新生儿急性肾功能衰竭抗利尿激素水平的变化

目的　探讨新生儿急性肾功能衰竭 (NARF)血浆抗利尿激素 (ADH)的变化及其对肾功能的影响。方法　NARF 3 3例 ,其中少尿型 10例 ,非少尿型 2 3例 ,对照组为同期肾功能正常的轻型病例 2 8例。FM - 6型冰点渗透压仪测定血浆、尿液渗透压 ,放射免疫法检测血清ADH ,同时检测血钠、尿钠、血肌酐、尿肌酐 ,计算出钠排泄分数 (FENa)、肌酐清除率 (Ccr)、肾衰指数 (RFI)、自由水清除率 (CH2 O)。结果　少尿型、非少尿型ARF及对照组的ADH分别为 18.98± 7.65、14.2 3± 6.61、6.5 8± 3 .46ng/L ,差异有显著性意义 (P <0 .0 5 )。FENa、RFI、Ccr、CH2 O 3组比较 ,差异有显著性意义 (P <0 .0 5 )。 3组尿 /血渗透压无显著性差异 (P >0 .0 5 )。ADH与RFI、FENa均正相关 (r=0 .3 6　P =0 .0 0 5 ) ,与Ccr负相关 (r=- 0 .3 6　P =0 .0 0 5 )。结论　NARF有ADH的异常分泌 ,ADH增高与肾小球滤过率降低相关 ,对肾小管有部分效应     

Acute heart failure and acute renal failure in Kawasaki disease

Acute renal failure and acute heart failure are rare in Kawasaki disease. We experienced two patients with Kawasaki disease who presented acute renal failure and acute heart failure. These two patients gave us an important insight into the understanding of water balance and fluid therapy in Kawasaki disease. One patient showed acute prerenal failure due to fluid exudation from the intravascular to the extravascular space, and subsequent acute heart failure. The other patient showed acute heart failure caused by fluid infusion for the treatment of dehydration. It is suggested that acute renal failure could be caused by a fluid shift from the intravascular to the extravascular space in Kawasaki disease. It is also demonstrated that the reserve of cardiac function could be decreased in patients with Kawasaki disease due to myocarditis even with normal echocardiography and chest X-rays.     

Exercise-induced acute renal failure in a girl with renai hypouricemia

A 10-year-old Japanese girl developed acute renal failure following a 100-meter dash during physical training at school. After the run, she experienced intense pain in the loins with nausea and vomiting lasting more than 12 h. On the following morning, she was found to have mild proteinuria and acute renal failure (ARF). Serum creatinine and blood urea nitrogen were elevated, but the serum uric acid level was normal (3.1 mg/dL). With recovery of renal function over the ensuing days, hypouricemia (0.6 mg/dL) became evident in the patient. Although the pathophysiological association between renal hypouricemia and ARF is not known, oxygen free radicals have been implicated in the pathogenesis for ischemic-reperfusion ARF. Superoxide production by neutrophils stimulated by N-formyl methionine leucyl-phenylalanine was normal in the patient both before and following exercise. Pyrazinamide and probenecid tests were undertaken on both the patient and her parents, who had borderline hypouricemia, to determine their renal tubular handling of uric acid. Results showed that the patient and her mother had a subtotal reabsorption defect, while the father had defective postsecretory uric acid reabsorption.     

