Acute renal failure in children: prognostic features after treatment with acute dialysis

A 12-year review (1972–1983) is presented of 76 children who were dialysed because of acute renal failure. The causes of acute renal failure were mainly the haemolyticuraemic syndrome (53%), trauma (16%) and operation (13%).Fifty-eight children (76%) survived, 18 children (24%) died. Fifty-two children, the majority suffering from haemolytic-uraemic syndrome, regained complete or partial renal function after a period of dialysis lasting between 1 and 57 days. One to 7.7 years after dialysis, clearance studies with inulin (C_In), p-aminohippuric acid (C_PAH) and phosphate (T_p/C_In) for staging renal function were carried out. The results of this investigation show a significant inverse correlation between the glomerular function regained and the duration of intermittent dialysis.Abbreviations C_In clearance of inulin - C_PAH clearance of p-aminohippuric acid - FF filtration fraction - T_p/C_In fractional phosphate reabsorption - HUS haemolytic-uraemic syndrome - ARF acute renal failure - SCR serum creatinine - GFR glomerular filtration rate - CRF chronic renal failure - a.t. antihypertensive treatment     

Acute renal failure in Congolese children: a tertiary institution experience

Aim: Published data on acute renal failure in children from the Democratic Republic of Congo are rare. The objective of this study was to review clinical manifestations, aetiologies and outcome in hospitalized children with acute renal failure. Methods: A retrospective study at Pediatric Nephrology Unit of University Hospital of Kinshasa was carried out. Results: Fifty‐six children with acute renal failure were eligible. There were 31 boys (55.4%) and 25 girls (44.6%) with a sex ratio of 1.24. The median age was 6.7 years (range 1–13 years). Fever (80.3%), oligo‐anuria (73.2%), jaundice (67.9%) were the common clinical presentation. Blackwater fever (42.8%) was the leading cause of Acute Renal Failure. The incidence of severe dehydration because of gastroenteritis was low (5.3%). Around 12.5% of patients’ misused herbal plants. Acute Peritoneal Dialysis was indicated in 15/56 children and only performed in four patients. Fourteen children (25%) died. Conclusion: A wide spectrum of features was seen in hospitalized Acute Renal Failure children and limited access to Acute Peritoneal Dialysis remained an important mortality risk factor.     

Acute renal failure following wasp sting in children

The medical records of patients admitted between 1985 and 2007 with wasp stings were retrospectively analyzed. Among the 45 children, seven developed acute renal failure. Classical clinical and laboratory data pointed to hemolysis and rhabdomyolysis as the underlying pathophysiology. All patients had hyponatremia and hyperkalemia as well as metabolic acidosis. Six patients had anemia. Five patients were oliguric for 9 to 15 days. Maximum serum creatinine was 4.0 to 11.9 mg/dl. Peritoneal dialysis was performed for 3 to 15 days. One patient died due to hyperkalemia, the remaining ones recovered completely. This paper wants to remind pediatricians to watch for acute renal failure in children with wasp stings.     

Assessment of cardiac and renal function in children immediately after open-heart surgery: The significance of a reduced radionuclide ejection fraction (postoperative ejection fraction)

Summary Ventricular ejection fractions, calculated from radionuclide studies, and inulin clearance, were determined in 33 infants and children immediately after surgical repair of their congenital or rheumatic heart defects. Of these children, the seven whose surgery did not require a period of ischemic arrest served as controls. The immediate postoperative ejection fractions in the 26 children who did undergo a period of ischemic arrest were significantly less than their preoperative values (P≥0.001), but this decline was not observed in the control group. Ejection fraction tended to be depressed, transiently, in children 3–5 h after open-heart surgery. Early postoperative ejection fraction was significantly related to aortic cross-clamp time even when controlling for preoperative ejection fraction (r=0.74,n=25,P≤0.001). Some striking declines in ejection fraction were observed among children whose aortic cross-clamp time exceeded 42 min. The decline in ejection fraction was transient; late postoperative (>1 week) ejection fraction was not significantly different from preoperative values. Though glomerular filtration rates (GFRs) were often above normal, they were significantly correlated with ejection fraction (r=0.74,n=19,P≤0.01). The lower GFRs were associated with the lower early postoperative ejection fractions.     

Acute renal failure complicating diabetic ketoacidosis

Two previously healthy children, aged 13 and 14 years, respectively, presented with diabetic ketoacidosis. Both children developed acute renal failure, a rare complication of diabetic ketoacidosis and required dialysis.     

