View
448
Download
4
Category
Tags:
Preview:
DESCRIPTION
Detail presentation about Acute Kidney Injury in children
Citation preview
WELCOME TO SEMINARPresented by
Dr. Bipin Karki Dr. Amlendra Yadav Dr. Chandra shekhar
CASE
Tuhin 7 yrs old male child from sylhet , admitted with a complain of oliguria for 2 days associated with respiratory distress for same duration. He had h/o bee sting all over body surface 7 days back when he was returning home from school. He was afebrile , puffy face, restless , mild pale , dyspenic , edema present. Abdomen was soft, distended, non-tender, no organomegaly , ascites present evidenced by shifting dullness.
INVESTIGATION
S creatinine: 8 mg/dl Blood urea: 400 mg/dl Urine R/E
Pus cell – (4-6)/ HPFEpi. Cell – (2-4)/HPFRBC – NilProtein – (++)
ACUTE KIDNEY INJURY
DEFINITION
Rapid deteriotion of renal function resulting in retention of nitrogenous wastes and inability of kidney to regulate fluid and electrolyte homeostasis.
In year 2004 the acute dialysis quality initiative (ADQI) proposed RIFLE criteria for defining AKI .
Later, Acute Kidney Injury Network (AKIN)
classified AKI based on the RIFLE system.
RIFLE CRITERIA
R = risk for renal dysfunction I = injury to the kidney F = failure of kidney function L = loss of kidney function E = end-stage renal disease
> 3 months
INCIDENCE
The precise incidence of AKI in children is not well known.
Data from bangladesh is not available A data from india . 4-6 % case of AKI seen in general ward and upto
40% in PICU . Affects childrens who have sepsis and multiorgan
failure. Children undergoing major cardiac surgery and
organ transplantation are at considerable risk for developing AKI.
ETIOLOGY
Pre renal Intrinsic or renal Post renal
PRE RENAL
Acute gastroenteritis Blood loss Shock Fulminant hepatic failure Reye syndrome Congestive cardiac failure Nephrotic syndrome Hepatorenal syndrome
INTRINSIC RENAL Renal Major vessel obstruction
- renal vein thrombosis , renal arterial obstruction, hemolytic uremic syndrome , HSP , polyarteritis and other vasculitis
Glomerular Acute glomerulonephritis ( poststreptococcal , other
infections ), cresentic GN Acute tubulointerstitial nephritis Acute tubular necrosis Prolongation of pre-renal insult , intravascular hemolysis ,
sepsis , nephrotoxixc agents , multiorgan failure , rhabdomyolysis , snakebite , other envenomations , falciparum malaria , leptospirosis
POST RENAL
Posterior urethral valves Ureteropelvic junction obstruction Ureterovesicular junction obstruction Ureterocele Tumor Urolithiasis Hemorrhagic cystitis Neurogenic bladder
PRE RENAL
Also called prerenal azotemia, is characterized by diminished effective circulating arterial volume, which leads to inadequate renal perfusion and a decreased GFR .
Renin
Angiotensin II
Aldosterone
Renal Tubular Na Reabsorption
Vasopressin
Renal Tubular H2O Reabsorption
Urine Volume
Concentrated Urine
Urine Sodium
Decreased Renal Perfusion
Mechanisms of Sodium and Water Conservation in Prerenal Azotemia
POST RENAL
It includes a variety of disorders characterized by obstruction of the urinary tract.
In a patient with 2 functioning kidneys, obstruction must be bilateral to result in AKI.
Relief of the obstruction usually results in recovery of renal function except in patients with associated renal dysplasia or prolonged urinary tract obstruction.
RENAL CAUSES
It includes a variety of disorders characterized by renal parenchymal damage, including sustained hypoperfusion , ischemia and nephrotoxins.
OBSTRUCTION OF RENAL ARTERIES AND VEINS
Bilateral renal arterial thrombosis may occur after umbilical artery catheterization in neonates.
Renal vein thrombosis may be a complication of infant of diabetic mother especially following dehydration.
In older children renal vein thrombosis may occur with nephrotic syndrome with anasarca and dehydration.
Gross hematuria, enlargement of kidney and azotemia are typical manifestation.