持续静脉-静脉血液滤过治疗12例婴幼儿先天性心脏病术后急性肾功能衰竭预后的回顾性分析

目的 探讨持续静脉-静脉血液滤过（CVVH）在救治婴幼儿先天性心脏病术后急性肾功能衰竭的疗效和预后。方法 回顾性分析2013年1月至2014年8月于重庆医科大学附属儿童医院经体外循环心脏直视术后发生急性肾功能衰竭进行CVVH治疗的12例婴幼儿临床资料,比较CVVH治疗前后尿量、BUN、SCr、PLT、平均动脉压和血管活性药物使用情况及患儿预后。结果 12例患儿年龄1～24月龄,平均（8.8±6.5）月龄;体重3.5～9.5 kg,平均（6.6±1.9）kg。11例先经腹膜透析治疗,后改为CVVH治疗;1例术后出现腹膜炎,直接行CVVH治疗。①12例行CVVH治疗血流量为15～35 mL·min-1,置换液流量为4～10 mL·min-1。12例均采用肝素抗凝。②经过CVVH治疗后7/12例肾功能和尿量均恢复正常,CVVH治疗前后平均BUN分别为（17.8±8.1）和（5.5±2.2）mmol·L-1（P=0.001）,平均SCr分别为（169.6±38.2）和（81.4±25.1）μmol·L-1（P=0.000）,正性肌力药物评分分别为（20.3±8.5）和（19.9±12.0）（P＝0.858）,平均动脉压分别为（59.0±16.2）和（55.2±12.4）mmHg（P＝0.273）。PLT在CVVH治疗后［35.0(21.2~83.7)×109·L-1］较治疗前［147.8(100.2~214.2)×109·L-1］明显下降（P=0.001）,3例在CVVH治疗后因PLT低,出现了消化道或呼吸道出血。③7/12例（58.3％）死亡。死亡患儿正性肌力药物评分明显高于存活患儿,平均动脉压明显低于存活患儿,差异均有统计学意义（P均<0.05）。结论 对于先天性心脏病术后发生急性肾功能衰竭的婴幼儿,可采用CVVH进行肾脏替代治疗以减轻液体过负荷、改善肾功能,CVVH治疗前正性肌力药物使用强度及平均动脉压可能是影响患儿预后的重要因素,CVVH治疗时需警惕PLT降低。     

新生儿非少尿型急性肾功能衰竭临床研究

目的探讨新生儿非少尿型急性肾功能衰竭的临床特点、病因、发病机制及预后。方法前瞻性研究新生儿非少尿型急性肾功能衰竭(ARF)22例。冰点渗透压仪测定血浆、尿液渗透压,放射免疫法检测血清抗利尿激素(ADH)、血清及尿液β2-微球蛋白(β2-M);同时检测血钠、尿钠、血肌酐、尿肌酐、血尿素氮;计算钠排泄分数(FENa)、肌酐清除率(Ccr)、肾衰指数(REI)。对照组为同期肾功能正常的轻型病例。结果本组原发疾病为新生儿窒息12例,占54％。非少尿型急性肾功能衰竭组尿/血渗透压0.95±0.34,血β2-M4.51±1.97(mg/L),ADH14.71±5.04(ng/L)明显增高,Ccr10.5±7.3ml/(min·1.73m2),明显降低,尿β2-M改变不明显。结论新生儿窒息是导致非少尿型ARF的最主要病因。非少尿型ARF主要为肾前因素所致,肾小管损害较轻,对ADH有效应,且预后较好。     

Characterization of renal tubular damage in preterm infants with renal failure

This study attempts to clarify the characteristics of renal tubular damage in preterm infants with renal failure. Sixty-one neonates (17 term and 44 preterm infants) were divided into three groups: 15 infants with intrinsic renal failure (IRF), five term and 10 preterm; 19 with pre-renal renal failure (PRF), five term and 14 preterm; and 27 without renal dysfunction (control), seven term and 20 preterm. Urine was collected for an 8 h period on the 2nd or 3rd day of life to determine the following parameters: creatinine clearance (Ccr), fractional excretion of sodium (FENa), urinary N-acetyl-beta-D-glucosaminidase (NAG) index and endothelin-1 (ET-1) excretion. Parameters of renal tubular function and/or renal tubular damage such as FENa, NAG index and ET-1 excretion were considered as a useful marker to differentiate IRF from PRF in preterm infants. However, these parameters were significantly elevated in preterm infants with PRF. These findings led us to make the following speculations: (i) renal tubular damage may easily occur in preterm infants; and (ii) there still remains difficulty in differentiation between IRF and PRF using Ccr instead of the fluid challenge test.     

婴幼儿三聚氰胺相关泌尿系结石并发急性肾衰竭诊疗分析

目的 探讨食用受三聚氰胺污染的婴幼儿配方奶粉致泌尿系结石并发急性肾衰竭患儿的临床特点、诊断和治疗措施.方法 回顾性分析首都医科大学附属北京儿童医院和徐州市儿童医院2008年收治的34例因食用三聚氰胺污染的婴幼儿配方奶粉致泌尿系结石、梗阻发生急性肾衰竭的患儿.分析其流行病学、临床表现及影像学特点,总结4种不同的治疗方法 及疗效.结果 34名患儿均存在急性肾衰竭,血尿素氮(24.1±8.2)mmol/L,血肌酐(384.2±201.2)μmol/L.对留取的14例结石标本分析证实,结石是三聚氰胺和尿酸的合成体.膀胱镜治疗组血肌酐降至正常的平均时间为(3.5±1.9)d;切开取石组(2.7±1.1)d;透析组(3.8±2.3)d;内科保守治疗组(2.7±1.6)d.四组肾功能恢复时间差异无统计学意义(P=0.508),组问差异无统计学意义(P=0.803～1).经治疗34例患儿急性肾衰竭全部治愈,泌尿系结石完全或部分排出.肾功能恢复时间为(3.0±1.8)d.结论 三聚氰胺污染婴幼儿配方奶粉可以导致婴幼儿泌尿系结石引发的梗阻性急性肾衰竭,治疗首选药物或透析方法 纠正电解质紊乱,特别是高钾血症,尽快通过内、外科方法 解除梗阻引流尿液.患儿近期预后良好.     

