Infant Acute Kidney Injury Maricor Grio, MD, MS Orlando Health Arnold Palmer Hospital for Children Orlando, Florida [email protected] Maricor

Infant Acute Kidney Injury

Infant Acute Kidney Injury

Maricor Grio, MD, MSOrlando Health

Arnold Palmer Hospital for ChildrenOrlando, Florida

[email protected]

Maricor Grio, MD, MSOrlando Health

Arnold Palmer Hospital for ChildrenOrlando, Florida

[email protected]

Infant AKIInfant AKI

How common is this problem? What are the causes? Who are the patients at risk? What are the prevention and treatment options? What are the long term consequences?


Definition of AKIDefinition of AKI

Reduction of GFR to a level insufficient to adequately filter and excrete solute and water and maintain fluid and electrolyte balance

Urine volume below 0.5-1ml/kg/hr after 1st day Urine volume is a poor indicator of renal function

Increased serum creatinine > 1.5mg/dl Serum creatinine is a poor indicator of renal function

Daily rise in serum creatinine of 0.3mg/dL to 0.5 mg/dL?

Reduction of GFR to a level insufficient to adequately filter and excrete solute and water and maintain fluid and electrolyte balance

Urine volume below 0.5-1ml/kg/hr after 1st day Urine volume is a poor indicator of renal function

Increased serum creatinine > 1.5mg/dl Serum creatinine is a poor indicator of renal function

Daily rise in serum creatinine of 0.3mg/dL to 0.5 mg/dL?

Creatinine Clearance According to Gestational Age

Creatinine Clearance According to Gestational Age

0

5

10

15

20

25

30

35

28wks 32wks 36wks 40wks

Gestational age (wks)

CC

r (m

l/m

in/1

.73M

2

Chevalier.J Urol.1996:156Chevalier.J Urol.1996:156

StonestreetStonestreet. Pediatr.1978:61:788-789. Pediatr.1978:61:788-789

Serum Creatinine During First Serum Creatinine During First Three Months in LBW Infants < Three Months in LBW Infants <

2000g2000g

-0.1

0.1

0.3

0.5

0.7

0.9

1.1

1.3

1.5

10 20 30 40 50 60 70 80 90

Age (days)

Crea

tin

ine (

mg

/dl)

Incidence and Epidemiology of AKIIncidence and Epidemiology of AKI

Precise incidence and prevalence is unknown Incidence of AKI in NICU patients is 6-24% 60% non-oliguric / 25% oliguric / 15% anuric Higher incidence in patients undergoing cardiac

surgery More common in neonates with severe asphyxia Some infants may have genetic risk factors for

development of AKI

Precise incidence and prevalence is unknown Incidence of AKI in NICU patients is 6-24% 60% non-oliguric / 25% oliguric / 15% anuric Higher incidence in patients undergoing cardiac

surgery More common in neonates with severe asphyxia Some infants may have genetic risk factors for

development of AKI

Andreoli. Seminars in Perinat.2004:28 (2):112-123

Pediatric AKI Epidemiology at a Tertiary Care Center 1999-2001 (n=254 pts)

Pediatric AKI Epidemiology at a Tertiary Care Center 1999-2001 (n=254 pts)

0-30 days1-12 mos1-5 yrs6-15 yrs16-21 yrs

Hui-Stickle et al. AJKD.2005: 45:96Hui-Stickle et al. AJKD.2005: 45:96

AKI in Neonates 1999-2001 n=62 ptsAKI in Neonates 1999-2001 n=62 pts

Ischemic ATN most common in 16 pts (26%) Estimated GFR 11.5 + 89.8 ml/1.73m2 56% survived Length of ICU stay 97 days 58% required renal replacement therapy

Ischemic ATN most common in 16 pts (26%) Estimated GFR 11.5 + 89.8 ml/1.73m2 56% survived Length of ICU stay 97 days 58% required renal replacement therapy

