Prognosis of acute renal failure in children

Acute renal failure (ARF) is the acute loss of renal function over a period of hours or days. Given the poor prognosis of ARF among children, there is some urgency to identifying more effective prognostic indicators for detecting disease onset. Such indicators would help provide the means of selecting patients who would benefit the most from early aggressive treatment. In this study we assessed the etiologic and prognostic indicators of ARF, including several risk factors such as sepsis, respiratory distress, age, among others, in 300 children who were admitted to the Ali Asghar Children’s Hospital, Tehran, Iran, from 1990 to 2003. Statistical analysis was performed using multiple regression and chi-square methods, and a score to determine the prognosis of ARF in children was developed. Result: Based on the results of this study the three common causes of ARF are acute tubular necrosis (ATN, 38%), acute glumerulonephritis (24%) and hemolytic uremic syndrome (24.1%). The overall mortality rate among our patients was 24.7%, with the highest risk group being those patients suffering from ischemic ATN. In addition, the correlation (p<0.0005) between the etiology and mortality rate was particularly high in patients with ischemic ATN. Mortality was also high (68%) in children younger than 2 years. Multiple regression models revealed that among those factors that significantly differed between the survivors and nonsurvivors, only the necessity of dialysis (p<0.0005), the use of mechanical ventilation (p=0.05) and disseminated intravascular coagulation (p=0.038) can be regarded as independent determinants of ARF prognosis in children.     

妊娠合并急性肾衰竭的临床分析

目的探讨妊娠合并急性肾衰竭ARF）诊治。方法回顾性分析24例妊娠并急性肾衰竭患者的临床资料。结果24例患者中22例患者治愈或好转出院，2例患者死亡。结论早期诊断、积极治疗妊娠合并急性肾衰竭，可以挽救母婴生命。治疗措施包括：适时终止妊娠、早期透析、积极治疗原发病、防治感染。     

Rhabdomyolysis and acute renal failure in children

Acute renal failure (ARF) is an important complication of rhabdomyolysis. However, the contributing factors to the development of ARF in children with rhabdomyolysis remain obscure. The aim of this study was to clarify the factors contributing to the development of ARF in children with rhabdomyolysis. This is a retrospective review of the clinical characteristics, laboratory data, pediatric risk of mortality (PRISM) scores, the occurrence of systemic inflammatory response syndrome (SIRS) criteria, and the number of dysfunctional organs in 18 children with rhabdomyolysis seen in our hospital between 1991 and 2000. The patients were divided into an ARF group (n=9) and a non-ARF group (n=9). All patients with ARF had more than two dysfunctional organs. The incidence of dehydration, serum concentrations of myoglobin, creatinine kinase, aspartate aminotransferase, and lactate dehydrogenase, PRISM scores, and the numbers of SIRS criteria and dysfunctional organs were higher in the ARF group than the non-ARF group. The blood pH and base excess, and urinary pH were lower in the ARF group than in the non-ARF group. These results suggest that ARF is more likely to develop in the presence of dehydration, metabolic acidosis, or severe muscle damage, or with multiple organ failure in children with acute rhabdomyolysis. Received: 12 April 2001 / Revised: 20 August 2001 / Accepted: 21 August 2001     

Antioxidant status of children with acute renal failure

The production of free radicals can cause renal injury and play a role in the pathogenesis of acute renal failure (ARF). The indirect markers of reactive oxygen species (ROS) were evaluated in children with ARF and controls. Forty patients with ARF aged 0–10 years were selected. Twenty age- and gender-matched healthy children were included as controls. Plasma malondialdehyde, protein carbonyl, nitrite, copper, ascorbic acid, zinc, and ceruloplasmin levels were estimated in patients with ARF and controls. The plasma malondialdehyde (p < 0.01), copper (p < 0.001), ascorbic acid (p < 0.05), and ceruloplasmin (p < 0.001) levels were significantly raised in ARF patients in comparison with controls. Significantly higher levels of plasma malondialdehyde (p < 0.01), nitrite (p < 0.001), copper (p < 0.001), and ceruloplasmin (p < 0.001) and lower plasma zinc (p < 0.01) were found in ARF nonsurvivors in comparison with survivors. The cutoff levels of plasma nitrite and ceruloplasmin were found to be most accurate in predicting mortality in ARF patients and had maximum sensitivity (100%) and specificity (60.7%) among the parameters studied. In conclusion, the increased levels of oxidants and antioxidants suggest the production of ROS and their possible role in ARF pathogenesis. Plasma nitrite and ceruloplasmin concentrations demonstrated predictive ability in relation to mortality. Financial Support: The study was supported by Departmental Research Grant of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi-221005, India.     

