Acute Kidney Injury in Children: Azilah Sulaiman
Acute Kidney Injury in Children: Azilah Sulaiman
Acute Kidney Injury in Children: Azilah Sulaiman
Azilah Sulaiman
Case scenario..
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Discussion
Introduction
Abrupt decrease in kidney function that include, but is not limited to acute renal
failure
Reversible increase in blood concentration of creatinine and nitrogenous waste
products & inability of kidney to regulate fluid and electrolyte homeostasis
appropriately
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1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
2. Acute kidney injury in children, S. Phillips Andreoli, Pediatr Nephrol (2009) 24:253263
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Acute kidney injury in children,S. Phillips Andreoli, Pediatr Nephrol (2009) 24:253263
Concerns: suboptimal care contributes to development of acute kidney injury
2009 NCEPOD reports the results of an enquiry into deaths of a large group of adult patients
with acute kidney injury that described systemic deficiencies in the care of patient who died of
AKI
ONLY 50% of these patient received GOOD care. Other deficiencies in the care of patient
who died of AKI included failure in AKI prevention, recognition, therapy and timely access
to specialist services
NICE develops its first guideline in AKI in adults, children and young people in 2013
AIMS:
Early intervention
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Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy; NICE clinical guideline 2013
Risk Assessment
Kidney usually able to withstand several insults without causing significant structural or
functional change
If present: indicate severe systemic derangement and predicts poor prognosis
Risk of AKI: by exposure to factors that cause AKI, by presence of factors that
increased susceptibility to AKI
Risk assessment:
Hospital acquired AKI
Community- acquired AKI
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
How to.
Prevent AKI:
Consider pediatric early warning score (PEWS) to identify children and young
people who are at risk of developing AKI
Best: PEWS with multiparameter or aggregate weighted scoring systems that measure
HR/RR/SBP/ GCS/ O2 saturation/ temperature/ capillary refill time
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Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy; NICE clinical guideline 2013
Detecting AKI:
Serum creatinine (sCr) still remains the cornerstone of clinical diagnosis of AKI
Criteria that may be used:
RIFLE
pRIFLE
the slow rate of rise in sCr might prohibit accurate classification of AKI. Consequently, the criteria emphasizes
estimated creatinine clearance (using the Schwartz formula) over fold increase in sCr
Application of pRIFLE definitions has, however, been inconsistent between studies and consequently associated
with differing risk between studies
AKIN
KDIGO
Adult and pediatric AKI definitions have been harmonized to emphasize fold change in sCr in adults and children
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Acute kidney injury: an intensivists perspective, John R. Prowle, Pediatr Nephrol (2014) 29:1321
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AKI in the ICU: definition, epidemiology, risk stratification, and outcomes,Kai Singbartl and John A Kellum, Kidney International 81, 819-825 (May (1) 2012)
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KDIGO staging system for severity of AKI
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
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Management of AKI
Stage-based management of AKI
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Fluid Management
Fluid overload
Associated with increased morbidity and mortality in adult and children developing AKI
Degree of fluid overload has been suggested as an Index of AKI severity in pediatric
population
Associated with impaired recovery of renal function in patient surviving critical illness
Children have smaller window of appropriate treatment as they are more at risk of harm from
inadequate cardiac preload & more sensitive to adverse effects of fluid overload
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Acute kidney injury: an intensivists perspective, John R. Prowle, Pediatr Nephrol (2014) 29:1321
Protocolized hemodynamic management
Suggested for use to prevent development or worsening of AKI in high risk patient in
perioperative settings or in patient with sepsis induced tissue hypoperfusion
(defined as hypotension persisting after initial fluid challenge or blood lactate >4mmolL)
Suggest targeting resuscitation to normalize lactate in patients with elevated lactate level
Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 19
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Diuretics and dopamine receptor agonist
Diuretics and renal dose dopamine commonly used to prevent or limit AKI
Diuretics:
Observational studies: 59-70% of patient with AKI were given diuretics at the time of