Hui-Stickle et al. AJKD.2000545:96Hui-Stickle et al. AJKD.2000545:96




Prenatal AKIPrenatal AKI

Intrinsic AKIIntrinsic AKI

Pre-renal AKIPre-renal AKI

Obstructive AKIObstructive AKI

Etiology of AKI Etiology of AKI

Etiology of Prenatal AKIEtiology of Prenatal AKI

Obstructive uropathy Renal hypoplasia/dysplasia Renal cystic disease Agenesis Nephrotoxic agents Intrauterine infection Intrauterine medications- NSAIDs, ACE-i Complications during pregnancy and delivery

Obstructive uropathy Renal hypoplasia/dysplasia Renal cystic disease Agenesis Nephrotoxic agents Intrauterine infection Intrauterine medications- NSAIDs, ACE-i Complications during pregnancy and delivery

Etiology of Pre-renal AKI Etiology of Pre-renal AKI

Hypovolemia Dehydration Gastrointestinal losses Hemorrhage Salt wasting (renal or

adrenal) Central or nephrogenic

diabetes insipidus Third space losses

(sepsis, traumatized tissue)

Hypovolemia Dehydration Gastrointestinal losses Hemorrhage Salt wasting (renal or

adrenal) Central or nephrogenic

diabetes insipidus Third space losses

(sepsis, traumatized tissue)

Cardiac Failure Congenital heart

disease Congestive heart

failure Pericarditis Cardiac tamponade

Cardiac Failure Congenital heart

disease Congestive heart

failure Pericarditis Cardiac tamponade

Etiology of Pre-renal AKI Etiology of Pre-renal AKI

Hypotension Sepsis DIC Bleeding hypothermia

Hypotension Sepsis DIC Bleeding hypothermia

Hypoxemia Neonatal asphyxia Severe hyaline

membrane disease Pneumonia Cardiac surgery

Hypoxemia Neonatal asphyxia Severe hyaline

membrane disease Pneumonia Cardiac surgery

Etiology of Acquired Intrinsic AKIEtiology of Acquired Intrinsic AKI

Acute Tubular Necrosis Ischemic / hypoxic insults Drug induced

Aminoglycosides NSAIDS Antifungal agents Antiviral agents Chemotherapy Intravascular contrast

Toxin mediated Uric acid nephropathy

Hemoglobinuria Myoglobinuria

Acute Tubular Necrosis Ischemic / hypoxic insults Drug induced

Aminoglycosides NSAIDS Antifungal agents Antiviral agents Chemotherapy Intravascular contrast

Toxin mediated Uric acid nephropathy

Hemoglobinuria Myoglobinuria

Interstitial Nephritis Infectious Drug induced Idiopathic

Vascular Lesions Cortical necrosis Renal artery thrombosis Renal vein thrombosis

Infectious Causes Sepsis Pyelonephritis

Interstitial Nephritis Infectious Drug induced Idiopathic

Vascular Lesions Cortical necrosis Renal artery thrombosis Renal vein thrombosis

Infectious Causes Sepsis Pyelonephritis

Etiology of Congenital Intrinsic AKIEtiology of Congenital Intrinsic AKI

Bilateral renal agenesis Dysplasia/ Hypoplasia Cystic renal diseases Congenital nephrotic syndrome Congenital nephritis

Bilateral renal agenesis Dysplasia/ Hypoplasia Cystic renal diseases Congenital nephrotic syndrome Congenital nephritis

Etiology of Obstructive AKIEtiology of Obstructive AKI

Congenital obstructive uropathy Obstruction in a solitary kidney Bilateral UPJO Bilateral UVJO Large obstructive ureterocele Posterior urethral valves Urethral stenosis/atresia Neurogenic bladder

Acquired obstruction Foley catheter obstruction Fungus balls Urethral trauma External compression

Congenital obstructive uropathy Obstruction in a solitary kidney Bilateral UPJO Bilateral UVJO Large obstructive ureterocele Posterior urethral valves Urethral stenosis/atresia Neurogenic bladder

Acquired obstruction Foley catheter obstruction Fungus balls Urethral trauma External compression

Posterior urethral valvesPosterior urethral valves

HydronephrosisHydronephrosis

Cystic Renal DiseaseCystic Renal Disease


How common is this problem? What are the causes? Who are the patients at risk? What can we do to prevent this problem? What are the prevention and treatment options? What are the long term consequences?

