Done By Dr.Ma'ad Al-Jubouri <<< Iraq-Baghdad

2. Acute Renal Failure
in Children
Done By : Ma’ad Adnan
Supervised By : Dr.Mahdi Al-Zuhairy

3. Definition
•A clinical syndrome in which a sudden
deterioration in renal function results in the
inability of the kidneys to maintain fluid and
electrolyte homeostasis.
•Also k/a Acute renal insufficiency
•2-3% of children admitted to pediatric tertiary
care centres
•8% of infants in neonatal ICU

4. •Anuria < 0.5 cc/kg/hour
•Oliguria more than 1 cc/kg/hour‖
•70% Non-oliguric , 30% Oliguric
•Non-oliguric associated with better prognosis and
outcome
•―Overall, the critical issue is maintenance of
adequate urine output and prevention of further
renal injury.‖

5. Classifications
Pre-renal = in which decrease renal
perfusion 55%
Renal parenchymal (intrinsic)= in
which there is renal paranchymal injury 40%
Post-renal = in which there is obstruction of
renal outflow 5-15%

6. 1.Pre renal
2. Intrinsic Renal
3. Post-renal

7. Causes of ARF
Pre-renal :
vomiting, diarrhea, poor fluid intake, fever, use of
diuretics, and heart failure
cardiac failure, liver dysfunction, or septic shock
Intrinsic :
Interstitial nephritis, acute glomerulonephritis,
tubular necrosis, ischemia, toxins
Post-renal :
prostatic hypertrophy, cancer of the prostate or
cervix, or retroperitoneal disorders
neurogenic bladder bilateral renal calculi, papillary
necrosis, coagulated blood, bladder carcinoma,
and fungus

8. Symptoms of ARF
1.Decrease urine output (70%)
2.Edema, esp. lower extremity
3.Mental changes
4.Heart failure
5.Nausea, vomiting
6.Pruritus
7.Anemia
8.Tachypenic
9.Cool, pale, moist skin

9. 1.Sunken Fontanels
3.Dry Tongue & Mucous
Membranes
3.Loss of skin turgor
4.rritability
5.Feeble Pulses
Sign of Collapse
1.Anorexia
2.Vomiting
3.Nausea
4.Lethargic
5.Hypertension
4.Uremic Encephalopathy
5.Seizure
Sign of uremia

10. Acute Tubular Necrosis
Renal insults, including
•renal ischemia
•exposure to exogenous or endogenous
nephrotoxins.
The net effect is a rapid decline in renal
function that may require a period of dialysis
before spontaneous resolution occurs.

11. Major Causes of Acute Tubular Necrosis
•Renal Ischemia:
* Severe prerenal disease from any
cause.
•Exposure to Nephrotoxins:
* Amphotericin B
* Aminoglycosides * Heme Pigments *
NSAID's (hemoglobinuria/myoglobinura)

12. Investigation of ARF
Urine Examination:
•Urine Na-- > 20 mEq/l show intrinsic renal
< 10 mEq/l show pre-renal
•Urine Microscopy---Pus, RBC’s, White Cell Casts
Blood Counts:
•Low Hb---blood loss
•Leukocytosis---infection
•Platelet Counts---low in HUS, Renal Vein
Thrombosis

13. Blood Urea & Creatinine:
Raised due to diminished renal function
Serum Calcium, Phosphate, AlkalinePhosphates:
•S.Ca low
•S.Phosphate raised
Serum Electrolytes & Osmolality:
•Na low & K high

14. C3 Complement Level:
Low in Acute Glomerulonephritis, SLE Nephritis
Radiological examination
1.ultrasonography:
pelvic ultrasonogrophy may show mass and
calculate the residual urine.
it is useful for guiding needle for renal biopsy or
aspiration of perirenal collection.
Doppler flow imaging of the renal vessels may help in
diagnosis of renal artery occlusion or stenosis , renal
vein thrombosis and kidney transplant rejection.

15. 2.plain abdominal x-ray (KUB):(kidney,ureter,bladder)may show
a.stones
b.calcification of the kidney ,urinary bladder, seminal vesicles.
c.renal contour and soft tissue shadow
3.Intravenous urography (IVU): shows any mass ,stones
,back pressure changes and also demonstrates kidney
function and obstruction. It should be done in the light of
renal function .
4.angiography: this includes
a.renal arteriography It is mainly indicated for
diagnosis of renovascular hypertension or persistent
haematuria following trauma.
b. renal venography. This is indicated for diagnosis of
renal vein thrombosis.
5.Computerized tomography (CT):it is strongly indicated in
patients with obstructive uropathy with non-evident cause.
6.Magnetic resonance imaging (MRI)
helpful in studying malignancies of the urinary tract and
assessment of renal vessels by MRI angiography.

16. Kidney biopsy
•It shows the pathology of the underlying renal disease.
•The biopsy should be examined by light microscope (LM)
,electronic microscope (EM) and immunofluorescent
microscope (IF)
•Very helpful in diagnosing, prognosis and therapeutic
guidance.
cystoscopy, ureteroscopy
Diagnostic :
of bladder disease , (tumour)by direct vision or biopsy.
Therapeutic:
ureteric catheter: also , ascending pyelography , differential
renal function.

