‫بسم الله‬

‫الرحمن الرحيم‬
‫“قالوا ل علم لنا ال ما علمتنا‬
‫انك انت العليم الحكيم”‬
 ANALYSIS OF CLINICAL
AND LABORATORY DATA OF
INFANTS AND CHILDREN
ADMITTED WITH ACUTE
RENAL FAILURE TO
DIALYSIS UNIT OF
ALEXANDRIA UNIVERSITY
CHILDREN’S HOSPITAL: TEN
YEARS EXPERIENCE
(1995-2004)
 Definition of Acute Renal
Failure:
ARF is a syndrome with multiple causes;
defined as a sudden loss of renal functions (over
several hours to several days).
ARF results in derangement in extracellular
fluid balance, acid base, electrolytes and divalent
cation regulation.
An increase in serum creatinine
concentration, accumulation of other nitrogenous
waste products and often a decline in urinary output
are the hall marks of ARF.
 Classification of ARF

Acute Renal Failure

Pre-renal Intrinsic Post-renal

Glomerular Interstitial Tubular Vascular

Pre-renal Causes
• Intravascular volume depletion
• Low cardiac output.
• Impaired renal autoregulatory responses.
Specific Renal Diseases That May Lead to
Acute Renal Failure:
I-Vascular Causes of Intrinsic ARF:
Small vessel vascular diseases that cause renal
failure e.g: Hemolytic-uremic syndrome
II- Acute Nephritis
 e.g: Acute post-streptococcal glomerulonephritis
(APSGN), Rapidly progressive glomerulonephritis .
Urinary findings including proteinuria ,erythrocytes,
leukocytes and erythrocyte casts with dysmorphic
erythrocytes are characteristic features.
RBCs casts
WBCs Casts
Renal tubular epithelial
cells casts
Muddy brown granular casts
Broad casts (form in dilated,
damaged tubules
 III-Renal Interstitial Diseases:
• Acute tubulointerstitial nephritis (ATIN) is a clinical
syndrome characterized by inflammation of the renal
interstitium accompanied by interstitial edema and renal
tubular injury.

• ATIN may be caused by numerous drugs, infectious agents

and systemic illnesses.

• Clinically apparent disease usually develops days to

weeks after exposure to the inciting drug or agent but may
be immediate.
IV-Acute Tubular Necrosis
• Most common cause of intrinsic ARF

• Tubules are damaged by ischemia or toxins

resulting in desquamation of tubular cells,
intraluminal tubule obstruction, and back
leakage of glomerular filtrate
Urinary Tract Obstruction :

Obstruction of urine flow may result in ARF.

Various clinical causes of urinary tract
obstruction are:calculi, ureteropelvic junction
obstruction, posterior urethral valves, prune
bel ureterocele, neurogenic bladder, duplicated
ureters.
The most important factors determining
recovery of renal and tubular function are the
degree and severity of obstruction.
Post-Renal ARF
ARF: Signs and Symptoms
• Hyperkalemia
• Nausea/Vomiting
• HTN
• Pulmonary edema
• Ascites
• Asterixis
• Encephalopathy
• Pruritus
• Seizures
• Chest pain
• Shortness of breath
Diagnosis
•Physical
examination

•Radiological
•Laboratory Evaluation
Diagnosis
Physical Examination
• Vital signs: espec temp and BP
• Fluid status: mucous membranes, JVP, peripheral
edema
• CVS: murmur, pericardial rub, CHF
• Resp: rales consistent with edema
• Abdo: bladder distension, masses, ascites, CVA
tenderness
• Derm: rash
– Maculopapular: interstitial nephritis
– Purpura: vasculitis
– Petechiae: HUS/TTP.
Laboratory investigation
• Blood
– CBC-D
– Lytes, Ca, Mg, P
– Urea
– Creatinine
• Urine
– Urine sodium
– Urine osmolality
– Urinalysis Consists of:
– dipstick for heme pigment, protein, glucose, ketones,
pH, leukocytes, and nitrites
– Microscopic examination of urine
Radiological Investigations
• Radiology
– CXR
– Renal U/S
– CT
– IVP •

