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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2006  |  Volume : 17  |  Issue : 2  |  Page : 153-158
Acute Renal Failure in Children: Etiology, Treatment and Outcome


Children & Young People's Kidney Unit, Nottingham City Hospital, NHS Trust, Hucknall Road, Nottingham NG5 1PB, United Kingdom

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   Abstract 

Children with acute renal failure (ARF) may be treated in pediatric renal or intensive care (PICU) units where there is an increasing use of continuous renal replacement therapies such as hemofiltration (HF). Over three years, we prospectively recorded details of all patients with ARF treated both within our regional pediatric renal unit, in two local neonatal intensive care units (NICUs), and one PICU, which are all supported by our institution. Our study included eighty-three ARF patients (43% male) with a median age of 5.7 years (range 1 day - 19.8 years); 41% of patients were < 2 years, 20% 2-5 years, 13% 5-10 years and 26% > 10 years of age. A total of 37 patients (45%) were treated in the renal unit versus 46 (55%) patients in NICU/PICU. The initial treatment modality was conservative in 33%, peritoneal dialysis (PD) in 23%, hemodialysis (HD) in 15%, HF in 28%, and isolated plasmafiltration in one percent of the patients. About 16% of the patients required more than one treatment modality. Outcome data at three months showed normal renal function in 49%, deaths in 20%, dialysis dependent disease in 14%, chronic renal failure (GFR < 60ml/min/1.73m 2 ) in eight percent, and proteinuria and/or hypertension in seven percent of the patients. Only one (3%) death occurred in 37 patients treated in the renal unit compared to 16 deaths in 46 patients (35%) treated in the NICU/PICU. Our findings further confirm the low mortality rate with isolated renal failure and the substantial mortality and renal workload in intensive care areas where renal failure is often part of multi­organ failure. Further prospective studies will be required to analyze the impact of early hemofiltration in such patients.

Keywords: Acute renal failure, Continuous renal replacement therapy, Hemofiltration, Intensive care, Dialysis.

How to cite this article:
Shaheen lS, Watson AR, Harvey B. Acute Renal Failure in Children: Etiology, Treatment and Outcome. Saudi J Kidney Dis Transpl 2006;17:153-8

How to cite this URL:
Shaheen lS, Watson AR, Harvey B. Acute Renal Failure in Children: Etiology, Treatment and Outcome. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2020 Jun 5];17:153-8. Available from: http://www.sjkdt.org/text.asp?2006/17/2/153/35783

   Introduction Top


Acute renal failure (ARF) is a relatively uncommon condition in pediatric practice. [1],[2],[3] However, the exact incidence is difficult to define as it depends upon the referral patterns of the reporting pediatric renal unit and the proximity to, and expertise within, the related intensive care units (ICUs). [4],[5] Although peritoneal dialysis (PD) has been frequently used as the dialysis treatment of choice in young children [6],[7] there have been increasing reports of the use of other continuous renal replacement techniques such as continuous veno-venous hemofiltration (CVVH) being employed in the intensive care setting. [4],[8] Recent guidelines have emphasized the need for collaboration between intensive care and nephrology units.[9] Additionally, since the incidence of ARF is low in childhood, training issues arise with nursing staff using dialysis techniques infrequently. [10],[11]

We reviewed the etiology, treatment moda­lities, and outcomes for children being treated for ARF in the past three years, treated both within the regional pediatric nephrology unit, two local neonatal intensive care units (NICU), and one pediatric intensive care unit (PICU).


   Patients and Methods Top


A database of patients with ARF is main­tained prospectively in our unit for the purposes of annual survey by the clinical effectiveness department. Acute renal failure was recognized when renal excretory function declined rapidly, usually accompanied by oliguria. However, there are no strict biochemical guidelines at which renal replacement therapy is initiated and referrals are accepted after discussion with the on call consultant on an individual case basis. [9]

Between January 2000 and December 2002, a total of 83 patients were recorded with details including age, weight, diagnosis, and treatment modality. Outcome at three months was recorded as death, dialysis dependent, chronic renal failure [estimated glomerular filtration rate (GFR) < 60ml/min/ 1.73m 2 ], proteinuria (early morning protein: creatinine ratio > 20mg/mmol), and/or hypertension, and normal (blood pressure within the normal range with normal predicted GFR, no proteinuria or hypertension).[12]

We further sub-divided the patients into those that were treated in the renal unit (admitted to the nephro-urology ward or to a high depend­ency area; Group 1) versus those in whom renal support was required initially on either the two NICUs or sub-regional PICU; (Group 2).

The renal unit serves a population of approxi­mately 5.5 million for "renal only" renal failure patients with the local PICU having 400-450 admissions. It is not a referral centre for primary cardiac or liver problems. The two NICUs serve a birth population of approximately 10,000 per annum and would also care for outside referrals to the nephrology team where renal support was required.