Rhabdomyolysis and acute renal failure in a child with influenza A infection

A 13-year-old previously healthy girl developed rhabdomyolysis and acute renal failure during influenza A infection. The patient recovered renal function completely with supportive therapy. This complication has been described in adult patients, but progression to acute renal failure in this context has not been reported previously in children. This diagnosis should be considered in the differential diagnosis of a pediatric patient presenting with acute renal failure and viral symptomatology. Received July 16, 1996; received in revised form and accepted November 6, 1996     

Non-fatal acute renal failure due to wasp stings in children

We report two children who developed acute renal failure after multiple wasp stings. Each case involved intravascular hemolysis which caused acute renal failure, volume overload, hypertension, anemia, hyponatremia, hyperkalemia, and metabolic acidosis. Peritoneal dialysis was required for short periods. The children recovered completely with blood urea nitrogen and creatinine returning to normal within 3 months. One child had a renal biopsy which showed mild tubulointerstitial nephritis. Although there is no specific treatment or antivenom, dialysis and supportive care have proved to be successful. Received February 4, 1997; received in revised form June 23, 1997; accepted July 2, 1997     

Peritoneal dialysis for acute renal failure in children

Fifty infants and children with acute renal failure were treated with acute peritoneal dialysis between 1987 and 1990. The patients were dialyzed using either a catheter introduced percutaneously over a guide-wire (n=40) or a Tenckhoff catheter (n=10). The cause of the acute renal failure was primary renal disease in 17 children, cardiac disease in 19, and trauma/sepsis in 14. Peritoneal dialysis succeeded in controlling metabolic abnormalities, improving fluid balance, and relieving the complications of uremia. The procedure had few major complications. Overall mortality was 50%, reflecting the serious nature of the underlying diseases. We conclude that acute peritoneal dialysis is a safe and effective treatment in most pediatric patients with acute renal failure. Our series of patients treated with acute peritoneal dialysis serves as a basis of comparison for the evaluation of new modalities of therapy in childhood acute renal failure.     

Renal replacement therapy for acute renal failure in children: European Guidelines

Acute renal failure (ARF) is uncommon in childhood and there is little consensus on the appropriate treatment modality when renal replacement therapy is required. Members of the European Pediatric Peritoneal Dialysis Working Group have produced the following guidelines in collaboration with nursing staff. Good practice requires early discussion of patients with ARF with pediatric nephrology staff and transfer for investigation and management in those with rapidly deteriorating renal function. Patients with ARF as part of multi-organ failure will be cared for in pediatric intensive care units where there should be access to pediatric nephrology support and advice. The choice of dialysis therapy will therefore depend upon the clinical circumstances, location of the patient, and expertise available. Peritoneal dialysis has generally been the preferred therapy for isolated failure of the kidney and is universally available. Intermittent hemodialysis is frequently used in renal units where nursing expertise is available and hemofiltration is increasingly employed in the intensive care situation. Practical guidelines for and the complications of each therapy are discussed.This paper is written on behalf of the European Pediatric Peritoneal Dialysis Working Group. The group includes Alberto Edefonti, I Clinici di Perfezionamento, Milan, Italy; Michel Fischbach, Hôpital de Hautepierre, Strasbourg, France; Günter Klaus, University of Marburg, Marburg, Germany; Constantinos J. Stefanidis, A. and P. Kyriakou Childrens Hospital, Athens, Greece; Cornelis Schröder, Wilhelmina Kinderziekenhuis, Utrecht, The Netherlands; Eva Simkova, I. Detska klinika FN v Motole, Prague, Czech Republic; Kai Ronnholm, Hospital for Children and Adolescents, Helsinki, Finland; Mesiha Ekim, Ankara University Hospital, Ankara, Turkey; Johann Vande Walle, University Hospital, Ghent, Belgium; Franz Schaefer, University of Heidelberg, Germany; Aleksandra Zurowska, Gdansk University Medical School, Poland     

Prognosis of acute renal failure in the elderly

Life expectancy is uncertain in the elderly with ARF. In orderto determine whether a costly supportive management is worthwhile,we have studied a group of 68 elderly patients (over 65 yearsof age) admitted to the ICU with ARF. Patients: 47 male; 21 female; 72 ± 6 years old. Types of ARF include prerenal 24; obstructive 9; intrinsic 35(acute tubular necrosis 30; glomerulo-nephritis 4; vascular1). The mean simplified acute physiology score (SAPS) was 14±4;39 patients (57.3%) had more than two underlying diseases; 42patients (61.7%) were on mechanical ventilation; 40 patients(60%) underwent haemodialysis. The overall survival rate was 36.7%. Among the parameters studied,organic systemic failure index (OSF), diuresis, blood lactate,systolic blood pressure, urea appearance rate (UAR), differedsignificantly in survivors and deceased. From these resultswe conclude that the elderly with non-oliguric ARF, normal bloodlactate, low catabolic state, and no more than two organ failureshave a fair chance of recovering and should therefore be treatedaggressively. In other cases, decisions to proceed with intensivesupportive measures should be made according to individual characteristics.