How common is this problem? What are the causes? Who are the patients at risk? What can we do to prevent this problem? What are the prevention and treatment options? What are the long term consequences?

Patients at RiskPatients at Risk

PrematurityLBW infantsIDMCHDPerinatal asphyxiaSepsisRDS VentilatorsVasopressors

PrematurityLBW infantsIDMCHDPerinatal asphyxiaSepsisRDS VentilatorsVasopressors

Volume depletion Hemorrhage Aminoglycosides NSAIDS Antifungal Chemotherapy Hemolysis Postoperative (cardiac) Contrast Agents

Volume depletion Hemorrhage Aminoglycosides NSAIDS Antifungal Chemotherapy Hemolysis Postoperative (cardiac) Contrast Agents

AKI in Asphyxiated Term NeonatesAKI in Asphyxiated Term Neonates

Fetal HR

Nl VariableDecel.

LateDecel.

ProlongedBrady

Apgar (5min)

>6 5-6 3-4 0-2

Base Deficit

<10 10-14 15-19 >19

0 20 40 60 80 100

Scores 1-5

Scores 6-9Inc. LFTDeathSzARF

% of pts% of pts

Karlowics. Ped. Karlowics. Ped. Nephrol.1995Nephrol.1995

PointsPoints 00 22 3311

TNF-, IL-1B, IL-6 & IL-10 haplotype variants in VLBW infants with AKI & non-AKI

TNF-, IL-1B, IL-6 & IL-10 haplotype variants in VLBW infants with AKI & non-AKI

0

10

20

30

40

50

60

AKI non-AKITNF-308/IL-1B TNF-308/IL-6 TNF-308/IL-10IL-1/IL-6 IL-10/IL-6

0

10

20

30

40

50

60

AKI non-AKITNF-308/IL-1B TNF-308/IL-6 TNF-308/IL-10IL-1/IL-6 IL-10/IL-6

Vasarheli et al. Pediatr Nephrol .2002:17:713Vasarheli et al. Pediatr Nephrol .2002:17:713

**%%

*p<0.05*p<0.05

Variance of ACE and AT1 receptor gene in VLBW infants with AKI and non-AKI

Variance of ACE and AT1 receptor gene in VLBW infants with AKI and non-AKI

0

5

10

15

20

25

30

35

40

AKI non-AKI

ACE-II ACE-ID ACE-DD ATr-AA Atr-AC Atr-CC

0

5

10

15

20

25

30

35

40

AKI non-AKI

ACE-II ACE-ID ACE-DD ATr-AA Atr-AC Atr-CC

Vasarheli et al. Pediatr Nephrol .200116:1063Vasarheli et al. Pediatr Nephrol .200116:1063

%%

Diagnostic Evaluation in AKIDiagnostic Evaluation in AKI

Prenatal history Family history Medications Oligohydramnios Complications during pregnancy Prenatal ultrasounds

Delivery Fetal distress Bleeding Infections Medications

Prenatal history Family history Medications Oligohydramnios Complications during pregnancy Prenatal ultrasounds

Delivery Fetal distress Bleeding Infections Medications

Clinical Evaluation of AKI Clinical Evaluation of AKI

Chart review Intake and output Infections Respiratory distress Medications Contrast studies Surgical procedures

Physical examination General appearance (Potter’s sequence) Hydration status Cardiac examination Pulmonary examination Abdominal masses

Chart review Intake and output Infections Respiratory distress Medications Contrast studies Surgical procedures

Physical examination General appearance (Potter’s sequence) Hydration status Cardiac examination Pulmonary examination Abdominal masses

Diagnostic Evaluation in AKIDiagnostic Evaluation in AKI

Laboratory studies Urinalysis and culture Urine electrolytes / creatinine / osmolality Urine protein / creatinine Electrolytes BUN and creatinine / osmolality Calcium / phosphorus and uric acid

Imaging studies Renal ultrasound with doppler VCUG CT Renal scan (DTPA or MAG3) Echocardiogram CXR

Laboratory studies Urinalysis and culture Urine electrolytes / creatinine / osmolality Urine protein / creatinine Electrolytes BUN and creatinine / osmolality Calcium / phosphorus and uric acid

Imaging studies Renal ultrasound with doppler VCUG CT Renal scan (DTPA or MAG3) Echocardiogram CXR