   Results Top


Over the three years, 83 patients (43% male) with a median age of 5.7 years (range 1 day to 19.8 years) were managed. A total of 41% of patients were < 2 years, 20% were 2 to 5 years, 13.5% were 5 to 10 years and 26% were over 10 years at the time of treatment. Thirty­seven of the patients (45%) were treated in the renal unit (group 1). The etiology of ARF is shown in [Table - 1], which also demonstrates the different etiologies for the 46 (55%) patients in group 2 who were treated in the PICU or NICU.


   Treatment Modality Top


The initial treatment was conservative manage­ment (fluid and electrolyte monitoring, blood pressure control and nutritional advice) in 33% with hemofiltration (HF) being employed in 27%, peritoneal dialysis (PD) in 22% and hemodialysis (HD) in 15% of the patients. One patient received plasmafiltration (PF) for carbamazepine overdosage.

The treatment modalities employed in those patients treated in the renal unit compared with those treated in the PICU are shown in [Figure - 1]. This illustrates the predominant use of HF in the form of CVVH in the intensive care setting where HD is not available. This latter technique is more commonly employed in the renal unit, as it requires appropriately trained staff with an appropriate water supply. [9]


   Outcome Top


A total of 66 of the 83 patients (80%) survived with only one death occurring in the renal unit patients from hemolytic uremic syndrome (HUS) compared to 16 deaths in the PICU/NICU patients where the main cause was overwhelming sepsis. At three months, 53% of the 36 survivors in group 1 had normal renal function compared to 22 of 30 in group 2 (73%) [Figure - 2]. Of the 23 patients who received HF, 13 (57%) survived compared to 18 of 20 (90%) treated with PD and 11 of 12 (92%) on HD.


   Combination Treatment Top


Three patients in group 1 required a combination of treatments. One patient with HUS was changed from PD to HD due to technical problems in the PD catheter. The other two patients had glomerulonephritis (crescentic and autoimmune) and required HD followed by HF to maintain fluid balance status. The patient with ANCA positive auto­immune glomerulonephritis required PF as part of her initial immunosuppressive therapy, HF to control fluid overload, and HD when her renal function declined significantly.

Ten patients in group 2 required more than one modality of treatment; five had PF followed by HF due to severe sepsis while the other three septic patients required HF and HD. Of the remaining two patients in group 2, one had hypoxic ischemic encephalopathy and was changed from PD to HF because of catheter problems. The other had tumor lysis syndrome and was changed from HF to HD.


   Discussion Top


This three year survery illustrates the fact that the majority of ARF patients are now receiving treatment in the intensive care areas compared to 'renal only' renal failure which is managed predominantly in the renal unit. This raises questions of communication and shared care policies between the PICU and pediatric nephrology staff, especially in situations similar to that described previously, where one of the two neonatal units and PICU are located in different hospitals. The workload generated by frequent liaison and visits can be considerable. The study also demonstrates that the frequent use of more than one treatment modality obviates the need for properly trained clinical staff.

The choice of renal replacement therapy is dependent upon a number of patient factors as well as the technical expertise available. [9] PD appears to be losing ground to extracorpo­real techniques in recent years although it is still a reliable method of management in the neonatal age group especially when the clinical situation allows.[7]

The increasing use of CVVH also necessitated the development of an education and support program for the PICU nurses who had little experience and confidence in extracorporeal circuits. This was addressed by the local appointment of a Renal Critical Care Educator to liaise not only with the local PICU, but also the two other PICUs within our region.[11],[13]

Our overall mortality rate of 20% is lower than quoted figures of 35-73% in recent studies. [3],[6],[12],[14] However, the variation can be accounted for by the differences in etiology of the patients included in these studies. Our study emphasizes the fact that the mortality rate of 'renal only' ARF is very low. Hemolytic uremic syndrome accounts for the majority of patients in this category and the one fatality was due to cerebral hemorrhage in association with HUS. In a series of 114 patients with HUS reported from our unit from 1986 - 1996 the mortality rate was <2%. [12]

Patient survival rates in critically ill children with ARF receiving renal replacement therapy range from 52% to 58%. [3],[6][,15],[16] A recent review noted survival rates were lower when HF is employed (34-42%) compared to PD (49-64%) or HD (73-89%). [16] Comparable survival rates in our study with the patient sample described are 57% with CVVH, 90% with PD, and 92% with HD.

Children appear to develop severe and life­threatening multi-organ failure very early on in their ICU course.[17] However, critical illness scores at the time of PICU admission or time of CVVH initiation correlate poorly

with patient outcomes. [18],[19] Since many patients with multi organ failure have underlying sepsis, there has been an increasing interest in both plasmafiltration (PF) and early HF. Although there is some evidence that PF improves outcome in sepsis in adults, there is still a paucity of randomized trials. The available studies show an absence of benefit for HF and conclude that further studies are needed for PF. [20],[21],[22] Hence, the need for initiatives such as the recently formed US Prospective Pediatric Continuous Renal Replacement Therapy Registry Group.

