1. Prof. Rai Muhammad Asghar Department of Pediatrics
Rawalpindi Medical College

2. Acute Renal Failure

3. Acute Renal Failure:. Clinical Syndrome
Acute Renal Failure: * Clinical Syndrome * Sudden deterioration in renal Function * Inability of kidneys to maintain fluid and electrolytes homeostasis * 2-3% children, 8% neonates

4. Paediatric-Modified Rifle (Prifle) Criteria
Estimated CCI
Urine Output
Risk
eCCI decrease by 25%
< 0.5mL/kg/hr for 8 hr
Injury
eCCI decrease by 50%
< 0.5mL/kg/hr for 16 hr
Failure
eCCI decrease 75% or eCCI <35 ml/min/1.73m2
< 0.3mL/kg/hr for 24 hr or anuric for 12 hr
Loss
Persistent failure >4 wk
End-Stage
End-stage renal disease (persistent failure >3 mo)

5. Acute Renal Failure Stage I Stage II Stage III
Rise in serum creatinine >150%
Stage II
Rise in serum creatinine > 200%
Stage III
Rise in serum creatinine > 300%

6. Classified into 3 categories. 1- Prerenal ARF. 2- Intrinsic Renal ARF
Classified into 3 categories Prerenal ARF 2- Intrinsic Renal ARF 3- Postrenal ARF

7. Pathogenesis and Causes Prerenal ARF * Diminished effective circulating arterial volume * Inadequate renal perfusion * Decreased GFR * No evidence of kidney damage

8. Causes of Prerenal ARF. 1- Dehydration. 2- Hemorrhage. 3- Sepsis
Causes of Prerenal ARF 1- Dehydration 2- Hemorrhage Sepsis Hypoalbuminemia Cardiac Failure

9. Intrinsic Renal ARF. Renal parenchymal damage
Intrinsic Renal ARF * Renal parenchymal damage * Sustained hypoperfusion / ischemia

10. Causes of Intrinsic Renal ARF. 1- Glumerulonephritis
Causes of Intrinsic Renal ARF 1- Glumerulonephritis * Post streptococcal * Lupus nephritis * Henoch-schonlein purpura * Membranoproliferative * Anti-glomerular basement membrane nephritis

11. Causes of Intrinsic Renal ARF (cont). 2- Hemolytic uremic syndrome
Causes of Intrinsic Renal ARF (cont) 2- Hemolytic uremic syndrome Acute Tubular Necrosis Renal vein thrombosis Rhabdomyolysis Acute interstitial nephritis Tumor lysis Syndrome

12. Postrenal ARF. Obstruction of urinary tract. Causes
Postrenal ARF Obstruction of urinary tract Causes Posterior urethral valves Ureteropelvic junction obstruction Urolithiasis Tumor 5- Hemorrhagic cystitis Neurogenic bladder

13. Clinical Manifestation Depends upon the cause

14. Diagnosis Detailed History Physical Examination

15. Investigations. 1- Blood urea / creatinin. 2- Electrolytes
Investigations Blood urea / creatinin 2- Electrolytes CBC, platelet count 4- Urine RE 5- C3 6- ASO titer 7- X-ray chest 8- Renal ultrasonography Renal Biopsy

16. Urinary Indices. Urinary Indices. Prerenal ARF
Urinary Indices Urinary Indices Prerenal ARF Intrinsic ARF Specific gravity > < Urine osmolality >500 mOsm\kg <350mOsm\kg Urine Sodium <20mEqIL >40mEqIL Fractional Excretion Na<1% >2%

17. Treatment. Depends upon cause / complication. Bladder catheterization
Treatment Depends upon cause / complication Bladder catheterization (relieve obstruction & monitor urine output)

18. Volume Resuscitation. If no evidence of volume overload /
Volume Resuscitation If no evidence of volume overload / cardiac failure Isotonic saline 20ml/kg over 30 minutes Severe hypovolemia require additional fluid boluses Hypovolemic patient voids within 2 hours

