Management of acute kidney injury in children: a guide for pediatricians.
ABSTRACT Acute kidney injury (AKI; previously called acute renal failure) is characterized by a usually reversible increase in the blood concentration of creatinine and nitrogenous waste products and by the inability of the kidney to appropriately regulate fluid and electrolyte homeostasis. The incidence of AKI in children appears to be increasing and the etiology of AKI over the past decades has shifted from primary renal disease to multifactorial causes, particularly in hospitalized children. Renal failure can be divided into prerenal failure, intrinsic renal disease including vascular insults, and obstructive uropathies. The history, physical examination, and laboratory studies including a urinalysis and radiographic studies can establish the likely cause(s) of AKI. Once intrinsic renal failure has become established, management of the metabolic complications of AKI requires meticulous attention to fluid balance, electrolyte status, acid-base balance, and nutrition. Many children with AKI will need renal replacement therapy to remove endogenous and exogenous toxins and to maintain fluid, electrolyte, and acid-base balance until renal function improves. Renal replacement therapy may be provided by peritoneal dialysis (PD), intermittent hemodialysis (HD), or hemofiltration with or without a dialysis circuit. Many factors--including the age and size of the child, the cause of renal failure, the degree of metabolic derangements, blood pressure, and nutritional needs--are considered in deciding when to initiate renal replacement therapy and which modality of therapy to use. The prognosis of AKI is highly dependent on the underlying etiology of the AKI. Children who have AKI as a component of multisystem failure have a much higher mortality rate than children with intrinsic renal disease. Recovery from intrinsic renal disease is also highly dependent on the underlying etiology of the AKI. Children who have experienced AKI from any cause are at risk for late development of renal failure long after the initial insult. Such children need life-long monitoring of their renal function, blood pressure, and urinalysis.
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ABSTRACT: Acute renal failure associated with a fulminant, life-threatening systemic disease is rare in previously healthy young children; however, when it occurs, the most common cause is hemolytic-uremic syndrome (HUS). In most cases (90%), this abrupt and devastating illness is a result of ingestion of food or drink contaminated with pathogens that produce very potent toxins. Currently, there are no proven treatment options that can directly inactivate the toxin or effectively interfere with the cascade of destructive events triggered by the toxin once it gains access to the bloodstream and binds its receptor. However, HUS is self-limited, and effective supportive management during the acute phase is proven to be a life saver for children affected by HUS. A minority of childhood HUS cases, approximately 5%, are caused by various genetic mutations causing uncontrolled activation of the complement system. These children, who used to have a poor prognosis leading to end-stage renal disease, now have access to exciting new treatment options that can preserve kidney function and avoid disease recurrences. This review provides a summary of the current knowledge on the epidemiology, pathophysiology, and clinical presentation of childhood HUS, focusing on a practical approach to best management measures.International Journal of Nephrology and Renovascular Disease 01/2014; 7:231-9.
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ABSTRACT: Acute kidney injury (AKI) leads to high rates of morbidity and independently increases mortality risk. Therapy for AKI is likely limited by the inability to reliably diagnose AKI in its early stages, and, importantly, small changes in serum creatinine may be associated with poor outcomes and severe AKI. Whereas AKI biomarker research seeks to identify more sensitive and timely indices of kidney dysfunction, AKI lacks physical signs and symptoms to trigger biomarker assessment in at-risk patients, limiting biomarker efficacy. Accurate models of AKI prediction are unavailable. Severity of illness (SOI) scoring systems and organ dysfunction scores (OD), which stratify patients by prediction of mortality risk, are AKI reactive, not predictive. Kidney-specific severity scores do not account for AKI progression, and stratification models of AKI severity are not predictive of AKI. Thus, there is a need for a kidney scoring system that can help predict the development of AKI. This review highlights the concept of renal angina, a combination of patient risk factors and subtle AKI, as a methodology to predict AKI progression. Fulfillment of renal angina criteria will improve the efficiency of AKI prediction by biomarkers, in turn expediting early therapy and assisting in creation of AKI-predictive scoring systems.Pediatric Nephrology 10/2011; 27(7):1067-78. · 2.88 Impact Factor
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ABSTRACT: BACKGROUND: In this study we applied the pediatric version of the RIFLE criteria (pRIFLE) to an at-risk hospital population, analyzed the incidence and association of acute kidney injury (AKI) with mortality and length of stay in both the intensive care unit (ICU) and the hospital, and evaluated the applicability of pRIFLE as a prognostic tool in the ICU. METHODS: This study was a prospective single-center cohort study in which 126 patients were enrolled. The affected group included patients who were diagnosed with AKI. Subgroups of the diagnosed patients were established according to their maximum pRIFLE strata, which were defined as the worst pRIFLE score attained during the study period. RESULTS: Fifty-eight (46 %) of our patients developed AKI. The lengths of stay in the ICU and in the hospital were longer in the affected group than in the unaffected group. The advanced strata of pRIFLEmax were associated with longer stays in the ICU and hospital and higher median Pediatric Index of Mortality II scores. The hospital mortality rate of AKI patients was 12-fold higher than that of the patients without AKI (36 vs. 3 %). CONCLUSION: The incidence of AKI in this population was both significant and directly associated with hospital mortality and the length of stay in the ICU and hospital. The pRIFLE classification facilitated the definition of AKI, indicating that it a significant prognostic predictor.Pediatric Nephrology 11/2012; · 2.88 Impact Factor