Diagnostic studies in AKIDiagnostic studies in AKI

Prerenal ATN

BUN/Cr >20:1 <20:1

Urine Na < 20 mEq/L 30-40mEq/L

U. Osmo > 350 < 300

FeNa < 2.5% 2.5-3%

U/P Osmo > 1.3 < 1.3

UA Increased specific gravity . Minor changes or NL

Prot / HemeGranular & epithelial casts




Treatment of AKITreatment of AKI

ConservativeConservativeMedical TherapyMedical Therapy

Renal Replacement Renal Replacement TherapyTherapy

Renal TransplantationRenal Transplantation

Conservative treatment in AKIConservative treatment in AKI

Avoiding other nephrotoxic insults• Antibiotics• Antifungal• NSAIDS• Contrast agents• Surgical procedures

Fluid allowance• Insensible losses• Ongoing losses

Avoiding other nephrotoxic insults• Antibiotics• Antifungal• NSAIDS• Contrast agents• Surgical procedures

Fluid allowance• Insensible losses• Ongoing losses

Insensible Water Loss During the First Week of LifeInsensible Water Loss During the First Week of Life

0

20

40

60

80

100

750-1000 1001-1250 1251-1500 >1501

Birth weight (g)

(ml/k

g/24

hr)

Clolherty. Manual of Neonatal Care.1998Clolherty. Manual of Neonatal Care.1998

Factors Affecting Insensible Water LossesFactors Affecting Insensible Water Losses

Prematurity: 100-300% Radiant Warmer: 50-100% Phototherapy: 25-50% Hyperventilation: 20-30% In. activity: 5-25% Hyperthermia: 120C

Prematurity: 100-300% Radiant Warmer: 50-100% Phototherapy: 25-50% Hyperventilation: 20-30% In. activity: 5-25% Hyperthermia: 120C

Incubator: 25-50% Humidified air: 15-30% Sedation: 5-25% Dec. activity: 5-25% Hypothermia: 5-15%

Incubator: 25-50% Humidified air: 15-30% Sedation: 5-25% Dec. activity: 5-25% Hypothermia: 5-15%

Protein Requirements in Newborns with AKIProtein Requirements in Newborns with AKI

0

1

2

3

4

0-6 month 6-12 month

CRI

HD

PD

CRI HD PD

Pro

tein

g/k

g/d

Pro

tein

g/k

g/d

Yiu VW et al. J Renal Nutr .1996.6:203Yiu VW et al. J Renal Nutr .1996.6:203

Energy, Calcium and Phosphorus Requirements in Newborns with AKIEnergy, Calcium and Phosphorus Requirements in Newborns with AKI

0

100

200

300

400

500

0-2 moth 2-6 month

Ca (mg/d) P04 (mg/d) Kcal/Kg/d

Yiu VW et al. J Renal Nutr.1996 6:203Yiu VW et al. J Renal Nutr.1996 6:203

Conservative Management of AKIConservative Management of AKI

Adjustments of medications according to renal function Prevention and management of complications

• Fluid overload with HTN and RDS• Electrolyte imbalance

Sodium Potassium Uric acid

• Metabolic acidosis• Anemia• Bone and mineral metabolism disorders

Hypocalcemia Hyperphosphatemia

Adjustments of medications according to renal function Prevention and management of complications

• Fluid overload with HTN and RDS• Electrolyte imbalance

Sodium Potassium Uric acid

• Metabolic acidosis• Anemia• Bone and mineral metabolism disorders

Hypocalcemia Hyperphosphatemia

Treatment of AKITreatment of AKI

Dopamine Diuretics Phosphorus binders Non-dialytic treatment for hyperkalemia

NaHC03: 1-2meq/kg IV over 10-30 min Glucose / Insulin: (0.5g/kg) /( 0.1U/kg) IV over 30 min Calcium gluconate (10%): 0.5-1cc/kg IV over 5-15 min B-Agonist (albuterol): 5-10mg nebulizer in adults 2.5mg in

children? Kayexalate (0.5-1g/kg) PO or PR Q6h

Dopamine Diuretics Phosphorus binders Non-dialytic treatment for hyperkalemia

NaHC03: 1-2meq/kg IV over 10-30 min Glucose / Insulin: (0.5g/kg) /( 0.1U/kg) IV over 30 min Calcium gluconate (10%): 0.5-1cc/kg IV over 5-15 min B-Agonist (albuterol): 5-10mg nebulizer in adults 2.5mg in

children? Kayexalate (0.5-1g/kg) PO or PR Q6h

Future Therapy to Decrease Injury and Promote Recovery?Future Therapy to Decrease Injury and Promote Recovery?

