RENAL FAILURE IN

CHILDREN
MIHAI CRAIU MD PhD
IOMC
 RENAL FAILURE IN CHILDREN
Renal failure is a medical condition in which
kidney fail to adequately filter water-soluble
waste products from the blood [like BUN,
ureea, creatinine, uric acid, H+ , K+].
There are two types of disease
Acute renal failure
Chronic renal failure [end-stage renal disease]
 RENAL FAILURE
More than 26 million Americans - one in nine
adults-have kidney disease*.
Millions more are at increased risk for getting
it, and most don't know it.

*http://www.kidney.org/kidneydisease/threesimpletests.cfm
 RENAL FAILURE IN CHILDREN
Can be divided into two categories: acute
kidney injury or chronic renal disease.
ACUTE
Acute kidney injury
Acute Exacerbation of ESR disease
CHRONIC
Chronic end-stage renal disease
The type of renal failure is determined by
the trend in the serum creatinine.
 RENAL FAILURE IN CHILDREN
Acute kidney injury (AKI), previously called acute
renal failure (ARF) is a rapidly progressive loss
of renal function*
generally characterized by
FLUID&ELECTROLYTE DISTURBANCES AND
OLIGURIA
less than 400 ml/day in adults
less than 0.5 mL/kg/h in children
less than 1 mL/kg/h in infants

* Moore, EM; Bellomo, R; Nichol, AD The meaning of acute kidney injury

and its relevance to intensive care and anaesthesia. Anaesthesia and
intensive care 2012;40 (6): 92948
 RENAL FAILURE IN CHILDREN

AKI can result from a

variety of causes,
generally classified as
prerenal,
intrinsic,
postrenal.
RENAL FAILURE IN CHILDREN
 RENAL FAILURE IN CHILDREN

AKI is NOT just a renal

disease.

It represents a severe
impairment with multiple
organ involvement
RENAL FAILURE IN ADULTS
RENAL FAILURE IN CHILDREN
 RENAL FAILURE IN CHILDREN
Most frequent cause in children is prerenal
Renal cause
Glomerulonephritis
Toxic [NSAIDs* or combinations with NSAIDs**]
Vascular
Embolic
HUS
* - NSAIDs: acute kidney injury, in children also. Prescrire Int. 2013 Oct
;22(142):242.
** Lapi F, Azoulay L, et al Concurrent use of diuretics, angiotensin converting
enzyme inhibitors, and angiotensin receptor blockers with non-steroidal anti-
inflammatory drugs and risk of acute kidney injury: nested case-control study.
BMJ. 2013; 346:e8525.
 RENAL FAILURE IN CHILDREN

The underlying cause must be identified

and treated to arrest the progress, and
renal replacement therapy [dialysis] may
be necessary to bridge the time gap
required for treating causes of AKI.
 RENAL FAILURE IN CHILDREN
Acute kidney injuries can be present on
top of chronic kidney disease, a condition
called acute-on-chronic renal failure
(AoCRF).
The acute part of AoCRF may be
reversible, and the goal of treatment, as
with AKI, is to return the patient to baseline
renal function, typically measured by
serum creatinine.
 RENAL FAILURE IN CHILDREN
Symptoms can vary from person to person.
Children in early stage kidney disease may
not feel sick or notice symptoms as they
occur.
When kidneys fail to filter properly, waste
accumulates in the blood and the body, a
condition called azotemia.
Renal failure accompanied by noticeable
symptoms is termed uraemia.
 RENAL FAILURE IN CHILDREN
Main signs and symptoms of AKI are
Fluid overload [oedema]
Urine-output decrease / anuria
Electrolyte imbalance
Hyperkalemia
Hypocalcaemia
Hyponatremia
Hyperphosphatemia
Metabolic acidosis [bicarbonate loss & tubular disfunct]
 Failure of kidneys to
remove excess fluid
may cause:
Oedema
Dispnoea [also because
of severe anemia]
 RENAL FAILURE IN CHILDREN
Signs associated with seric BUN and
creatinine increase
Vomiting and/or diarrhea
Nausea
Weight loss and/or increase [oedema]
Nocturnal urination
Frequent or infrequent urination
Difficult urination
 RENAL FAILURE IN CHILDREN
A build up of phosphates in the blood that
kidneys cannot filter out may cause
Itching
Bone damage (spontaneous fractures)
Nonunion or delayed fusion of fractures
Muscle cramping (caused by low levels of
calcium which can be associated with
hyperphophatemia)
 RENAL FAILURE IN CHILDREN
A build up of K+ in the
blood that kidneys
cannot filter out
(hyperkalemia) may
cause
Abnormal heart rhythms
Muscle paralysis
RENAL FAILURE IN CHILDREN
hypokalemia
 RENAL FAILURE IN CHILDREN

Acute kidney failure usually occurs when the blood

supply to the kidneys is suddenly interrupted or when
the kidneys become overloaded with toxins.
 RENAL FAILURE IN CHILDREN
The National Kidney Foundation (NKF)
recommends three simple tests to check
for kidney disease:
Blood pressure
Urinalysis
GFR
 RENAL FAILURE IN CHILDREN
Blood pressure.
High blood pressure is the second most
common cause of kidney disease.
High blood pressure may also happen as a
result of kidney disease.
Blood pressure in children
Blood pressure in children
 RENAL FAILURE IN CHILDREN
Urinalysis
One of the tests is called the protein to
creatinine ratio. It is the most accurate way
to measure protein in the urine.
A value of 200 mg/g or less per day is normal.
A value higher than 200 mg/g is too high.
 RENAL FAILURE IN CHILDREN
Urinalysis
Another test, called the albumin to creatinine ratio,
is good for people at increased risk for kidney
disease.
A value of less than 30 mg/g per day is normal for the
albumin to creatinine ratio; a value of 30 mg/g per day
or higher is high and may be a sign of early kidney
disease.