– Retrograde pyelogram

Other investigations
– ECG
– serum C3
– Antineutrophil cytoplasmic antibodies.
– Glomerular basement membrane antigens.
The most urgent aspects of
ARF are:
• Hyperkalaemia
• Severe hypertension
• Severe plasma and extracellular volume
expansion leading to heart failure and
pulmonary edema.
• Unremitting metabolic acidosis.
• Hypocalcemia / hyperphosphatemia.
• Uremia.
 Therapy

i c t h er a py
o n-d i al y t
N

Dialysis:
 Non-dialytic therapy
Growth factor.
Atrial Natriuretic Peptide (ANP)
Intra Cellular Adhesion Molecules
 Anti oxidant therapy
Dopamine •
Mannitol
 Diuretics •
Adjuvant Measures has to include
cardiorespiratory support, nutrition, prevention and
treatment of sepsis, and treatment of the condition that
precipitated the ARF.
Dialysis:
Indications of dialysis:
 Severe derangements in electrolyte
concentrations .
 Volume overload.
 Acid-base imbalance.
 Pronounced azotemia; blood urea
nitrogen >100mg/dl
 Florid symptoms of uremia
(pericarditis,encephalopathy, bleeding,
nausea, vomiting or pruritus).
 Dialysis:
• Hemodialysis :
 Peritoneal Dialysis
Indications for Peritoneal Dialysis in
Acute Renal Failure

• Hemodynamically unstable patients

• Bleeding diathesis
• Acute necrotizing pancreatitis
• Difficulty obtaining vascular access
• High molecular weight toxin
removal (contrast)
• Hypothermia
• Children with ARF
 AIM OF THE WORK
The aim of this work was to study acute
renal failure (ARF) in infants and children
admitted to dialysis unit of Alexandria
University Children’s Hospital in 10 years
(January 1995 - December 2004).
 MATERIAL

This study was conducted on the files of

all infants & children who presented
with ARF and have already undergone
dialysis in Alexandria University
Children’s Hospital (AUCH) during the
period from 1/1/1995 - 31/12/2004.
 METHODS
Files of dialysis patients who attended the
dialysis unit of Alexandria University
Children’s Hospital (AUCH) during the
period from 1/1/1995 to 31/12/2004 were
reviewed. Recorded data from the history,
clinical examination, laboratory
investigations, and treatment given,
including the type of dialysis as well as
the follow up were summarized.
 Demographic data of studied
cases
250

200

150
No. of cases
100

50

0
Neonate infant preschool school adolescent

Distribution of cases according to their age

Demographic data of studied
cases

0%
Female
40%

Male
60%

Distribution of cases according to their sex.

 Family history
positive
family history

negative
family history

Distribution of cases according to their family history.

 Residency.

35%
urban

rural
65%

Distribution of cases according to their residency

 Clinical findings at presentations of
ARF
500

450

Oliguria or anuria
400

350

Volume overload
300

Gastrointestinal bleeding
No. of cases 250

Hypertension

Bleeding diasthesis
200

1 50

Heart failure
Convulsions
1 00

50

Coma
0

.In this study it was demonstrated that 88 % of cases at

presentation had oligo / anuria (most frequent clinical
presentation), followed in frequency by volume
overload (73.9 %) .
 Clinical presentations in different age
groups.
1 00

90

80
Oligo/anuria %
70
V. overload %
Hypertension % 60

Heart failure %
% 50
GIT. Bleeding %
40
Bl. Diasthesis %
Convulsions % 30
Coma %
20

10

0
Neonate Infant Preschool School Adolescent
  Hepatitis profile of the patients

600

500

400

300

200

100

0
HBs Ag HBs Ag HCV Ab HCV Ab
negative positive positive negative
 Results of renal biopsy in
patients with ARF.
14
 
Membranoproliferative GN
12 Rapidly progressive GN
Lupus nephritis
10 End stage renal disease
Nephronophthisis

8 ATN
Mesangioproliferative GN
Focal segmental GN
6
Acute interstitial nephritis
Renal tumour
4
Not adequate
Alport syndrome
2
Uric acid nephropathy
HUS
0
 Ultrasonographic data of
cases.
Increased cortical echogenicity