Renal blood flow velocity in acute renal failure following cardiopulmonary bypass surgery

Diminished renal perfusion is believed to be the main factor precipitating acute renal failure (ARF) following cardiopulmonary bypass surgery (CPB). We aimed to assess renal perfusion in patients following CPB surgery using Doppler ultrasound measurements. The Pulsatility index (PI) of the renal and intrarenal arteries was calculated as an index of renal perfusion. Two groups of patients were studied. Group 1 consisted of children with complex cardiac malformations who developed ARF following CPB. Group 2 consisted of children with atrial septal defects who were studied before and after CPB, but who did not develop ARF. In group 1, there were significant correlations between PI of the renal artery and standard deviation score of systolic blood pressure (SDS) (correlation coefficient =– 0:588, p < 0:0001), and PI and urine output (UOP) (correlation coefficient =– 0:46, p = 0:001). In the survivors, PI of the renal artery dropped significantly at the onset of recovery from ARF (6.27–2.15, p = 0:007). In group 2, PI of renal and intrarenal arteries remained unchanged on day 1 and day 4 post-CPB surgery in comparison with preoperative values. PI of the renal artery may aid the prediction of onset and recovery from ARF following CPB surgery, and help modify treatment in these critically ill patients.     

Doppler evaluation of renal blood flow velocity as a predictive index of acute renal failure in perinatal asphyxia

Aim of our study was to evaluate Doppler renal blood flow velocity in asphyxiated neonates and to correlate renal function to Doppler findings. Doppler renal blood flow velocity was evaluated in 23 severely asphyxiated neonates born at a gestational age >32 weeks and compared to our standard Doppler data obtained in 25 healthy neonates comparable for gestational age and birth weight. Renal Doppler ultrasound was performed on the 1st and 3rd days of life. Renal function was investigated in the first 2 weeks of life. Asphyxiated neonates showed mean values of systolic velocity and mean velocity significantly reduced (P< 0.001) compared with our standard Doppler values on the 1st day of life. Seven out of the 23 asphyxiated neonates were affected by acute renal failure and 14 showed no renal involvement. Two neonates were oliguric but did not develop acute renal failure. On the 1st day of life, neonates with acute renal failure had significantly lower mean values of systolic velocity and mean velocity than the asphyxiated neonates without renal involvement (P< 0.01). All 7 neonates affected by acute renal failure showed a systolic velocity more than 2SD below the mean standard value, while only 4 of the 16 asphyxiated neonates (25%) without acute renal failure had low systolic velocity values on the 1st day of life. Doppler velocities in asphyxiated neonates were similar to standard values on the 3rd day of life. Renal failure recovered before the 11th day of life in all cases. Conclusion Our findings indicate that decreased Doppler renal flow systolic velocity observed in asphyxiated neonates on the 1st day of life is a useful predictive index for subsequent development of acute renal failure, with 100% sensitivity and 63.6% specificity. Received: 21 July 1997 / Accepted in revised form: 24 November 1997     

Ceftriaxone induced hemolysis complicated by acute renal failure

Over the last decade, second and third generation cephalosporins have been the most common drugs causing hemolytic anemia (HA). Of these cases, 20% have been attributed to ceftriaxone. The clinical presentation of ceftriaxone-induced HA is usually abrupt with sudden onset of pallor, tachypnea, cardio-respiratory arrest and shock. Acute renal failure (ARF) has been reported in 41% of such cases with a high fatality rate. We report a pediatric patient with ARF complicating ceftriaxone-induced HA who survived. Ceftriaxone is a commonly used drug, and early recognition of HA and institution of supportive care, including dialysis is likely to improve the outcome.     

