Kidney failure in infants and children

1. Kidney failure in infants and children Presented by:Dr.Doaa Al-Masri Discussed by:Dr.Y.K.Abu-Osbaa Pediatrics in review vol.23 No.2 February 2002

2. Introduction • Acute renal failure(ARF):life-threatening ,abrupt reduction of urinary output to less than 300cc/m‌2/day. • High-output renal failure: • Incidence :variable.

4. Etiology • Proximal tubular necrosis: -toxins & drugs. -sickle cell crisis. -myoglobulinemia. -uric acid. -renal vein thrombosis. • In neonates:-asphyxia -erythroblastosis. -mechanical ventilation.

6. Lab markers in the differential diagnosis • Kidney failure index: UNa/(U/PCreatinine). • Fractional excretion of Na: (U/P)Na/(U/P)Creatinine

9. Treatment • Emergency fluid management: .PICU management • Replace insensible water loss + loss in volume & electrolytes from urinary or other outputs. • Subtract the endogenous water produced from tissue catabolism.

10. Treatment • Monitor urine output and other outputs and daily weight. • Careful restoration of caloric,fluid and electrolyte losses. • Administer Lasix. • Caloric management: at least 25% of the daily caloric requirement. • Provision of essential amino acid???!!!

11. Hyperkalemia • K more than 6.5mEq/l with ECG changes requires treatment by: -Ca gluconate. -insulin and gucose. -kayexalate cation exchange resin.

12. Metabolic acidosis & other complications • NaCHO3 used when total serum bicorbonate is less than 10mmol/L. • Metabolic alkalosis can develop. • Seizures (multifactorial)and its management. • Infection,pericarditis,anemia.

13. Indications for dialysis • 1-serum urea more than 150mg/dl. • 2-serum creatinine more than 10mg/dl. • 3-k more than 6.5mEq/l with ECG changes unrelieved by medical means. • 4- severe metabolic acidosis with HCO3 less than 10mEq/l unrelieved by bicarbonate therapy. • 5- congestive heart failure & fluid overload. -Peritoneal vs hemdialysis. -Growth hormone and insulin-like growth factor.

14. Outcome • 3 phases of ARF: • Oliguric. • Diuiretic. • Recovery. • The overall survival rate is 70%.

15. Chronic renal failure • Clinical presentation: • 1:GFR 50-75% of normal for age. • 2:GFR 25-50% of normal for age (chronic renal insufficiency) -asymptomatic proteinuria -hyposthenuria & nocturia • 3:GFR 10-25%of normal for age (chronic renal failure) -anemia & acidosis. -hyperphosphatemia ,hypocalcemia. -renal osteodystrophy & rickets. • 4:GFR is less than 10% of normal for age.

17. Chronic renal failure • Accelerating factors: • Dehydration . • Hypertension & congestive heart failure. • Hypercalcemia , hyperuricemia, hypokalemia, alkalosis. • Nephrotoxic agents.

19. Complications

20. Complications Renal osteodystrophy.

23. Complications Growth failure

25. Complications • Anemia : • Oral Folic acid. • Oral iron supplement. • Erythropoietin

26. Complications

27. Complications • Metabolic acidosis & growth failure: -increased proteolysis. -inhibition of growth hormone pulsatile excretion. • So maintain serum bicarbonate at 22mEq/l.

29. Nutritional deficiencies • Caloric intake should be maintained at the recommended dietary allowance for healthy children of the same height & age, with protein kept only to 10% of the total. • With vigorous caloric & protein supplementation to reach close to 100% of the recommended dietary allowance,weight gain without linear growth acceleration or head circumference was demonstrated. • Glucose intolerance in uremia is due to insulin resistance. • The retention of nitrogenous products results in anorexia,nausea ,vomiting and uremic stomatitis.

31. Other systemic disorders • Impaired immunolgic defence mechanisms. • Neurological complication &uremic encephalopathy. • Duodenal ulcers. • Pericardial effusion & pericarditis. • Pulmonary edema. • Sexual dysfunction. • Pruritis .

32. Recommendations

34. Recommendations • Treatment of renal osteodystrophy. • Alkali therapy. • Phosphate restriction. • Protein restriction. • Recombinant human growth hormone. • Treatment of hypertension. • Recombinant human erythropoietin.

36. The end Thank you