IGF-1 ANP Epidermal growth factor Hepatocyte growth factor Melatonin stimulating factor Thyroxine C5a receptor antagonist Selective inhibitors of inducible nitric oxide synthase Inhibition of monocyte chemoattractant protein-1

IGF-1 ANP Epidermal growth factor Hepatocyte growth factor Melatonin stimulating factor Thyroxine C5a receptor antagonist Selective inhibitors of inducible nitric oxide synthase Inhibition of monocyte chemoattractant protein-1

Theophylline Prophylaxis in Perinatal AsphyxiaTheophylline Prophylaxis in Perinatal Asphyxia

Randomized, placebo controlled study Single theophylline dose vs. placebo (n=70) Theophylline group (n=40) ; placebo group( n=30) Higher GFR and lower beta 2 microglobulin excretion

in theophylline group Single dose theophylline (8mg/kg) in the 1st hour of

birth may prevent AKI in asphyxiated term infants

Randomized, placebo controlled study Single theophylline dose vs. placebo (n=70) Theophylline group (n=40) ; placebo group( n=30) Higher GFR and lower beta 2 microglobulin excretion

in theophylline group Single dose theophylline (8mg/kg) in the 1st hour of

birth may prevent AKI in asphyxiated term infants

Bhat et al..J Pediatr.2006:149:180-184

Indications for Renal Replacement Therapy (RRT)Indications for Renal Replacement Therapy (RRT)

Oliguria with fluid overload Respiratory distress Hypertension CHF

Electrolyte imbalance Hyperkalemia Hyponatremia Hyperphosphatemia Hypocalcemia Hyperuricemia

Uremic symptoms Nutritional needs Others (blood products, medications, other fluids)

Oliguria with fluid overload Respiratory distress Hypertension CHF

Electrolyte imbalance Hyperkalemia Hyponatremia Hyperphosphatemia Hypocalcemia Hyperuricemia

Uremic symptoms Nutritional needs Others (blood products, medications, other fluids)

Options for RRTOptions for RRT

Peritoneal dialysis Manual PD Cycler PD

Hemodialysis Continuous renal replacement therapy

CAVH CAVHD CVVH CVVHD

Peritoneal dialysis Manual PD Cycler PD

Hemodialysis Continuous renal replacement therapy

CAVH CAVHD CVVH CVVHD

Renal Replacement ModalityRenal Replacement Modality

0

10

20

30

40

% of patients

HemodialysisPeritoneal dialysisCRRT

Beisha et al. Pediatr. Nephrol.1995Beisha et al. Pediatr. Nephrol.1995

Peritoneal DialysisPeritoneal Dialysis

Access less of a problem No special equipment needed Can be done by NICU nurses Can be done in pts of all size Less need for blood products No need for anticoagulation Gradual change in volume

and electrolyte composition

Access less of a problem No special equipment needed Can be done by NICU nurses Can be done in pts of all size Less need for blood products No need for anticoagulation Gradual change in volume

and electrolyte composition

Relatively few if any contraindications Recent abdominal surgery Ostomies V-P shunt? Peritonitis? Peritoneal scarring Abnormal anatomy

Modality of choice for infants with ESRD

Relatively few if any contraindications Recent abdominal surgery Ostomies V-P shunt? Peritonitis? Peritoneal scarring Abnormal anatomy

Modality of choice for infants with ESRD

Hemodialysis in Infants Less Than 5KgHemodialysis in Infants Less Than 5Kg

216 acute hemodialysis treatments 1980-1991 33 pts (32-43wks) with wt of 2.2-4kg / total of 216 treatments Age 2-120 days (median 10 days) Indications for hemodialysis

