INVESTIGATIONS

Blood: Full blood count, Arterial blood gas, serum albumin, Calcium ,Phosphate. Urine: UFEME, Urinalysis Renal function test: blood urea, electrolytes, creatinine. Imaging: Renal ultrasound Chest Xray

TO DIFFERENTIATE PRE RENAL AND INTRINSIC RF

1) Fractional excretion of sodium [U/P Na U/P Creatinine] x 100 U= Urine concentration P= Plasma concentration <1%= pre renal azotemia >2%= intrinsic renal dysfunction
2) Urine Chemical Profile -Pre renal : Na<20mEq/L -Intrinsic RF : Na>40mEq/L

Nelson Paediatric Textbook 6th Ed.

URINALYSIS

RENAL FUNCTION TEST

Blood Urea Nitrogen - If elevated = AZOTEMIA - <2years = 4-15mg/dL - >2 years= 5-20mg/dL Creatinine clearance 75-125ml/min ( decreases with age)
Serum BUSE Hyperkalemia [serum K > 6.0 mmol/l (neonates) and > 5.5 mmol/l (children] Hyponatremia [136-145mmol/L] Hypocalcemia [9-11mg/dL]

Serum creatinine - 0.6-1.3mg/dL

Hyponatremia is due to dilutional disturbance , corrected by fluid restriction

Nelson Paediatric Textbook 6th Ed.

Acute Kidney Failure

Considerations
Volume status Blood pressure status Electrolyte abnormalities status Acid Base status

Management
CONSERVATIVE AND SUPPORTIVE Fluid resuscitation(30% of maintenance) Fluid bolus of isotonic saline (1020ml/kg/dose) with careful hemodynamic monitoring If fluid therapy adequate but oliguria persists, give furosemide to convert to non oliguric state Monitor for fluid overload signs (hypertension,raised JVP, basal crepitations,hepatomegaly)

Medical Management Hypertension Electrolyte imbalance Acid base imbalance

If the child did not pass urine within 2 hours, a catheter/suprapubic tap has to be done to assess if there is any urine formation. If the child has no urine formation, CVP has to be monitored. Post renal causes should be elicited and treated.
Paediatric Protocol 3rd Edition

Fluid Balance
In hypovolaemia: Fluid resuscitation regardless of oliguric or anuric state Give crystalloids, e.g. isotonic 0.9% saline/ Ringers lactate 20ml/kg fast(in <20minutes) Transfuse blood if haemorhage is the cause of shock Hydrate to normal volume status If urine output increases, continue fluid replacement

 In hypervolaemia: Features of volume overload signs (hypertension,raised JVP, basal crepitations,hepatomegaly) If necessary to give fluid, restrict to insensible loss (400ml/m2/day or 30ml/kg in neonates depending on conditions) IV Frusemide 2mg/kg/dose9over 10-15minutes), maximum of 5mg/kg/dose. Dialysis if no response or if volume overload is life threatening

Hypertension
Related to fluid overload or alteration in vascular tone. Choice of anti hypertensive drugs depends on degree of BP elevation, presence of CNS symptoms of hypertension and cause of renal failure. A diuretic is usually needed.

Electrolyte Abnormalities
Hyperkalaemia: - serum K+ > 6.0mmol/L(neonates) and > 5.5 mmol/L (children) - cardiac toxicity develops when plasma potassium >7mmol/L
Hyperkalemia on ECG 1. Tall peak T waves k>6 2. Prolonged PR interval K>8 3. Widened QRS complex K>7 4. Flattened P wave K>9 5. Sine waves QRS complex merge with peaked T waves) K> 6-7 6. VF or asystole K> very high

Hyponatraemia: Usually dilutional from fluid overload If asymptomatic, fluid restrict Dialyse if symptomatic or above measure fails

Hypocalcaemia: - Treat if symptomatic(serum Ca2+ < 1.8mmol/L) and if sodium bicarbonate is required for hyperkalaemia, with IV 10% Calcium gluconate 0.5ml/kg, given over 10-20 minutes, with ECG monitoring. Hyperphosphataemia: - Phosphate binders e.g. calcium carbonate or aluminium hydroxide orally with main meals

Acid Base Imbalance

Mild metabolic acidosis is common in ARF as a result of retention of hydrogen ions, phosphate, and sulfate, but it rarely requires treatment. If acidosis is severe (arterial pH < 7.15; serum bicarbonate < 8mEq/L) or contributes to hyperkalemia, treatment is required. Correction of metabolic acidosis with intravenous sodium bicarbonate may precipitate tetany in patients with renal failure as rapid correction of acidosis reduces the ionized calcium concentration. Ensure that patients serum calcium is >1.8mmol/L to prevent hypocalcemic seizure with sodium bicarbonate therapy. Bicarbonate deficit= 0.3x body weight(kg)x base excess -replace the half of deficit with IV 8.4% sodium bicarbonate

Indications for Dialysis

Volume overload with evidence of severe pulmonary edema and refractory hypertension
Persistent hyperkalemia

Severe electrolyte abnormalities (Calcium/phosphorus imbalance, with hypocalcemic tetany, symptomatic hyponatraemia)
Severe metabolic acidosis unresponsive to medical therapy Blood urea nitrogen > 100-150mg/dL

Types of Dialysis
Intermittent hemodialysis:

Useful in patients with relatively stable hemodynamic status.

This highly efficient process accomplishes both fluid and electrolyte removal in 34/hr sessions using a pump-driven extracorporeal circuit and large central venous catheter. Intermittent hemodialysis may be performed three to seven times a week based on the patient's fluid and electrolyte balance.

 Peritoneal dialysis: Most commonly employed in neonates and infants with ARF. Hyperosmolar dialysate is infused into the peritoneal cavity via a surgically or percutaneously placed peritoneal dialysis catheter. The fluid is allowed to dwell for 4560/min and is then drained from the patient by gravity (manually or with the use of a cycler machine). Cycles are repeated for 824?hr/day based on the patient's fluid and electrolyte balance; peritoneal dialysis is contraindicated in patients with abdominal disorders.

 Continuous renal replacement therapy : (CRRT) is useful in patients with unstable hemodynamic status, concomitant sepsis, or multiorgan failure in the intensive care setting. CRRT is an extracorporeal therapy in which fluid, electrolytes, and smalland medium-sized solutes are continuously removed from the blood (24hr/day) using a specialized pump-driven machine. Usually, a double-lumen catheter is placed into the subclavian, internal jugular, or femoral vein. The patient is then connected to the pump-driven CRRT circuit, which continuously passes the patient's blood across a highly permeable filter.

CRRT
CVVHF Continuos Veno-Venous Hemofiltration CVVHD Continuous Veno-Venous HemoDialysis CVVHDF Continuous Veno-Venous HemoDiafiltration

(CVVH-D) utilizes the principle of diffusion by circulating dialysate in a countercurrent direction on the ultrafiltrate side of the membrane. No replacement fluid is used. Continuous hemodiafiltration (CVVH-DF) employs both replacement fluid and dialysate, offering the most effective solute removal of all forms of CRRT.

CVVHD Circuit

CVVHDF Circuit

H2O

H2O

H2O

Continuous Hemofiltration
Advantages Disadvantages

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

References
Nelson Paediatric Textbook 6th Ed. Malaysian Paediatric Protocol 3rd Edition