 
   References Top

1.Moghal NE, Brocklebank JT, Meadow SR. A review of acute renal failure in children: incidence, etiology and outcome. Clin Nephrol 1988;49:91-5.  Back to cited text no. 1    
2.Fitzpatrick MM, Kerr SA, Bradbury MG. Acute renal failure. In: Webb N, Postlethwaite R (eds). Clinical Paediatric Nephrology (3rd ed) Oxford University Press, Oxford, 2003; pp 405-25.  Back to cited text no. 2    
3.Williams DM, Sreedhar SS, Mickell JJ, Chan JC. Acute kidney failure: a pediatric experience over 20 years. Arch Pediatr Adolesc Med 2002;156:893-900.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Pediatr Nephrol 2000;15:11-3.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Pediatr Nephrol 2002;17:61-9.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Gallego N, Peres-Caballero C, Gallego A, Estepa R, Liano F, Ortuno J. Prognosis of patients with acute renal failure without cardiopathy. Arch Dis Child 2001;84:258-60.  Back to cited text no. 6    
7.Wong W, McCall E, Anderson B, Segedin E, Morris M. Acute renal failure in the paediatric intensive care unit. N Z Med J 1996;109:459-61.  Back to cited text no. 7  [PUBMED]  
8.Parekh RS, Bunchmann TE. Dialysis support in the pediatric intensive care unit. Adv Ren Replace Ther 1996;3:326-36.  Back to cited text no. 8    
9.Strazdins V, Watson AR, Harvey B. European Pediatric Peritoneal Dialysis Working Group. Renal replacement therapy for acute renal failure in children: European guidelines. Pediatr Nephrol 2004:19:199-207.  Back to cited text no. 9    
10.Baldwin I, Elderkin T, Bridge N. Nursing management concepts for CRRT in the child. In: Bellomo R, Baldwin I, Ronco C, Golpe T (eds) Atlas of hemofiltration. WB Saunders, London 2002;17:83-95.  Back to cited text no. 10    
11.Harvey B, Watson AR, Jepson S. A renal critical care educator: the interface between paediatric intensive care and nephrology. Intensive Crit Care Nurs 2002;18(4):250-4.  Back to cited text no. 11    
12.Small G, Watson AR, Evans JH, Gallagher J. Hemolytic uremic syndrome: defining the need for long-term follow-up. Clin Nephrol 1999;52:352-6.  Back to cited text no. 12  [PUBMED]  
13.Harvey B, Watson AR. Support for renal replacement therapy in the paediatric intensive care unit. Br J Renal Med 2004;9(1):12-4.  Back to cited text no. 13    
14.Kandoth PW, Agarwal GJ, Dharnidha VR. Acute renal failure in children requiring dialysis therapy. Indian Pediatr 1994; 31:305-9.  Back to cited text no. 14    
15.Bunchman TE, McBryde KD, Mottes TE, Gardner JJ, Maxvold NJ, Brophy PD. Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol 2001;16:1067-71.  Back to cited text no. 15  [PUBMED]  [FULLTEXT]
16.Goldstein SL. Overview of pediatric renal replacement therapy in acute renal failure. Artif Organs 2003;27:781-5.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Proulx F, Gauthier M, Nadeau D, Lacroix J, Farrell CA. Timing and predictors of death in pediatric patients with multiple organ system failure. Crit Care Med 1994;22:1025-31.  Back to cited text no. 17  [PUBMED]  
18.Fargason CA, Langman CB. Limitations of the pediatric risk of mortality score in assessing children with acute renal failure. Pediatr Nephrol 1993;7:703-7.  Back to cited text no. 18  [PUBMED]  
19.Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R. Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 2001;107:1309-12.  Back to cited text no. 19    
20.Busund R, Koukline V, Utrobin U, Nedashkovsky E. Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial. Intensive Care Med 2002;28(10):1434-9.  Back to cited text no. 20    
21.Stegmayr BG. Apheresis as therapy for patients with severe sepsis and multiorgan dysfunction syndrome. Ther Apher 2001; 5:123-7.  Back to cited text no. 21  [PUBMED]  [FULLTEXT]
22.McMaster P, Shann F. The use of extracorporeal techniques to remove humoral factors in sepsis. Paed Crit Care Med 2003;4:2-7.  Back to cited text no. 22    

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Correspondence Address:
Alan R Watson
Children & Young People's Kidney Unit, Nottingham City Hospital, NHS Trust, Hucknall Road, Nottingham NG5 1PB
United Kingdom
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