infant acute kidney injury maricor grio, md, ms orlando health arnold palmer hospital for children...
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Infant Acute Kidney Injury
Infant Acute Kidney Injury
Maricor Grio, MD, MSOrlando Health
Arnold Palmer Hospital for ChildrenOrlando, Florida
Maricor Grio, MD, MSOrlando Health
Arnold Palmer Hospital for ChildrenOrlando, Florida
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?
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
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?
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?
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
Infant AKIInfant AKI
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
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?
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?
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
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?
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?
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