INVOLVEMENT OF RENAL MICROVASCULATURE
Hemolytic uremic sundrome is a common cause in children developing AKI .
Following dysentry shigela-toxin enters the circulation and lead to endothelial injury in microvasculature .
Localized coagulation and deposition of platelet thrombi and fibrin in glomeruli causing decrease in GFR.
ACUTE INTERSTITIAL NEPHRITIS
Allergic: antibiotics (β-lactams, sulfonamides, quinolones, rifampin), nonsteroidal anti-inflammatory drugs, diuretics, other drugs
Infection: pyelonephritis (if bilateral) Infiltration: lymphoma, leukemia, sarcoidosis Inflammatory, nonvascular: Sjögren’s syndrome,
tubulointerstitial nephritis with uveitis The patient may have fever , arthralgia , rash
and eosinophilia : urine often shows eosinophils .
Etiology of AIN
ACUTE TUBULAR NECROSIS
Occurs most often in critically ill infants and children who have been exposed to nephrotoxic and/or perfusion insults.
Common causes of ATN include renal hypoperfusion following volume contraction , severe renal vasoconstriction , nephrotoxic agents , sepsis , shock and hypotension.
The mechanisms of injury in ATN can include alterations in intrarenal hemodynamics, tubular obstruction, and passive backleak of the glomerular filtrate across injured tubular cells into the peritubular capillaries.
CLINICAL PRESENTATION
Pre renal There may be history of volume loss
from vomiting, diarrhea, or blood loss and may present with dehydration , hypotension , tachycardia , pallor , and decreased urine output .
RENAL
Hematuria, edema, and hypertension indicates a glomerular etiology for AKI.
Dysentry, patechie and pallor- HUS Sudden passage of dark red urine, pallor and
jaundice- acute intravascular hemolysis Presence of rash, arthritis might suggest SLE
or HSP. History of prolong hypotension or with
exposure to nephrotoxic medication most likely have ATN.
Allergic interstitial nephritis should be suspected with fevers, rash, arthralgias, and exposure to certain medications, including NSAIDs and antibiotics.
POST RENAL
History of interrupted urinary stream and palpable bladder or kidney suggest obstructive uropathy.
Abdominal colic hematuria and dysuria suggest urinary tract calculi.
DIAGNOSIS
Physical examination Obtaining a thorough physical examination is
extremely important when collecting evidence about the etiology of AKI. Clues may be found in any of the following
Skin Eyes Ears Cardiovascular system Abdomen Pulmonary system
Skin :- Palpable purpura - Systemic vasculitis Maculopapular rash - Allergic interstitial
nephritis
Eye :- Evidence of uveitis may indicate interstitial nephritis
and necrotizing vasculitis. Ocular palsy may indicate
ethylene glycol poisoning or necrotizing vasculitis
Ear :- Hearing loss - Alport disease and aminoglycoside toxicity
Mucosal or cartilaginous ulcerations - Wegener granulomatosis
Pulmonary system :- Respiratory rate , pattern On Auscultation of lungs basal
crepts
CARDIOVASCULAR EXAMINATION
Pulse rate and blood pressure recordings Close inspection of the jugulovenous pulse Careful examination of the heart and lungs Assessment for peripheral edema Cardiovascular examination may reveal the
following: Murmurs - Endocarditis Pericardial friction rub - Uremic pericarditis Increased jugulovenous distention, rales, S3 - Heart
failure
Abdomen Abdominal or costovertebral angle
tenderness - Nephrolithiasis, papillary necrosis, renal artery thrombosis, renal vein thrombosis
distended bladder – Urinary obstruction The presence of tense ascites can indicate
elevated intra-abdominal pressure that can retard renal venous return and result in AKI.
CONT…….
Urine R/E CBC with PBF 24 hour urinary protien Blood urea and S. creatinine level Serum electrolyte ASO titer C3 level Serum calcium Serum phosphate Serum uric acid ANA ABG
IMAGING
Ultrasound of KUB - evaluates renal size, able to detect masses, obstruction, stones
Chest x-ray DTPA DMSA
RENAL BIOPSY
Indicated in Patient in whom the etiology is not
identified. Unremitting AKI lasting longer then 2-3
wks or in accessing the extent of renal damage and out come.
