Renal Failure

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Definition: acute kidney injury (AKI) is failure of the kidneys to regulate electrolyte, acid-base and fluid homeostasis adequately with concomitant reduction in glomerular filtration rate (GFR). pRIFLE (paediatric Risk, Injury, Failure, Loss, End-Stage Criteria).

Chronic renal failure: hyperfiltration, estimated creatinine clearance <75 ml/min/1.73m2 , hypertension, microalbuminuria.

Causes:

Multi-organ failure, congenital heart surgery, nephrotoxic substances, stem-cell transplantation, sepsis, HUS.


pRIFLE
Grade estimated Crea Clearance Urine Output
Risk decrease by 25 % < 0.5 ml/kg/hr for 8 hours
Injury decrease by 50 % < 0.5 ml/kg/hr for 16 hours
Failure decrease by 75 % or< 35 ml/min/1.73m2 < 0.3 ml/kg/hr for 24 hours or anuric for 12 hours
Loss persistent failure > 4 w
End Stage persistent failure > 3 mo

Causes:

AKI, dysplasia, renal reflux, obstructive nephropathy, chronic GN.


Options for renal replacement therapy (RRT):

CVVHD (continuous venovenous haemodialysis – clearance via diffusion)

CVVH (continuous venovenous haemofiltration – clearance via convection)

CVVHDF (continuous venovenous haemodiafiltration – clearance via convection and diffusion), most commonly done, PD (peritoneal Dialysis), SCUF, IHD (intermittent haemodialysis).

Comparison of Renal Replacement Therapy
Variable PD CRRT IHD
Convection + +++
Diffusion ++ ++
Fluid control ++ ++
Uraemia control ++ +
Vascular access Tenkhoff required required
Anitcoagulation not applicable required required

References:

[1] Kidney International 71, 2007, 1028 – 1035, Akcan-Arikan et al: Modified RIFLE criteria in critically ill children with acute kidney injuryAKI in critically ill children

[2] Am J Kidney Dis. 2005, Jan;45(1):96-101: Hui-Stickle et al: Pediatric ARF epidemiology at a tertiary care center from 1999 to 2001

[3] Adv Chronic Kidney Dis, 2008 July ; 15(3): 278-283: Goldstein et al: PROGRESSION FROM ACUTE KIDNEY INJURY TO CHRONIC KIDNEY DISEASE: A PEDIATRIC PERSPECTIVE: An invited review for Advances in Chronic Kidney Disease

[4] Pediatr Nephrol, 2009, 24: 37-49: Walters et al: Dialysis and pediatric acute kidney injury: choice of renal support modality

[5] Pediatr Nephrol. 2005 Jul;20(7):972-6: McNiece et al: Adequacy of peritoneal dialysis in children following cardiopulmonary bypass surgery

[6] Schrier: www.kidneyatlas.org


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Marc Anders is a paediatric intensivist.

Author: Marc Anders

Marc Anders is a paediatric intensivist.