Dr Hodan Ahmed

Dept of Pediatrics and Child Health

Amoud Medical School, AU
ACUTE KIDNEY INJURY
DEFINITION
Acute loss of kidney function
Retention of urea, creatinine
Inability to maintain fluid and electrolyte balance
Objectives
To understand the definition of acute kidney
failure
Clinical manifestations of acute kidney failure
Investigations and management of acute kidney
failure
Classification of causes
1. Prerenal
2. Intrinsic renal
3. Post renal
PRERENAL CAUSES
Hypovolaemia
Peripheral vasodilation
Impaired cardiac output
Bilateral renal vessel occlusion
Drugs
Others


Pre-renal Failure
Decreased renal perfusion in intrinsically
normal kidney
Restoration of normal renal perfusion results
in return to normal renal function
If not may progress ATN
Acute tubular necrosis(ATN) implies kidney
has suffered intrinsic damage

Renal Hemodynamics in ARF
Renal vasoconstriction in response to renal
tubular epithelium


Activation of renin angiotensin system has
evidence for and against

Generates Prostaglandins(PGs)
Vasodilatory PGs including prostacyclin
Maintains renal perfusion

PATHOPHYSIOLOGY
Multifactorial
Renal vasoconstriction
Vasoactive compounds
Free radicals
Largely still unknown
Intrinsic renal failure
Disease of kidney, AGN, ATN, HUS,
Myoglobinuria
Intratubular obstruction
Iatrogenic
Tumour infiltrate
drugs
POSTRENAL
PUV
Blocked catheter
Neurogenic bladder
Calculi
Tumours
Trauma

ARF according to urine output
Oligo/anuria
More common
Due to hypoxia/ischaemic insults ATN
Cortical necrosis

Normal urine output
Nephrotoxic insults aminoglycoside and contrast
nephropathy

Nephrotoxic Acute Renal Failure
Endogenous agents
haemoglobinuria, myoglobinuria
Drugs
Aminoglycosides
NSAIDs
Intravascular contrast

Aminoglycosides
10-20% show increase in creatinine
Non-oliguric acute renal failure with normal
urine
Toxicity related to
Dose & duration
Level of renal function prior to drug
Aetiology lysosomal dysfunction of prox
tubule and is reversible on stopping

CASE
T I
3 month old
Presenting complaint: cough, fast breathing, fever
On exam: tachypnoeic, crepitations, reduced air
entry right side
Day 3 deteriorating renal function with anuria

INVESTIGATION
FBC:
Hb 6.7g/dl, Platelets 40,
Renal function:
Urea 10/ creatinine 4.5/ pottassium 4
Coagulation studies:
INR 1.17, PTT 14/12, D DIMER NEGATIVE
Blood culture : strep pneumoniae

CLINICAL PRESENTATION
History may give an idea to the back ground of
renal failure
Oliguria
Anuria
Volume overload
Hypertension
Cardiac failure
Encephalopathy
Investigations
Urine output, microscopy, SG
Fractional excretion of sodium
Urea, creatinine
Potassium
Ultrasound
CXR
FBC
OTHER
Investigations
Urine : SG, blood, protein, microscopy red cell
casts
Urine chemistry: sodium <20mmol/l (prerenal) >30
(renal)
Fractional excretion of sodium FE
Na
< 1% (prerenal) >
2%(renal)

MANAGEMENT
TREATMENT OF UNDERLYING DISEASE
FLUIDS
ELECTROLYTES
ACIDOSIS
HYPERTENSION
SEPSIS
RENAL REPLACEMENT
NUTRITION
Fluid balance
Important to differentiate prerenal from renal
cause
Important to assess hydration as hypovolemic
states need to be given fluids
If hypervolemic may need fluid restriction
If in doubt give fluid challenge with saline
Lasix challange
FLUIDS
CHECK INPUT/OUTPUT
Daily weights
Urine Na
Check hydration
Fluid restriction 300-400ml/m
2
Medical management
Diuretics - Frusemide
Also increases urine flow rate to decrease
intra-tubular obstruction

Inhibits Na/K/ATPase
Impact on oxygen consumption in already damaged
tubules with low O2 supply

Problems: high doses in ARF assoc with
ototoxicity

Increased urine flow does not mean improving
GFR
Giving diuretics to patients with prerenal
azoteamia may worsen the situation!!
Therefore CAUTION!!

Acidosis
Acid excretion is impaired in ARF
Correct serum bicarbonate
Administer bicarbonate

electrolytes
Potassium
Sodium
calcium
Medical management
Hyperkalaemia

Peaked T waves, loss of P waves, wide QRS
complex, bradycardia, VT
Place on cardiac monitor
Ca gluconate
Salbutamol nebs
Correct acidosis sodium bicarbonate
Glucose and insulin

Hypocalcemia
Acute hypocalcemia:
10%Ca gluconate
Correct hypomagnesemia
Sodium
Hyponatremia
Dehydration calculate sodium deficit
Use 3% Na
NUTRITION
Marked catabolism
Early Enteral feeding if possible
Feeds compromised due to fluid balance issues
Earlier initiation of dialysis
Hypertension
prevalence of hypertension high even with mild
reduction in GFR
meticulous control of hypertension BP < 90
th

centile or 130/80 mmHg

retard the progression of CRF
ABCD of antihypertensives
.


Dialysis

Indications:
1. Hyperkalemia
2. Overload
3. Acidosis not responding
4. Ureamia clinical urea levels >30mmol/l

TAKE HOME MESSAGE
Early diagnosis of renal failure important
Supportive management crucial
Early replacement therapy may be life saving
Acute peritoneal dialysis is ideal modality for
children
What looks like normal renal function might
not be normal after all
If in doubt call a friend ( seek help)
ANY QUESTIONS