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Aki in neonate
AKI in neonates can be caused by prerenal, intrinsic renal, or postrenal factors. It is defined and classified using creatinine and urine output criteria. Management involves identifying and treating the underlying cause, maintaining fluid/electrolyte balance, and considering renal replacement therapy for refractory cases. Peritoneal dialysis is often preferred for neonates as it is gentler than hemodialysis and can provide both fluid removal and metabolic control. However, peritoneal dialysis also carries risks of peritonitis, mechanical issues, and complications in critically ill infants.
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Aki in neonate
- 1. AKI in aneonate Bharathi B
- 2. Sub headings Definition Classification –AKIN / RIFLE Pathophysiology Evaluation Management Medical Dialysis
- 3. Definition Acute kidney injury(AKI) - a sudden impairment in kidney function, that results in the retention of nitrogenous waste products and alters the regulation of extracellular fluid volume, electrolytes, and acid-base homeostasis. “ recognize the injury , don’t wait for the failure” ( Mehta 2007)
- 4. Creatinine based definition Creatinine≥1.5 mg/dL independent of day of life and regardless of the rate of urine output. Problems of this approach 1. Will not change till 25 – 50 % func loss 2. Overestimates renal function 3. Varies by muscle mass, age , sex, hydr 4. Different methods of est ( Jaffe/ enzymatic) 5. Easily dialysed Avery diseases of the neonate – 9 th edition
- 5. P- RIFLE Creatinine Urineoutput Risk eCCl decrease by 25% <0.5 mL/kg/hr for 8 hr Injury eCCl decrease by 50% <0.5 mL/kg/hr for 16 hr Failure eCCl decrease by 75% or eCCl <35 ml/min/1.73 m2 <0.3 mL/kg/hr for 24hr or anuric for 12 hours Loss Persistent failure >4 wk End stage Persistent failure > 3 months Proposed by bellomo et al ; modified by ackan - arikan
- 6. AKIN criteria (Mehta et al , 2007) Abrupt (within 48 h) reduction in kidney function currently defined as an absolute increase in serum creatinine of 0.3 mg/dL or more or A percentage increase in serum creatinine of 50% or more (1.5-fold from baseline) or A reduction in urine output (documented oliguria of < 0.5 mL/kg/h for >6 h)
- 7. KDIGO staging forAKI severity ( Mehta et al 2007) Creatinine Urine output Stage 1 1.5-1.9 times baseline or ≥0.3 mg/dL increase <0.5 mL/kg/hr for 6 hr Stage 2 2- 2.9 times baseline <0.5 mL/kg/hr for 12 hr Stage 3 3 times baseline or Increase in serum creatinine to ≥4 mg/dL or < 0.3 mL/kg/h for 24 h or Anuria for ≥12 h
- 8. Problems Delineation between the1st week of life and changes in SCr level after the 1st week - needed in a neonatal AKI classification system. Despite these working classification systems, the diagnosis of AKI is problematic, because current diagnosis relies on two functional abnormalities: functional changes in SCr (marker of GFR) and oliguria. Avery diseases of the neonate – 9 th edition
- 9. Acute Renal Failurein the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 10. Etiopathogenesis Acute Renal Failurein the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 11. Prerenal failure –pathophysio Alteration in plasma flow Catecholami ne surge Prostagland in & RAAS activation Dilation of afferent arteriole / constric of efferent Acute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 12. Intrinsic renal failureIncreased transcapillary hydraulic pressure Failure of autoreg +- renal immaturity Tubular damage systemic inflammatory response Acute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 13. Post renal Reversible with reversalof obstruction Acute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 14. Evaluation Identify prerenal causes Isthere a volume contraction ? - Inadeq feeding - Dehydration - Large fetomaternal h’hage - Subgaleal bleeds - Warm shocks Congestive cardiac failure Acute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 15. Investigations Serum sodium, potassium,chloride, bicarbonate, calcium, phosphorus, magnesium, urea, creatinine, uric acid, glucose, blood gases, hemoglobin, and platelets S.Cr often does not rise for days after an injury, thus monitoring these values for several days after the inciting event is necessary to determine if AKI occurred.