Acute renal failure in neonates

Acute renal failure (ARF) is a common condition seen in neonatal intensive care units. It is broadly classified into prerenal, intrinsic renal and post renal failure. There is no consensus on the definition of neonatal ARF. Of utmost importance is to differentiate prerenal from intrinsic renal failure. The most common causes of neonatal ARF are hypovolemia, hypotension and, hypoxia. Among several indices that are available for differentiating prerenal failure from intrinsic renal failure, fractional excretion of sodium is the preferred index. Diagnostic fluid challenge with or without frusemide is a bed side method for differentiating prerenal failure from intrinsic renal failure. Babies with ARF have to be monitored for several metabolic derangements like hyponatremia, hyperkalemia, hypocalcemia, and acidosis and have to be managed accordingly. Fluid balance should be precise in order to avoid fluid overload. It is difficult to provide adequate calories due to fluid restriction. Dialysis has to be instituted to preempt complications. Peritoneal dialysis is the easiest and safest modality. These babies need long term follow up as they are prone for long term complications.     

Acute pyelonephritis with renal abscesses and acute renal failure after salmonella infection

Urinary tract infections, renal abscess formation and acute renal failure (ARF) after salmonella infection are rarely reported in children. We present a previously healthy teenager who developed ARF with renal abscess formation after salmonella infection, in whom we believe that acute salmonella pyelonephritis was the main causative factor for ARF and not dehydration, shock or rhabdomyolysis, which have already been described in the literature. With prolonged antibiotic treatment and adequate hydration, the boy’s condition improved, but chronic kidney disease was unfortunately inevitable. Conclusion: Salmonella pyelonephritis has, according to our knowledge, not yet been described to be the main causative factor of ARF in previously healthy children, as was the case in our patient. Long‐term antibiotic treatment of at least 6 weeks is probably a must in such patients, even though chronic kidney disease could not have been prevented.     

小儿急性肝功能衰竭定义和常见病因

小儿急性肝功能衰竭是危及生命的临床综合征,其定义和适用范围与成人有较大差别.发病主要与病毒感染、先天和遗传代谢性疾病、药物中毒等相关,但具体病因在婴儿和年长儿有明显不同.本文仅就小儿急性肝功能衰竭的定义和常见病因研究进展进行综述.     

Fetal liver-cell transplantation for surgically-induced acute hepatic failure in rats

Pediatric liver transplantation has become increasingly successful, but donor scarcity is a major limitation. We studied fetal liver-cell transplantation as an alternative to provide functional hepatic replacement and evaluated the efficacy of the intraperitoneal (i.p.) transplantation of fetal liver cells in the treatment of acute hepatic failure in rats. Outbred Wistar rat fetuses (18–20 days' gestation) were used as donors. In Wistar male rats (250–300 g), acute hepatic failure was achieved by simultaneous portacaval shunt and 70% hepatectomy. This model produced lethal hepatic failure in a highly reproducible manner. Fetal liver cells were isolated by the mechanical method. Group A consisted of 2×10⁷ fetal liver cells suspended in 1 ml phosphate-buffered saline (PBS) while group B consisted of only 1 ml PBS. Both were injected i.p. just after surgery. Fetal liver-cell transplantation (group A) significantly improved survival. The degree of hypoglycemia was significantly less significant 1 day after surgery in group A and the levels of plasma insulin and glucagon 3 days after surgery were significantly lower in group A than in group B. The results indicate that i.p. transplantation of fetal liver cells can provide metabolic support in rats. Correspondence to: Y. Hata     

Liver dysfunction and acute cardiocirculatory failure in children

We report 15 children who developed transient liver dysfunction related to hepatic ischaemia. All patients had cardiocirculatory failure 24 h before the onset of liver injury (day 1). Peak serum values of transaminases occurred between day 1 and day 3: SGOT (mean: 759 IU/l, range: 150–4400); SGPT (418 IU/l, 95–2547). Transaminase values decreased rapidly and normalised from day 6 to day 10. Minimum values of prothrombin test (PT) occurred on day 1 (31%, 10–70) and 13/15 patients had a PT<50% (27%, 10–44). PT values normalized from day 3 to day 10. Hypoglycaemia was present in 8/15 patients on day 1. Liver dysfunction improved after correction of the circulatory failure. These results confirm that transient hepatic dysfunction, probably as a consequence of hepatic hypoperfusion, may occur frequently in children after acute circulatory failure. We conclude that the diagnosis of ischaemic liver injury or shock liver syndrome in children can be made on clinical and biochemical criteria, and that liver biopsy is unnecessary.     

