RENAL FAILURE IN CHILDREN

MIHAI CRAIU MD PhD IOMC

RENAL FAILURE IN CHILDREN

Renal failure (also kidney failure or renal insufficiency) is a medical condition in which the kidneys fail to adequately filter waste products from the blood. There are two types of disease
Acute renal failure Chronic renal failure [end-stage renal disease]

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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

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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.

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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

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AKI can result from a variety of causes, generally classified as
prerenal, intrinsic, postrenal.

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AKI is NOT just a renal disease. It represents a severe impairment with multiple organ involvement

RENAL FAILURE IN ADULTS

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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.

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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.

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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.

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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]

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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

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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)

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A build up of K+ in the blood that kidneys cannot filter out (hyperkalemia) may cause
Abnormal heart rhythms Muscle paralysis

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hypokalemia

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Acute kidney failure usually occurs when the blood supply to the kidneys is suddenly interrupted or when the kidneys become overloaded with toxins.

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The National Kidney Foundation (NKF) recommends three simple tests to check for kidney disease:
Blood pressure Urinalysis GFR

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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

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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/gm or less per day is normal. A value higher than 200 mg/gm is too high.

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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/gm per day is normal for the albumin to creatinine ratio; a value of 30 mg/gm 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.

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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.

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The National Kidney Foundation offers an easy to use on-line GFR calculator

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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

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Dialysis works on the principles of
diffusion of solutes and ultrafiltration of fluid across a semi-permeble membrane.

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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).

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PERITONEAL DIALYSIS The process uses the patient's peritoneum as a membrane across which fluids and dissolved substancesare exchanged from blood. The fluid used typically contains Na, Cl, lactate or bicarbobate and a high percentage of glucose to ensure hyperosmolarity.

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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.

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PERITONEAL DIALYSIS The peritoneal catheter is your access for dialysis and therefore it will be permanent. It is important that the exit site is kept clean and free of infection.

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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)

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PERITONEAL DIALYSIS [advantages] 2 Minimal Fluid and Dietary Restrictions No Needle Punctures Required Ease Of Travel Minimal Cardiovascular Stress Overnight Dialysis Compact, Portable

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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.

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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.

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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

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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.

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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).