17. General Measures
Management
1.IV secure.
2.Take blood samples.
3.Collect urine sample.
4.Catheterize if bladder is palpable.
5.Record blood pressure.
6.Careful intake and output record.
7.Daily weight measurement.
8.Daily investigations.
.Urea
.Creatinine
.Serum electrolytes
.Blood gases
.ECG(to detect Hyperkalemia)

18. •Water and sodium restriction
•Protein restriction
•Potassium and phosphate
restriction
•Adjust medication dosages
•Avoidance of further insults
–BP support
–Nephrotoxins

19. .
•Catheterization - in newborn with suspected
posterior ureteral valves & nonambulatory older
children.
•If there is no evidence of volume overload or
cardiac failure, intravenous administration of
isotonic saline, 20 mL/kg over 30 min.
•hypovolemic patients generally void within 2 hr
after bolus; failure points to intrinsic or
postrenal ARF.
•Hypotension due to sepsis - vigorous fluid
resuscitation f/b continuous infusion of
norepinephrine

20. Diuretic therapy :
1.only after the adequate hydration.
2.Mannitol (0.5 g/kg) and furosemide (2-4 mg/kg) - as a
single IV dose. [Mannitol - effective in pigment (myoglobin,
hemoglobin)-induced renal failure.]
3.Bumetanide (0.1 mg/kg)- an alternative to furosemide.
If urine output is not improved - continuous diuretic
infusion may be considered.
1. Consider Dopamine (2-3 µg/kg/min) in conjunction with
diuretic therapy.
2.There is little evidence that diuretics or dopamine can
prevent ARF or hasten recovery

21. 1.Hyperkalemia
Symptoms
•Weakness
•Lethargy
•Muscle cramps
•Paresthesias
•Dysrhythmias
Hyperkalemia & EKG
•K > 5.5 -6
•Tall, peaked T’s
•Wide QRS
•Prolong PR
•Diminished P
•Prolonged QT
•QRS-T merge – sine wave
Management of Complications

23. Hyperkalemia Treatment
•Calcium gluconate (carbonate)
•Sodium Bicarbonate
•Insulin/glucose
•Kayexalate (sodium polystyrene sulfonate)
•Lasix
•Albuterol
•Hemodialysis

24. 2. ACIDOSIS:
Correct acidosis by NaHCO3
Total calculated dose divide in 3 doses;
•One part given start
•2nd part after 8 hrs
•3rd part discard
3. HYPOCALCEMIA
Can present as tetany or convulsions.
•iv calcium gluconate slow and diluted in 5 to 10
mints under cardiac monitoring.
•Treatment primarily involves efforts to lower the
serum phosphorous level.
•Calcium Carbonate (phosphate binder) help to
decrease the absorption of phosphorous & help its
excretion.

25. 4. Hyponatremia:
•Due to fluid overload or hypotonic fluid administration.
require correction with hypertonic sodium chloride
• In Hypertension due to fluid over load, contraindicated
to give Hypertonic Saline
•Do Dialysis to correct hyponatremia
5. Seizures:
•Due to primary renal disease, uremia,
hyponatremia, hypocalcaemia & hypertension
•Inj.Diazepam

26. 6. Infections:
•Due to bladder catheterization or peritoneal dialysis
•Broad Spectrum Antibiotics (B.Pencillin or Ceftrixone)
given.
•Nephrotoxic (Amikacin, Erythromycin) drugs avoided.
7. Anemia:
Due to volume expansion
•If Hb < 7 g/dl, blood should be given very slowly in 4
to 6 hrs.

27. Dialysis

28. Indications for dialysis
•Hyperkalemia unresponsive to medical therapy.
•Acidosis unresponsive to medical therapy.
•Fluid overload unresponsive to fluid restriction
or to diuretics.
•Symptoms & Signs of uremia.
•Hypertension & CCF not responding to medical
therapy.
•Blood urea N greater than 100-150mg/dl
•Mental status change

29. Types Of Dialysis
•Peritoneal Dialysis
•Acute Intermittent Hemodialysis
•Continuous Hemofiltration

31. Peritoneal dialysis
1.Simple to set up & perform
2.Easy to use in infants
3.Hemodynamic stability
4.No anti-coagulation
5.Bedside peritoneal access
6.Treat severe hypothermia or
hyperthermia
Advantages Disadvantages
1.Unreliable ultrafiltration
2.Slow fluid & solute removal
3.Drainage failure & leakage
4.Catheter obstruction
5.Respiratory compromise
6.Hyperglycemia
7.Peritonitis
8.Not good for
hyperammonemia or
intoxication with dialyzable
poisons

32. Intermittent Hemodialysis
•Maximum solute
clearance of 3 modalities
•Best therapy for severe
hyperkalemia
•Limited anti-coagulation
time
•Bedside vascular
access can be used
•Hemodynamic instability
•Hypoxemia
•Rapid fluid and electrolyte
shifts
•Complex equipment
•Specialized personnel
•Difficult in small infants
Advantages Disadvantages

33. Continuous Hemofiltration
•Easy to use in PICU
•Rapid electrolyte correction
•Excellent solute clearances
•Rapid acid/base correction
•Controllable fluid balance
•Tolerated by unstable pts.
•Early use of TPN
•Bedside vascular access
routine
•Systemic anticoagulation
(except citrate)
•Frequent filter clotting
•Vascular access in
infants
Advantages Disadvantages

34. Depends upon cause.
90 % complete remission in;
•ATN (Acute Tubular Necrosis)
•HUS (Hemolytic-uremic Syndrome)
Other Causes of pre-renal failure
Poor Prognosis when renal failure due to;
•RPGN (Rapidly Progressive Glomerulonephritis)
•Bilateral Renal Vein Thrombosis
•Bilateral Cortical Necrosis
Prognosis

35. THE END
Thank You