��ͯ�����Ը�˥�ߵĸ���ֲ����

??Fulminant hepatic failure is dangerous and often fatal disorder with high mortality. Pediatric fulminant hepatic failure causeing by different etiology should be ready to do liver transplantation with assessment as soon as possible??if conservative treatment can't stop progress. At present?? the technology of liver transplantation has been developed maturely. Both Living donor liver transplantation and Cadaver liver transplantation can obtain good prognosis. More importantly?? it’s critical to take time to save children’s life.     

Acute lymphoblastic leukemia presenting in fulminant hepatic failure

A previously healthy 4-year-old boy was admitted because of acute liver failure. He was icteric, lethargic, had elevated ammonia and abnormal liver function tests. Serology was negative for viral hepatitis. There was no history of hepatotoxic drugs. Family history was unremarkable. The child was taken to the operating room for a living-related hepatic transplant. Frozen section showed massive hepatic leukemic infiltration and hepatocellular necrosis. Bone marrow aspiration confirmed the diagnosis of acute lymphoblastic leukemia (ALL). Transplant was withheld and chemotherapy was attempted. He died the following day due to systemic leukemic infiltration, cerebral edema, and severe anoxic ischemic encephalopathy.     

Acute renal failure after treatment with non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are known to have adverse effects on kidney function. Situations with a stimulated renin-angiotensin system such as volume depletion or pre-existing chronic renal failure predispose to acute renal failure (ARF) via inhibition of prostaglandin synthesis by NSAIDs. To date, NSAIDs are frequently used as antipyretic drugs even in situations predisposing to ARF. Within 20 months, seven children presenting with diarrhoea and/or vomiting and fever were treated with therapeutic doses (11.5–32 mg/kg per day) of ibuprofen for 1 to 3 days before developing ARF. Maximum plasma creatinine levels were 180–650 µmol/l. One patient required emergency dialysis for hyperkalaemia, uraemia, and hyperphosphataemia. After cessation of NSAID treatment and rehydration, all patients recovered completely with a normalised creatinine level after 3 to 9 days. Once the acute phase is controlled, long-term outcome is excellent. Interstitial nephritis, another possible adverse effect of NSAIDs, might require steroid treatment and is the major differential diagnosis. Only histological examination can confirm the exact pathomechanism of ARF after NSAID exposure. If immunological events are responsible for the ARF, the recovery period is usually longer. Conclusion: non-steroidal anti-inflammatory drugs are potentially dangerous in situations with even moderate volume depletion.Abbreviations AIN acute interstitial nephritis - ARF acute renal failure - COX cyclo-oxigenase - NSAIDs non-steroidal anti-inflammatory drugs - PG prostaglandin - RAS renin-angiotensin system     

Hemodynamic effects of peritoneal dialysis in three children following open heart surgery

Summary We studied the hemodynamic responses of peritoneal dialysis (PD) in three children following open heart surgery. Hemodynamic measurements were made prior to a dialysis run, following the instillation of dialysis solution (20 ml/kg), and immediately prior to and 5 min after drainage of the peritoneal cavity. The same protocol was repeated 48 h later. There was a significant increase in right atrial pressure (RAP) and mean pulmonary artery pressure upon instillation of the dialysate into the peritoneal cavity (p<0.01). However, cardiac index, mean arterial blood pressure (MAP), systemic (SVRI) and pulmonary vascular resistances (PVRI), left atrial pressure (LAP), and oxygen saturation did not change significantly. There were no significant differences between responses in the initial study and that performed 48 h later. PD is associated with modest right-sided hemodynamic changes which, in this small group of patients, did not compromise patient care.     

Mid-term follow-up after multiple system organ failure following cardiac surgery in children

Multiple system organ failure after cardiac surgery in children is a severe complication with unknown mid- and long-term sequelae. We therefore evaluated 11 children (aged 20-126 mo, median: 67 mo) having survived multiple system organ failure after cardiac operations for congenital cardiac defects in a cross-sectional follow-up study 12-76 mo (median: 32 mo) after surgery. Clinical and laboratory examinations included cardiac, pulmonary, renal, hepatic, neurological and psychological function tests. All patients had adequate cardiac function. Lung mechanics were abnormal in three children and glomerular renal function was abnormal in two patients. Slight elevation of gamma-glutamyl transpeptidase and coagulation factor deficiency was present in six and seven patients, respectively (five of whom had undergone the Fontan operation). Severe neurological sequelae such as diplegia (n = 1) and mental retardation (n = 1) were observed in two patients. In addition, five children presented delayed motor, graphomotor and/or speech development. Two children were found to have abnormal intelligence. We conclude that with the exception of neurological impairment, mid-term sequelae of multiple system organ failure after cardiac surgery in children are mild. However, longer follow-up using an appropriate control group is mandatory.     

