PEADITRIC

NEFROLOGY
RAMESH K CHANDRAN

Introduction

The epidemiology of pediatric acute kidney

injury (AKI), the treatment approaches,
identification and validation of objective
variables and technological refinements in
monitoring equipment, access, and renal
replacement therapy (RRT) machinery
have all changed over the past decade.
(Goldstein,2006)
Overall, AKI remains a significant
contributor to the morbidity and mortality of
critically ill infants and children, especially
those with multi-system organ failure

Introduction

AKI is characterized by the

failure of the kidneys to regulate
electrolyte, acidbase and fluid
homeostasis adequately, with a
concomitant reduction in
glomerular filtration rate .

Introduction

In practical terms this may be

demonstrated in the pediatric patient
(Benfield & Bunchman (2004) :
an increase in nitrogenous waste
products [blood urea nitrogen (BUN)]
an associated increase in serum
creatinine (> 50% above baseline
level)
a concomitant reduction in urine
output (less than 0.51 ml/kg per
hour)

Introduction

However, controversy remains

as to when specifically RRT is
indicated in terms of
creatinine/BUN rise, fluid
overload, associated organ
failure, type of RRT to employ,
which patient population will
benefit most (if at all) from which
RRT therapy and how early
should therapy be initiated.

Introduction

According to The Acute Dialysis

Quality Initiative (ADQI, 2000), AKI
are known as the risk, injury, failure,
loss, and end-stage renal disease, or
RIFLE, criteria. ( Bellomo, Ronco,
Kellum, Mehta, Palevsky , 2004)
A recent pediatric study has
validated a modified form of these
criteria, the pRIFLE

INCIDENCE

Renal kidney failure is a condition

that can occur in children, though
quite rarely. According to the
National Institutes of Health US, it
occurs in only 1 or 2 out of 100,000
children
In adults the incidence is 30 :100000
Thus,adults has 20 times chances to
develop kidney failure than children

INCIDENCE

Kidney failure can be caused by

either an acute or a chronic
issue. Though acute diseases
can be serious, they are not
long-lasting like chronic cases.

Causes of Chronic Failure

Chronic ailments are not as easily

rectified as most acute cases. A child
may have a birth defect, such as a
fetal urinary blockage, that leads to
kidney damage or interferes with the
proper development of organs. Other
hereditary diseases, such as
polycystic kidney disease or Alport's
syndrome, can also lead to renal
failure.
Sources:US,Renal Data System,2005

Causes of Chronic Failure

Now, the most common causes in

developed countries may involve
multiple system diseases or failures,
including congenital heart disease,
acute tubular necrosis, nephrotoxic
medications, and sepsis.(Hui-Stickle,
Brewer, Goldstein, 2005)
In developing countries hemolytic
uremic syndrome (HUS) continues to
be reported as one of the primary
causes of pediatric AKI [Anochie,
Eke, 2006)

Treatment modality

Dialytic intervention for infants and children

with acute kidney injury (AKI) can take
many forms.
Whether patients are treated by intermittent
hemodialysis, peritoneal dialysis or
continuous renal replacement therapy
depends on specific patient characteristics.
Modality choice is also determined by a
variety of factors, including provider
preference, available institutional
resources, dialytic goals and the specific
advantages or disadvantages of each
modality

Treatment modality

In the setting of AKI, disturbed fluid or

metabolic balance often necessitates the
initiation of RRT.
Historically, the reported mortality rates for
children requiring dialysis ranged anywhere
from 35% to 73%.(Hui-Stickle, Brewer,
Goldstein, 2005).
However, more recent paediatric RRT
demographic data has stratified diagnoses
and clarified outcome numbers, suggesting
that refinement of variables, use of severity
of illness scores, and earlier intervention
are, for the first time, providing improved
care with improved outcome .

Treatment modality
A great number of modalities is currently available for
the provision of RRT in the pediatric patient with AKI.
(Benfield, Bunchman, 2004)
Intermittent hemodialysis (IHD)

peritoneal dialysis (PD)

continuous renal replacement therapies (CRRT)

continuous venovenous hemodialysis (CVVHD)

(predominantly diffusive clearance)

continuous venovenous hemofiltration (CVVH)

(convective clearance)

continuous venovenous hemodiafiltration

(CVVHDF) (both convective and diffusive
clearance)

Treatment modality

While temporary IHD is the most

efficient modality for fluid and
metabolic control,
However IHD pediatric intensive
care unit (ICU), due to large
extracorporeal circuit volumes
and the inability of patients to
tolerate rapid fluid shifts.

Treatment modality

PD or CRRT has become the

mainstay of RRT in ICU/HDU
CRRT, it is fast becoming the
standard of care in the ICU setting.
Warady and Bunchman Warady
(2000) noted that, in just a 4-year
period (19951999), the preferred
modality for the treatment of
pediatric AKI had changed from PD
to CRRT.

Treatment modality

100% (18 to 36) increase in the

number of centers reporting CRRT
as the primary initial modality of
treatment.
Currently, it is unclear which patients
with AKI require which specific
therapy, and some patients may
benefit from the provision of PD
rather than IHD or CRRT in specific
circumstances.

Figure5-5 Non-functional multicystic/dysplastic right kidney and grossly normal-appearing left kidney from an
infant who died in the perinatal period of non-renal causes. (See color plate 4)

The increased use of maternal-fetal

ultrasound has led to the
development of the field of perinatal
urology.
Antenatal hydronephrosis (ANH) is
identified in approximatelym13% of
all pregnancies and is one of the
most common birth defects detected.

Other urologic abnormalities have been

diagnosed
prenatally :
renal cystic disease,
renal agenesis,
stones and
tumors.
For the pediatric urologist, these prenatal
finding
have created numerous clinical dilemmas that
challenge our understanding of normal and
abnormal renal embryology and physiology

Vascular access: choice and

complications in European
paediatric haemodialysis units.

Pediatric Nephrology, Jun2012, Vol. 27 Issue 6, p999-1004, 6p, 4 Graphs

Graph; found on p1001

European and U.S. guidelines emphasise that permanent

vascular access in the form of arteriovenous fistulae (AVF) or
grafts (AVG) are preferable to central venous catheters (CVC) in
paediatric patients on long-term haemodialysis.
We report vascular access choice and complication rates in 13
European paediatric nephrology units. Methods: A survey of
units participating in the European Pediatric Dialysis Working
Group requesting data on type of vascular access, routine care
and complications in patients on chronic haemodialysis between
March 2010 and February 2011.
Results: Information was complied on 111 patients in 13
participating centres with a median age of 14 (range 0.25-20.2)
years.
Central venous catheters were used in 67 of 111 (60%) patients,
with 42 patients (38%) having an AVF and two patients (2%)
having an AVG.
Choice of vascular access was significantly related to patient
age, with patients with AVF/AVG having a median age of 16
years compared to 12 years for patients with CVCs

Vascular access: choice and complications in European paediatric haemodialysis units.

Goldstein SL (2006) Pediatric

acute kidney injury: its time for
real progress. Pediatr Nephrol
21:891895