Using NSAID in volume depleted children can precipitate acute renal failure

Non-steroidal anti-inflammatory drugs (NSAID) are increasingly popular in hospital medicine and general practice and are readily available over the counter. The vast majority of healthy children who ingest therapeutic doses of NSAID for a limited duration tolerate them without any significant adverse effects. However, the risk of renal toxicity is potentially increased in situations where there is stimulation of the renin-angiotensin system such as with volume depletion or in pre-existing chronic renal disease. We describe four cases which illustrate this complication occurring in a children's hospital. We have not proven cause and effect, but further research is needed to define the true risk of the potential renal complications of NSAID in patients at risk of dehydration.     

Acute renal failure after exercise in a child with renal hypouricemia

We describe a 15 year old boy with renal hypouricemia who developed acute renal failure after a school athletics meeting, accompanied by appendicitis. During acute renal failure, the highest level of uric acid was 5.0 mg/dL, creatinine 7.9 mg/dL and urea nitrogen 58.6 mg/dL. After recovery, the serum uric acid fell to 0.9 mg/dL and the fractional excretion of uric acid (FEu_A) exceeded the normal range. The probenecid and pyrazinamide tests showed that the patient had a total defect of uric acid reabsorption. This case suggested that strenuous exercise could be responsible for acute renal failure in patients with renal hypouricemia.     

Rapid national survey of renal stones in New Zealand infants

Aim:   The aim of this study was to determine if there have been recent serious renal problems because of melamine among infants in New Zealand.
Methods:   New Zealand paediatricians were surveyed in October 2008 using the New Zealand Paediatric Surveillance Unit network.
Results:   Two cases of renal stones and none of unexplained renal failure in the previous 12 months were reported. Both cases of renal stones had an identifiable cause, and neither had features of melamine-related stones.
Conclusion:   This survey confirmed the expectation that this was not a discernible problem of recent serious melamine-associated renal damage in New Zealand. The method did however prove to be an effective way of undertaking a rapid determination of a possible recent serious health problem among children.     

Successful high-dose methotrexate chemotherapy in a patient with acute lymphocytic leukemia who developed acute renal failure during the initial treatment

Methotrexate (MTX) is a key drug in the chemotherapy for childhood acute lymphocytic leukemia (ALL). It is essential in the treatment of such areas as the central nervous system (CNS) and reproductive organs. High-dose chemotherapy is applied for this purpose to obtain an effective plasma concentration in the target organs.There are three major mechanisms of nephrotoxicity related with MTX. One is that induced by allergic reaction, which usually appears as interstitial nephritis. In this case MTX is contraindicated. Another is direct pharmacological toxicity against renal tubules. The third is precipitation of MTX, which plugs the renal tubules. The latter two are consequently dose dependent, and are usually associated with high-dose chemotherapy. To prevent these nephrotoxicities, hydration and alkalinization of the urine are performed to accelerate the urinary excretion and avoid the precipitation of MTX.     

Bilateral wilms tumor presenting with acute renal failure and clinical findings mimicking cardiac failure

A six-year-old girl presented with clinical signs and symptoms of right-sided heart failure. Cardiac catheterization demonstrated filling defects in both pulmonary arteries felt to represent metastatic lesions or thromboemboli. Intravenous pyelogram revealed bilateral renal masses and intrarenal obstruction. Acute renal failure was unresponsive to standard therapy. An open renal biopsy revealed Wilms tumor with favorable histology. Aggressive chemotherapy and irradiation were undertaken and renal function returned. This case adds to the heterogeneity of presentations described for Wilms tumor, and review of the literature reveals no other cases with similar presenting signs.     

婴儿食用三聚氰胺污染奶粉致急性肾后性肾功能衰竭的治疗

目的 探讨因食用三聚氰胺污染奶粉致急性肾后性肾功能衰竭婴儿的外科急诊处理方法 与疗效.方法 应用半硬性输尿管镜(F6.8)逆行输尿管插管冲洗术11例,开放输尿管切开取石术2例.结果 本组除1例开放输尿管切开取石术后5h患儿又出现无尿且血红蛋白持续下降,再次行切口探查和腹膜透析外,其余12例均顺利恢复.本组13例肾功能均恢复正常,无手术并发症.结论 对婴儿因食用三聚氰胺污染奶粉致上尿路结石引起的急性肾后性肾功能衰竭,在输尿管镜下逆行捕管置入输尿管导管冲洗术是一种微创、安全而又有效的治疗方法 ;对婴儿尿道狭小输尿管镜不能进入者,开放输尿管切开取石术也是一种有效的方法 ,但对有明显出血倾向者需先纠正出血倾向后再考虑开放手术解除梗阻.