Suspected drug induced AKI in a patient receiving therapy with a potentially nephrotoxic drugs.
INDICES FOR DIFFERENTIATING PRE-RENAL FROM RENAL AKI
PRE-RENAL INTRINSIC
URINARY SODIUM (mEq/l) < 20 > 40
Urinary osmolality (mOsm/kg) > 500 < 300
Blood urea to creatinine ratio >20:1 < 20:1
Urine to plasma osmolality ratio >1.5 < 0.8 – 1.2
Fractional excretion of sodium < 1 > 1
MANAGEMENT
The basic principles of management include
Treatment of life-threatening complications
Maintenance of fluid and electrolyte balance
Nutritional support. Specific management of underlying
disorder
LIFE THREATENING COMPLICATIONS
Hyperkalemia Fluid overload with heart failure Severe hypertension with
encephalopathy Profound acidosis Severe anemia
MANAGEMENT OF COMPLICATION
Hperkalemia : Calcium gluconate 0.5-1 ml/kg over 5
to 10 minute Salbutamol nebulization Glucose 0.5-1 gm/kg with 0.1-0.2
unit/kg insulin Sodium bicarbonate 1-2 ml/kg
Fluid overload : fluid restriction (insensible loss + POD)
Pulmonary Edema Oxygen Dopamine (5-10) mcg /kg /min infusion Frusemide (2-4)mg /kg
Hypertension Nitroprusside 1-8 mcg/kg/min Frusemide 2-4 mg/kg Nifedipine 0.3-0.5 mg/kg
Acidosis Sodium bicarbonate
Anemia Pack red cell 3-5 ml/kg
SUPPORTIVE CARE
Fluids: amount given equals insensible loss plus urine volume
Nutrition: protein intake of 1 gm/kg Prevent infection and treat with
appropriate antibiotics. Avoid nephrotoxic drugs Measure Weight daily, Prevent weight
gain Monitor urine output
DIALYSIS Indication: Uremia: altered sensorium abnormal
behavior seizure Hyperkalemia: k+ > 6.5 meq/l, k+
5.5-6.5 meq/l with ECG changes Hyponatremia: Na+ < 120 meq/l if
symptomtic Fluid overload: resistant to diuretics,
CCF,HTN Metabolic acidosis: PH< 7.2 despite
sodium bicarbonate therapy.
MANAGEMENT OF COMMON CONDITION CAUSING AKI
Prerenal AKI: administer crystalloids, stop diuretics, NSAIDs, ACE inhibitors.
ATN: supportive care, discontinue drugs or toxin, treat cause of circulatory failure.
Glomerulonephritis: supportive care If post-infectious, antibiotic for endocarditis, shunt infection, immunosuppressive medication.
HUS: supportive care, plasma infusion, plasma exchange
Vasculitis: immunosuppressive medication, plasma exchange
Interstital nephritis: discontinue offending drugs, consider steroid therapy.
Renal artery , vein occlusion: anticoagulation, thrombolysis or surgery.
Intrarenal obstruction: discontinue offending drugs, alkaline diuresis for rhabdomyolysis , haemoglobinuria or urate crystal.
Urinary tract obstruction: bladder cathaterization or nephrostomy, surgical treatment of obstruction.
OUTCOME
Mortality rates from 30-50% have been reported from developing countries. But the results have markedly improved at tertiary centers with proper experties and modern facilities.
Outcome depend upon underlying cause. Prognosis is favourable in ATN from volume depletion,
intravascular hemolysis, acute interstial nephritis and drugs or toxin related AKI especially when complicating factor are absent .
In cresentic GN, atypical HUS, and AKI associated with sepsis, multi organ failure the prognosis is less satisfactory .
PREVENTION OF AKI
Important measures includes prompt rehydration therapy in acute diarrhea, avoidance or judicious use of nephrotoxic drugs.
Maintenance of proper hydration for patients undergoing diagnostic procedures with radio contrast media.
Force diuresis along with the use of allopurinol is effective preventing AKI in patient with TLS.
THANKYOU
Recommended