Hyperammonemia (8pts) Intrinsic or primary renal disease (7pts) Acute kidney injury (18pts)

Hemodialysis Access 7 Fr double lumen catheter (49%) ECMO circuit (24%) Umbilical vessels (27%)

216 acute hemodialysis treatments 1980-1991 33 pts (32-43wks) with wt of 2.2-4kg / total of 216 treatments Age 2-120 days (median 10 days) Indications for hemodialysis

Hyperammonemia (8pts) Intrinsic or primary renal disease (7pts) Acute kidney injury (18pts)

Hemodialysis Access 7 Fr double lumen catheter (49%) ECMO circuit (24%) Umbilical vessels (27%)

Jabs et al. KI.Vol45.1994.903-906Jabs et al. KI.Vol45.1994.903-906

0

20

40

60

80

100

AKI

Hyperammonemia

Renal

0

20

40

60

80

100

AKI

Hyperammonemia

Renal

• 9 Rx discontinued prematurely• Hypotension• Technical problems

• Mortality not influenced• Weight• # of HD treatments

• 9 Rx discontinued prematurely• Hypotension• Technical problems

• Mortality not influenced• Weight• # of HD treatments

Hemodialysis in Infants Less Than 5KgHemodialysis in Infants Less Than 5Kg

Jabs et al. KI.Vol45.1994.903-906Jabs et al. KI.Vol45.1994.903-906

% s

urv

ival

% s

urv

ival

Who are the non-candidates for RRT? Who are the non-candidates for RRT?

Severe neurological injury Inoperable life threatening congenital heart disease Severe lung disease Severe congenital anomalies Extreme prematurity? Anticipated mortality? Parents wishes need to be considered The decision needs to be individualized Close communication with parents is important

Severe neurological injury Inoperable life threatening congenital heart disease Severe lung disease Severe congenital anomalies Extreme prematurity? Anticipated mortality? Parents wishes need to be considered The decision needs to be individualized Close communication with parents is important

Factors Influential in Deciding to initiate ESRD in Infants 217 Pediatric Nephrologist Around the World

Factors Influential in Deciding to initiate ESRD in Infants 217 Pediatric Nephrologist Around the World

Family socioeconomic statusFamily socioeconomic status 1.8 1.8 ++ 1.7 1.7 1.7 1.7 ++ 1.7 1.7

Hospital / Government budgetHospital / Government budget 0.5 0.5 ++1.11.1 0.5 0.5 ++ 0.9 0.9

Family’s right to decideFamily’s right to decide 3.7 3.7 ++ 1.3 1.3 4.0 4.0 ++ 1.2 1.2

Doctor’s right to decideDoctor’s right to decide 2.9 2.9 ++ 1.3 1.3 3.0 3.0 ++ 1.3 1.3

Coexistent serious medical abnormalitiesCoexistent serious medical abnormalities 4.8 4.8 ++ 0.6 0.6 4.8 4.8 ++ 0.5 0.5

Anticipated morbidity for childAnticipated morbidity for child 4.1 4.1 ++ 1.2 1.2 4.3 4.3 ++ 1.0 1.0

Presence of oliguriaPresence of oliguria 1.8 1.8 ++ 1.8 1.8 1.9 1.9 ++ 1.9 1.9

No influence = 0 No influence = 0 Strong influence = 5Strong influence = 5

Responses 1-12 mo (x Responses 1-12 mo (x ++ SD) SD)

Geary et al. J Pediatr.1998:133:154Geary et al. J Pediatr.1998:133:154

Usually acceptableUsually acceptable Ever acceptableEver acceptable

< 1mo< 1mo 1-12mo 1-12mo < 1mo< 1mo 1-12mo 1-12mo

CanadaCanada 6/116/11 2/162/16 11/1211/12 11/1611/16

FranceFrance 4/74/7 3/103/10 5/75/7 8/118/11

GermanyGermany 13/1913/19 11/2511/25 19/1919/19 18/2518/25

HollandHolland 1/31/3 0/30/3 3/33/3 3/33/3

ItalyItaly 0/50/5 0/70/7 2/62/6 0/70/7

JapanJapan 3/113/11 2/132/13 3/113/11 3/133/13

UKUK 19/2619/26 5/265/26 25/2625/26 20/2520/25

USAUSA 38/8838/88 24/9324/93 71/8971/89 59/9859/98

UnidentifiedUnidentified 3/43/4 0/60/6 3/33/3 4/64/6

TotalTotal 87/17487/174 49/19949/199 142/176142/176 126/204126/204

If parents reject RRT for otherwise normal infants with If parents reject RRT for otherwise normal infants with ESRD, is this USUALLY or EVER ethically acceptable to ESRD, is this USUALLY or EVER ethically acceptable to

you ?you ?