Normal
200

180 Bilateral hydroureteronephrosis

160 Increased cortical echogenicity w ith loss of

CMD
140
Bilateral hypoplastic kidney
120
Single hypoplastic/singlehydronephrotic
No. of cases 100 kidney
Unilateral/bilateral renal stones w ith or
80 w ithout hydronephrotic changes

60 Renal tumour/mass

40 Increased cortical echogenicity w ith loss of

CMD w ith unilateral/bilateral renal cysts
20 Bilateral polycystic kidney

0
Nephrocalcinosis
ultrasonographic finding
 Results of VCUG done for some
cases with obstructive and/or
reflux nephropathy .

50

45
40

35
30
No. of cases 25

20
15
10

0
normal VUR PUV
 Results of DMSA scan done for
some cases with obstructive and/or
reflux nephropathy.

60

50

40

No. of cases 30

20

10

0
normal renal scarring
Diagnosis of cases dialyzed for
ARF
Acute tubular/cortical necrosis

Acute on top of chronic renal f ailure

Obstructive/ref lux nephropathy

HUS
Congenital anomaly
Nephrotic syndrome

Unknow n
Rapidly progressive GN

Bilateral nephrolithiasis
Tumour lysis syndrome

SLE

Hepatorenal syndrome
Juvenile/f amilial nephronophthisis

Bilateral polycystic kidney

Renal tumour
Uric acid nephropathy

Acute interstitial nephritis

Alport syndrome

Nephrocalcinosis
Renal trauma/nephrectomy
 Distribution of cases with acute
tubular or cortical necrosis
90

80

70

60

50
No. of cases
40

30

20

10

0
sepsis gastroenteritis others
 Fate of cases dialyzed for ARF
31.1%
died 39.7%
chronic 100
follow up
90
29.2%
80

70

60

Follow up %
% 50
Died %
Chronic % 40

30

20

10

0
Neonate Infant Preschool School Adolescent
Type of dialysis done for cases
with ARF

6% 1%
Peritoneal dialysis

Peritoneal/hem odialys is

Hem odialysis

93%
Distribution of cases as regards
their origin
450

400

350

300
Community acquired
Hospital acquired 250

ICU 200
NICU
150

100

50

0
 Morbidity and mortality of cases
with ARF regarding their origin.
100
 
90

80

70

Community acquired 60
Hospital acquired % 50
PICU
40
NICU
30

20

10

0
Follow up % Died % Chronic %
From this study we concluded that:
ARF occured with an average of 50 cases / year.
 Most of cases who presented with ARF were infants (37.9
% of cases ), followed by school age group (25 %). Male
patients out numbered female patients and patients from rural
areas out numbered those from urban areas.
 Presence of family history of renal problems or renal
failure was absent in most of the studied patients.
 The most common clinical findings at presentation in all
age groups were oligu/anuria and volume overload .
Most cases were HCV antibody negative and HBV surface
antigen negative at time of initiation of dialysis.
 Most cases of ARF due to obstructive uropathy,
had primary VUR.
 The most common causes of ARF were ATN,
obstructive uropathy, and hemolytic uremic
syndrome.
 Mortality rate of acute renal failure is high
specially in neonates and in cases dialyzed in PICU.
 Mortality rate in cases presenting with ARF due to
hepatorenal syndrome and renal tumours were the
highest.
 APD was the standered modality of dialysis in our
unit, and it proved to have a highly accepted efficacy.

 Most cases which presented with ARF were

community acquired.
 RECOMMENDATIONS
 ARF in most cases occur as a complication of
preventable causes hence more efforts and more
resources should be directed towards prevention,early
detection and treatmeant of such causes.
 Primary health care doctors should be taught how to
prevent occurrence of renal failure in cases of
gastroenteritis, merely by timely volume repletion.
 Renal failure secondery to urinary tract obstruction was
seen in many cases, more attention should be paied for
early detection and treatment of such cases.
 RECOMMENDATIONS
 All children with ARF need life-long monitoring
of their renal functions, blood pressure, and
urinalysis.
 Finally, we recommend that medical records
should be up graded to make it complete, easily
accessible and easily analyzed and modern
tecnology should be employed in such process.
•