated with increased morbidity and
mortality by increasing dialysis need as well as
further subsequent development of chronic
kidney disease and its progression to dialysis
dependency.3
Recognition of AKI requires
selection and use of easily measured criteria
that can be applied widely, across age groups
and clinical situations. Modified pRIFLE has
been used for diagnosis and grading of AKI in
children.4-6
The reported incidences of AKI in children and
adolescents hospitalized at PICU ranged from
8% to 30%.10
The present study found that
pRIFLE-R, pRIFLE-I, and pRIFLE-F in children
hospitalized at PICU in Wahidin Sudirohusodo
Makassar was 49.9%, 27.3%, and 10.4%,
respectively. This result is similiar to other
studies.
The common cause of childhood AKI reported
in New Zealand was post cardiac surgery
(58%), HUS (17%), sepsis (13%), and AGN (4%).8
In Houston Texas, the cause of AKI in children
were renal ischemia (21%), nephrotoxic
agents (16%), sepsis (11%), and primary renal
disease (7%).10
The present study showed that
RIFLE
failure
injyury
risk
normal
Count
20
10
0
ETIOLOGY
AGN
NS
UTI
others
Table 3 Distribution of pRIFLE grading according to underlying diseases
pRIFLE ETIOLOGY Total
AGN (n/%) NS (n/%) UTI (n/%) Others (n/%)
Normal 6/7.8% 1/1.3% 0/0.02% 8/10.4% 15/19.5%
Risk 18/23.4% 3/3.9% 5/6.5% 7/9.1% 33/42.9%
Injury 6/7.8% 3/3.9% 2/2.6% 10/13.0% 21/27.3%
Failure 2/2.6% 0/0.02% 0/0.02% 6/7.8% 8/10.4%
Total 32/41.6% 7/9.1% 7/9.1% 31/40.3% 77/100.0%
Pearson chi-square=13.896 df=9 p=0.126
Figure 1 Histogram of pRIFLE according to underlying diseases
JUDUL SUMBU Y: Number of patients
JUDUL SUMBU X: RIFLE category (ada ralat juga:“injyury”→ injury)
Table 4 Distribution of age, sex, nutritional status, creatinine serum and eCC of subjects according to pRIFLE grading
Parameters
RIFLE
Total
Normal Risk Injury Failure
P
Age <5 yr 7/9.1% 7/9.1% 2/2.6% 2/2.6% .075 18/23.4%
>5 yr 8/10.4% 26/33.8% 19/24.7% 6/7.8% 59/76.6%
Sex Boy 9/11.7% 21/27.3% 11/14.3% 4/5.2% .817 45/58.4%
Girl 6/7.8% 12/15.6% 10/13.0% 4/5.2% 32/41.6%
Nutrition Wellnourished 7/9.1% 10/13.0% 13/16.9% 6/7.8% .102 36/46.8%
Undernourished 8/10.4% 23/29.9% 8/10.4% 2/2.6% 41/53.2%
Serum creatinine Normal 15/19.5% 0/.0% 0/.0% 0/.0% .0001 15/19.5%
High 0/.0% 33/42.9% 21/27.3% 8/10.4% 62/80.5%
eCC Normal 15/19.5% 0/.0% 0/.0% 0/.0% .0001 15/19.5%
Low 0/.0% 33/42.9% 21/27.3% 8/10.4% 62/80.5%

4. 893
HASIL PENELITIAN
CDK-211/ vol. 40 no. 12, th. 2013
the need for RRT (renal replacement therapy)
and subsequently to reduce morbidity and
mortality rates.
CONCLUSION
Early diagnosis of AKI should be based on
pRIFLE grading and adequate preventive
measures should be instituted as early as
possibletoreducethemorbidityandmortality
rates at PICU.
the cause of AKI in children was AGN (41.6%),
NS (9.1%), UTI (9.1%), and others (40.3%)
including any shock conditions such as
dengue shock syndrome (DSS), dehydration
caused by diarrhea, and any cause of septic
shock. This result was similar to a study from
Anatolia, Turkey that AGN caused more than
60% of AKI in children.7
A limitation of this study is that data analysis
based on a retropective and cross-sectional
design. A prospective cohort study should
be done further to confirm the results from
this study. Early diagnosis of AKI in all children
hospitalized at PICU should be established
based on the pRIFLE criteria using Schwartz
formula. Since children hospitalized in PICU
are at high risk of AKI, early diagnosis and
adequate preventive measures should be
instituted as early as possible to decrease
REFERENCES
1. Siegel NJ,VanWSK, Devarajan P. Pathogenesis of acute renal failure. In: Avner ED, HarmonWE, Niaudet P,Yoshikawa N, editors. Pediatric nephrology. 5th
ed. Philadelphia, LippincottWilliams
& Wilkins; 2004. p. 1225-51.
2. Moghal NE, Brocklebank JT, Maedow RS. A review of acute renal failure in children: Incidence, etiology and outcome. Clin Nephrol. 1998;49:91-5.
3. Ozçakar ZB, Yalçinkaya F, Altas B, Ergün H, Kendirli T, Ateş C, et al. Application of the new classification criteria of the acute kidney injury network: A pilot study in a pediatric population.
Pediatr Nephrol. 2009;24:1379-84.
4. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, et al. Acute kidney injury network: Report of an initiative to improve outcomes in acute kidney injury. Critical Care.
2007;23:2147-9.
5. Mak RH. Acute kidney injury in children: The dawn of a new era. Pediatr Nephrol. 2008;23:2147-9.
6. Zappitelli M, Parikh CR, Akcan-Arikan A, Washburn KK, Moffett BS, Goldstein SL. Ascertainment and epidemiology of acute kidney injury varies with definition interpretation. Clin J Am Soc
Nephrol. 2008;3:948-54.
7. Cerda J, Lameire N, Eggers P, Pannu N, Uchino S, Wang H, et al. Epidemiology of acute kidney injury. Clin J Am Soc Nephrol. 2008;3:881-6.
8. Ball EF, Kara T. Epidemiology and outcomes of acute kidney injury in New Zealand children. J Paediatrics and Child Health. 2008;44:11:642-6.
9. Schwartz GJ, Haycock GB, Edelmann CM. A simple estimate of glomerular filtration rate in children derived from body length and plasma creatinine. Pediatrics. 1976;58:259-63.
10. Patzer L. Nephrotoxicity as a cause of acute kidney injury in children. Pediatr Nephrol. 2008;23:2159-73.