nephrology consultation or before the start of RRT
Stimulation of urine output eases management of AKI but conversion of oliguric to
non-oliguric AKI not proven to alter the course of renal failure
Retrospective study does actually demonstrated the use of diuretics in AKI was
associated with adverse outcome
High dose of frusemide can cause ototoxicity, continued use in individual patients
with AKI need to take into consideration the risk and potential benefits or lack of
benefits
Using diuretics is not recommended to prevent AKI or treat AKI except in the
management of fluid overload
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Renal dose dopamine
0.5g/kg/min to 3-5g/kg/min
To improve renal perfusion following ischemic insult common in intensive
units
Action: increased renal blood flow by promoting vasodilatation
May improve urine output by promoting natriuresis
No definitive studies to demonstrate low dose dopamine are effective in
decreasing need for dialysis or improve survival times in patient with AKI
Some study showed that renal dose dopamine is not effective in therapy of
AKI and one study demonstrated that low doses worsened renal perfusion
and renal function
Lauschke A, Teichgraber UKM, Frei U, Eckardt KU (2006) Low-dose dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int 69:16691674
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
General supportive management
Glycemic control
Tight glycemic control frequently used in patient at risk of AKI or developed AKI
Help reduce severity of AKI
Intensive Insulin Therapy (IIT glucose 4.44-6.11mmol/L) vs. Conventional Insulin therapy (CIT-
glucose 9.99-11.1mmol/L) in critically ill patient
Risk of hypoglycemia is higher in IIT (NICE-SUGAR trial in adult)
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Nutritional aspect:
Protein-calorie malnutrition is an important independent predictor of in-hospital mortality in
patients with AKI
Must consider metabolic derangement and proinflammatory state associated with renal failure and
derangement of nutritional balance due to RRT
Suggest achieving total energy intake of 20-30kcal/kg/day in patients with any stage of AKI
Avoid restriction of protein intake with the aim of preventing or delaying initiation of RRT
Protein administration:
0.8-1.0g/kg/day in noncatabolic AKI
1.0-1.5g/kg/day in patient with AKI on dialysis
Up to maximum 1.7g/kg/day in patient on continuous renal replacement therapy (CRRT) and in
hypercatabolic patient
Suggest enteral feeding help maintain gut integrity, reduce gut atrophy & bacterial or endotoxin
translocation
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Referring to Nephrologist:
Discuss the management of acute kidney injury with nephrologist as soon as possible
and within 24hours of detection when 1 of the following present:
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Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy; NICE clinical guideline 2013
Timing
for
Renal
Replacement
Therapy
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Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138
Discontinue RRT when it is no longer required, either because intrinsic kidney
function has recovered to the point that it is adequate to meet patient needs, or
because RRT is no longer consistent with the goals of care
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Prognosis of AKI
Highly dependent on etiology of AKI
Those developing AKI as a part of multiorgan failure has higher mortality rate than
children with intrinsic cause of AKI e.g. HUS, or RPGN.
Recovery: depends on etiology
Nephrotoxic AKI and hypoxic/ischemic AKI usually recover normal renal function
Some still can have CKD
Children that suffer substantial loss of nephrons as in HUS/ RPGN at risk of renal failure
long after initial insult
Follow up:
1. Adult- 2-3years
2. Children and young people: longer follow up beyond puberty
3. Important complications for children hypertension, proteinuria, reduced renal
function
1. Acute kidney injury in children, S. Phillips Andreoli, Pediatr Nephrol (2009) 24:253263
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2. Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy; NICE clinical guideline 2013
TAKE HOME MESSAGES:
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REFERENCES:
1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical
Practice Guideline for Acute Kidney Injury. Kidney inter., Suppl. 2012; 2: 1138.
2. Acute kidney injury: an intensivists perspective, John R. Prowle, Pediatr Nephrol (2014) 29:1321
3. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes, Kai Singbartl and John A Kellum,
Kidney International 81, 819-825 (May (1) 2012
4. Prevention, detection and management of acute kidney injury up to the point of renal replacement therapy;
NICE clinical guideline 2013
5. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock:
2012
6. Acute kidney injury in children, S. Phillips Andreoli, Pediatr Nephrol (2009) 24:253263