19. Diuretic therapy. Exclude hypovolemia. Mannitol 0. 5g / kg
Diuretic therapy * Exclude hypovolemia * Mannitol 0.5g / kg *Furosimide 2-4mg/kg * Continuous diuretic infusion * dopamine 2-3mcg / kg / min

20. Fluid requirements. 400ml / m2 / 24 hrs
Fluid requirements * 400ml / m2 / 24 hrs Plus Fluid equal to urine output * Replace extra renal fluid loss ml for ml * Fluid restriction in hypervolemic patients * Daily monitor for fluid intake, urine & stool output, body weight & serum chemistries

21. Hyperkalemia (>6mEq / l). Leads to cardiac arrhythmia & cardiac
Hyperkalemia (>6mEq / l) *Leads to cardiac arrhythmia & cardiac arrest * Peaked T wave, wide QRS, ST segment depression * Stop exogenous sources of K+ * Calcium gluconate 10% 1ml/kg * Sodium bicarbonate 1-2mEq / kg IV * Regular insulin 0.1U/kg with 50% dextoxe solution 1ml/kg over 1hr * Kayexalate 1g/kg * B-adrenergic agonist * Dialysis

22. Metabolic acidosis. Due to retention of hydrogen ions,
Metabolic acidosis * Due to retention of hydrogen ions, phosphate & sulphate * Treat if severe (PH<7.15, Serum bicarbonate <8mEq/l) * Correct partially (PH to 7.20) * Oral sodium bicarbonate

23. Hypocalcemia. Treat by lowering serum phosphorus
Hypocalcemia * Treat by lowering serum phosphorus * Do not give I/V calcium except if tetany * Low phosphorus diet * Phosphate binder (calcium carbonate, Ca acetate)

24. Hyponatremia. Mainly dilutional. Fluid restriction
Hyponatremia * Mainly dilutional * Fluid restriction * I/V 3% NaCl if seizures or <120mEq / l * mEq NaCl required = 0.6 X Wt (kg) X[ S.Na +(mEq/l)]

25. GIT Bleeding. Uremic platelet dysfunction. Increased stress
GIT Bleeding * Uremic platelet dysfunction * Increased stress * Heparin exposure * Give H2 blocker (Ranitidine)

26. Hypertension. Diuretic. Isradipine. 05 -0. 15mg/kg/24hrs. Amlodipine
Hypertension * Diuretic * Isradipine mg/kg/24hrs * Amlodipine mg/kg/24hrs * Propranolol 0.5 – 8mg/kg/24hrs * Labetalol 4-40mg/kg/24hrs

27. Neurogenic Symptoms. Headache, Seizures, Lethargy. I/V Diazepam
Neurogenic Symptoms * Headache, Seizures, Lethargy * I/V Diazepam * Treat precipitating cause

28. Anemia. Generally mild. Hemodilution
Anemia * Generally mild * Hemodilution * Packed red blood cells if Hb <7g/dl * Use fresh, washed RBCs

29. Nutrition. Restrict Na+, K+ & Phosphorus. Protein restriction
Nutrition * Restrict Na+, K+ & Phosphorus * Protein restriction * Parentral hyperalimentation

30. Dialysis. Indications. Volume overload with hypertension
Dialysis Indications * Volume overload with hypertension refractory to diuretics * Persistent Hyperkalemia * Severe metabolic acidosis * Neurological symptoms * BUN > mg/dl * Calcium /Phosphorus imbalance with hypocalcemic tetany

31. Types of dialysis 1- Intermittent hemodialysis Peritoneal dialysis Continuous renal replacement therapy

32. Prognosis. Depends entirely on underlying disease
Prognosis * Depends entirely on underlying disease * AGN has very low mortality (<1%) * ARF related to multiorgan failure has high mortality (>90%) * Recovery is likely if ARF due to HUS, ATN, AIN or tumor lysis syndrome * Recovery is unusual when ARF due to rapidly progressive GN, bilateral renal vein thrombosis, bilateral cortical necrosis

33. Thank You