Acute renal failure complicating pediatric cardiac surgery: A comparison of survivors and nonsurvivors following acute peritoneal dialysis

Summary The outlook for patients with cardiac surgery complicated by acute renal failure (ARF) is poor, with a reported mortality of 50–67%. In addition to assessing the impact of recent advances in pediatric cardiac surgery on the mortality rate and renal outcome of surgery complicated by ARF requiring peritoneal dialysis (PD), this study compares preoperative, operative, and postoperative variables in patients who survived surgery and those who did not survive. From 1982 through 1988, 44 postoperative cardiac patients developed ARF, and 40 (age: 2 days to 15 years) required PD. Seventeen of 40 patients survived (mortality 57.5%) and 16 of these patients recovered normal renal function. Preoperative variables, including operative age and weight, did not appear to directly influence survival. Operative profiles, including length of cardiopulmonary bypass, aortic cross-clamp time, and hypotension immediately off bypass, did not distinguish surviving patients from those that did not survive. Postoperative variables, such as postoperative hypotension treatment, arrhythmias, hematologic status, cardiac arrest with resuscitation, did not differentiate survivors from nonsurvivors. The mean duration of PD was less than 2 weeks, and compications were infrequent. Renal status following PD in survivors was usually normal.We conclude that recent advances in pediatric cardiac surgery have not further increased the high mortality of surgery complicated by ARF. Survival is associated with renal recovery and thus aggressive treatment using PD is warranted.     

Fulminant hepatic failure in childhood

Fulminant hepatic failure (FHF) is not an uncommon entity in pediatric age group. Although the exact incidence is difficult to assess, in our series, 25 per cent of children presenting with altered sensorium were due to FHF. The age incidence was between 4 weeks and 10 years. The overall mortality was 60 per cent. The clinical, biochemical, histopathological and prognostic features of FHF are presented in this paper. The study highlights the need for a high index of suspicion to recognise this entity when the presenting features simulate those of a central nervous system infection or Reye’s syndrome. FHF can exist with abnormal liver function tests but with a morphologically normal liver suggesting that it could be a functional syndrome.     

26例儿童横纹肌溶解综合征致急性肾衰竭临床分析

目的探讨儿童横纹肌溶解综合征(RM)致急性肾衰竭(ARF)的临床特点及预后。方法对77例RM患儿中合并ARF的26例患儿的临床资料、实验室检查、治疗转归进行分析。结果合并ARF的26例RM患儿病因均为非创伤性疾病,感染(69%)、糖尿病(12%)、代谢性疾病(8%)是前3位病因。合并ARF的RM患儿出现频率前5位的临床表现包括发热(69%)、多脏器功能障碍(69%)、抽搐(46%)、少尿或无尿(35%)、茶色尿(27%)。26例合并ARF的RM患儿血肌酸激酶(CK)均1 000 IU/L,伴AST升高的26例,ALT升高的25例,CK-MB升高的25例,LDH升高23例。合并ARF的RM患儿中22例检测了血肌红蛋(Mb),均有增高。合并ARF的26例RM患儿CK降至1 000 IU/L以下的平均时间为10±5 d。常规治疗基础上接受持续静脉-静脉血液滤过治疗的10例患儿的CK恢复时间与非血液净化治疗者的差异无统计学意义(P0.05)。合并ARF的26例RM患儿中7例放弃治疗,19例肾功能均恢复正常。结论急性肾衰竭及多脏器功能障碍是儿童RM的主要并发症,合并ARF的RM患儿原发病主要是感染性疾病,CK是诊断RM的主要指标。早期诊断、合理治疗可使ARF逆转,改善预后。     

��ͯ�����Ը�˥���˹�������

??The true incidence of fulminant hepatic failure in the pediatric population is unknown?? though fulminant hepatic failure is a rare but devastating syndrome??such as hepatic encephalopathy??DIC??MODS?? that results in the death of most children affected. The mainstay of the treatment is liver transplantation??however?? organ shortage limits its use.The purpose of this review is to introduce the current situation of fulminant liver failure in children??focusing on assessing the application of artificial liver??which is considered to play a pivotal role in the treatment of fulminant liver failure.According to its classification??we mainly discussed the application of non-biological artificial liver?? including its indications??advantages and disadvantages??especially the MARS. At present?? the artificial liver treatment also faces many problems. None of the ELS techniques has yet been evaluated systematically in children??and survival benefits have not yet been demonstrated.     

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.