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- 17. Management Supportive – keep thekid and kidney alive Acute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 18. Dopamine Dopamine can increaserenal perfusion in the sick pre- term and term infant with prerenal azotemia caused by hypoxemia, acidosis, or indomethacin administration (Seri, 1995; Seri et al, 1998, 2002). Compared with placebo, low-dose dopamine does not improve survival, shorten hospital stay, or limit dialysisAcute Renal Failure in the Neonate Steven Alan Ringer Neoreviews 2010;11;e243
- 19. Fenoldopam is aselective dopamine-1 receptor agonist whose effects include vasodilation of renal and splanchnic vasculature, increased renal blood flow, and increased GFR. Fenoldopam is approved to treat severe hypertension in adults, but is not clinically approved for the treatment of AKI. Avery ‘s diseases of newborn – 9th edition
- 20. Diuretic No studies inneonates, children, or adults have shown that diuretics are effective in preventing AKI or improving outcomes once AKI occurs (Bellomo et al, 2000). If loop diuretics are to be used in neonates, continuous doses of furosemide may be superior to larger intermittent doses
- 21. Volume & electrolyte/ acidbase imbalance Hyponatremia: Na Required (mEq) =(Na Desired − Na + Actual) × Body weight (kg) × 0.7 Hypocalcemia -100 to 200 mg/kg of calcium gluconate should be infused over 10 to 20 minutes and repeated every 4 to 8 hours as necessary. Hyperphosphatemia - Breastmilk and Simi- lac 60/40 both contain low phosphorous and low potassium compared with other neonatal infant formulas .
- 22. Treatment of hyperkalemia Vemgaland Olhson (2007) -no firm clinical practice recommendations on which treatment modality was best to treat preterm infants with hyperkalemia are available, except that insulin plus glucose may be better in premature infants.
- 23. Nutrition & drugs Nutritionalgoals in infants with AKI are similar to those of infants without AKI. Feeds or parenteral nutrition will need to be concentrated to avoid excessive fluid a neonate is receiving continuous peritoneal dialysis or hemodialysis, an additional 1 g/kg/day of protein is needed to supplement the protein losses that occur with these forms of dialysis (Zappitelli et al, 2008, 2009).
- 24. Indications For RenalSupport Severe electrolyte abnormalities that are not correctable with medicalinterventions Life-threatening intoxication by medications that can be cleared with dialysis inborn errors of metabolism fluid overload Acidosis – refractory to medical management Coma Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e DOI: 10.1542/neo.6-8-e384
- 25. Renal replacement therapy Thetiming of dialysis initiation in infants with AKI is controversial. Several observational studies show a clear advantage in adults receiving dialysis early versus late (Liu et al, 2006; Ronco et al, 1986). Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 26. Basic Physiology ofDialysis And Ultrafiltration Molecular movement across semipermeable membrane Basic mechanisms of water and particle removal include Diffusion Convection Ultrafiltration
- 27. Diffusion Movement of dissolvedparticles across semi- permeable membrane from area of high concentration to area of low concentration Favors movement of smaller particles Stops when concentration gradient achieves equilibrium
- 29. Convection Dissolved particles passacross semi permeable membrane due to effects of pressure gradient Ultrafiltration Describes movement of water across semipermeable due to pressure
- 31. 3 modalities Peritoneal dialysis IntermittentHemodialysis Continuous Renal Replacement Therapy
- 32. PERITONEAL DIALYSIS Physiology Peritoneum canbe used as a dialysing membrane Instillation of a dialysate into the peritoneal space permits diffusion of particles out of the blood across the peritoneum Through the use of a hypertonic solution , water also passes across the membrane generating an ultrafiltrate Water movement tends to drag particles across the peritoneum by convection After the dwell is complete , the spent dialysate is drained from the abdomen and fresh dialysate may be introducedNeonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 33. Indications Remove excess fluidand provide volume control in the patient with oligoanuria Much slower than intermittent hemodialysis Preferable in the critically ill patient Provides metabolic control Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 35. Technique Instill sterile dialysateinto peritoneal cavity Allow it to dwell End of dwell time the dialysate is removed Dialysate contains base in the form of lactate Ultrafiltration accomplished by osmotic pressure thro dextrose Should be warmed to body temp Start with 10 – ml/kg ( 500 ml/m2) Dwell period of 30 - 60 min Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 36. Neonatal Peritoneal Dialysis MarshaM. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 37. Complications Peritonitis Leakage around thecatheter exit site Tunnel infection Catheter malfunction, and obstruction by omentum (Coulthard and Vernon, 1995). Fluid leakage into other compartments (including the chest in patients without an intact diaphragm) can occur and if suspected, the fluid composition will reveal high glucose levels if a leak is presentNeonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 38. Issues Loss of protein– supplement it Hyperglycemia GER – stomach comp Critically ill – inc intra abd pressure leading to dec Venous return and dec diaphragm excursion Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 39. Poor candidates forPD worsening respiratory status or ventilatory Diaphragmatic hernias Abdominal wall defects Neonatal Peritoneal Dialysis Marsha M. Lee, Annabelle N. Chua and Peter D. Yorgin Neoreviews 2005;6;e384 DOI: 10.1542/neo.6-8-e384
- 41. AKI to CKD Adultstudies – 3- 5 % go on to have CKD Stapleton – retrospective study – 40 – 88 % CKD prevalence Preterms did worse than term babies