Geary et al. J Pediatr.1998. 133:154Geary et al. J Pediatr.1998. 133:154




Outcome and PrognosisOutcome and Prognosis

Highly dependent on the etiology of AKI Factors associated with poor prognosis

Multiorgan system failure Hypotension / hemodynamic instability Need for pressors RDS with need for mechanical ventilation Oligoanuria and need for dialysis

Overall mortality 10-61% Nephron loss can lead to long-term complications

Proteinuria Hypertension Chronic renal insufficiency

Highly dependent on the etiology of AKI Factors associated with poor prognosis

Multiorgan system failure Hypotension / hemodynamic instability Need for pressors RDS with need for mechanical ventilation Oligoanuria and need for dialysis

Overall mortality 10-61% Nephron loss can lead to long-term complications

Proteinuria Hypertension Chronic renal insufficiency

36 Month Post Transplant Patient Survival 36 Month Post Transplant Patient Survival

0

20

40

60

80

100

CRT LRD

0-1yr 2-5yr 6-12yr >12yr

NAPRTCS 2004NAPRTCS 2004

Neurodevelopmental Outcome of Children Initiating PD During Early Infancy

Neurodevelopmental Outcome of Children Initiating PD During Early Infancy

34 infants initiated long-term PD < 3mo of age

28/34 pts survived >1 year of life and underwent a formal neurodevelopment evaluation

27/28 pts received supplemental nasogastric tube feedings

Calcium carbonate was used as the only P04 binder

34 infants initiated long-term PD < 3mo of age

28/34 pts survived >1 year of life and underwent a formal neurodevelopment evaluation

27/28 pts received supplemental nasogastric tube feedings

Calcium carbonate was used as the only P04 binder

At 1yr HC SDS 0.96 + 1.2 At 1yr, developmental score in

22 pts (79%) were within avg range and in 1 pt (4%) significantly delayed

19 pts retested at > 4yrs, 15 pts (79%) performed in the average range and 1pt (5%) in the impaired

15/16pts (94%) > 5yrs of age attended regular school in age appropriate classrooms

At 1yr HC SDS 0.96 + 1.2 At 1yr, developmental score in

22 pts (79%) were within avg range and in 1 pt (4%) significantly delayed

19 pts retested at > 4yrs, 15 pts (79%) performed in the average range and 1pt (5%) in the impaired

15/16pts (94%) > 5yrs of age attended regular school in age appropriate classrooms

Warady et al. Pediatr.Nephrol. 1999:13(9)759Warady et al. Pediatr.Nephrol. 1999:13(9)759

SummarySummary

AKI is a relatively common among sick infants Certain infants are at higher risk

Probably under diagnosed in NICU nurseries Non-oliguric presentation is most common The diagnosis should follow a stepwise approach History Physical examination Diagnostic evaluations

Clinical knowledge and technological advancements have allowed for a variety of therapeutic options

Long-term renal follow up is necessary Management of AKI in infants is challenging but reasonable long-

term outcome is now possible More data is needed

AKI is a relatively common among sick infants Certain infants are at higher risk

Probably under diagnosed in NICU nurseries Non-oliguric presentation is most common The diagnosis should follow a stepwise approach History Physical examination Diagnostic evaluations

Clinical knowledge and technological advancements have allowed for a variety of therapeutic options

Long-term renal follow up is necessary Management of AKI in infants is challenging but reasonable long-

term outcome is now possible More data is needed

Documents

Infant Acute Kidney Injury Maricor Grio, MD, MS Orlando Health Arnold Palmer Hospital for Children Orlando, Florida [email protected] Maricor