With either of these tests, you don't need to collect a

24-hour urine sample, which may be hard to collect.
 RENAL FAILURE IN CHILDREN
Experts consider the glomerular filtration rate
(GFR) to be the best index of kidney function.
A normal GFR varies according to many factors,
including sex, age, body size and race.
A value of 60 or higher is normal (GFR
decreases with age).
A GFR number of less than 60 is low and may
mean that you have kidney disease.
 RENAL FAILURE IN CHILDREN
The National Kidney Foundation offers an
easy to use on-line GFR calculator
 RENAL FAILURE IN CHILDREN
In medicine dialysis (from greek
dialusis,"", meaning dissolution,
dia, meaning through, and lysis, meaning
loosening or splitting) is a process for
removing waste and excess water from
the blood, and is used primarily as an
artificial replacement for lost kidmey
function in people with AKI or CRF
 RENAL FAILURE IN CHILDREN

Dialysis works on the

principles of
diffusion of solutes and
ultrafiltration of fluid
across a semi-permeble
membrane.
 RENAL FAILURE IN CHILDREN
Diffusion is a property of substances in
water; substances in water tend to move
from an area of high concentration to an
area of low concentration.
Ultrafiltration - Smaller solutes and fluid
pass through the membrane, but the
membrane blocks the passage of larger
substances (for example, red blood cells,
large proteins).
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS
The process uses the
patient's peritoneum as a
membrane across which fluids
and dissolved substances are
exchanged from blood.
The fluid used typically
contains Na, Cl, lactate or
bicarbobate and a high
percentage of glucose to
ensure hyperosmolarity.
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS
Waste products pass from
the bloodstream across the
peritoneal membrane and
into the dialysis solution.
The used dialysis solution
is drained from the
peritoneal cavity and
replaced with fresh solution
at regular intervals.
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS
The peritoneal catheter
is the access for
dialysis and therefore it
will be permanent.
It is important that the
exit site is kept clean
and free of infection.
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS [advantages] 1
Continuous Dialysis Peritoneal dialysis keeps pace
with the bodys own natural processes by cleansing
the blood continuously rather than intermittently, as in
haemodialysis. Due to the continuous nature of
peritoneal dialysis, a steady blood chemistry is
achieved and maintaine. Generally, continuous
dialysis results in an improved feeling of well-being.
Self Care Dialysis No helper required.
Simple To Learn & Perform Short training period.
(1~2 weeks)
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS [advantages] 2

Minimal Fluid and Dietary Restrictions

No Needle Punctures Required
Ease Of Travel
Minimal Cardiovascular Stress
Overnight Dialysis
Compact, Portable
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS [disadvantages] 1
PERITONITIS - Peritonitis is the major
disadvantage associated with peritoneal
dialysis, but using a combination of
disconnect delivery systems and good
hygiene, the incidence is now much lower
than in the past.
 RENAL FAILURE IN CHILDREN
PERITONEAL DIALYSIS [disadvantages] 2
PROTEIN LOSS - Valuable body protein
escapes through the peritoneal membrane into
the peritoneal solution. These proteins are easily
replaced by increasing protein intake (meats,
fish, dairy products, etc) in diet.
POTENTIAL FOR ELEVATED BLOOD LIPID
(FAT) & TRIGLYCERIDE LEVELS - Elevated
levels of lipids and triglycerides in the blood may
lead to vascular atherosclerosis.
 RENAL FAILURE IN CHILDREN
RENAL TRANSPLANTATION
The indication for kidney transplantation is
end-stage-renal disease (ESRD),
regardless of the primary cause.
This is defined as a glomerular filtration
rate (GFR) <15ml/min/1.73/m2
 RENAL FAILURE IN CHILDREN
Common diseases leading to ESRD
include malignant hypertension, chronic
UTI, diabetes mellitus, and focal
segmental glomerulo-sclerosis;
In children genetic causes are frequent
cause of ESRD PKD [polykystic kidney
disease], a number of inborn errors of
metabolism, and autoimmune conditions
LES.
 RENAL FAILURE IN CHILDREN
Diabetes is the most
common cause of kidney
transplantation in adults,
accounting for
approximately 25% of those
in the US
On average, a transplanted
kidney should function for
about 10 years (from a
deceased donor) to 20
years (from a living donor).
RENAL FAILURE IN CHILDREN
TREATMENT
Main objective is to reduce seric levels of
protein metabolites
Rasburicase* [recombinant urate oxidase]
reduces levels of uric acid
Sinha R, Dugar P - Rasburicase for acute kidney injury. Indian Pediatr.
2013;50(11):1051-2.
Ejaz AA, Dass B et al - Effect of uric acid lowering therapy on the
prevention of acute kidney injury in cardiovascular surgery. J.Int Urol
Nephrol. 2013; 45(2):449-58.
Hobbs DJ et al Rasburicase improves hyperuricemia in infants with
acute kidney injury. Pediatr Nephrol. 2010;25(2):305-9.