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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA-AFRICA  
Year : 2013  |  Volume : 24  |  Issue : 2  |  Page : 413-417
Acute renal failure in children in a tertiary care center


Department of Pediatrics, Maulana Azad Medical College and Associated Hospitals, University of Delhi, Delhi, India

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Date of Web Publication26-Mar-2013
 

   Abstract 

In this retrospective study, records of all patients aged one month to 12 years who presented with acute renal failure (ARF) between May 2005 and August 2010 were retrieved. Clinical details, biochemistry, need for renal replacement therapy (RRT), cause of ARF and outcome at discharge were recorded. During this period, 230 children presented with ARF; their median age at presentation was 30 months (range: five-144 months); 120 (52.2%) were males. The causes of ARF were acute tubular necrosis (ATN) in 121 (52.6%), glomerular disorders in 5.7%, structural anomalies of the urinary tract in 9.6% and hemolytic uremic syndrome in 27 (11.7%). The mean duration of hospital stay was 17.8 ± 7.6 days. RRT was required for 54 patients (23.6%); peritoneal dialysis in 49 and hemodialysis in five patients. Complete recovery was noted in 99 study patients (43.2%) and sequelae remained in 84 patients (36.7%). Forty-six patients (20.1%) with ARF died. ATN secondary to septicemia was the most common cause of ARF in our study.

How to cite this article:
Bhattacharya M, Dhingra D, Mantan M, Upare S, Sethi GR. Acute renal failure in children in a tertiary care center. Saudi J Kidney Dis Transpl 2013;24:413-7

How to cite this URL:
Bhattacharya M, Dhingra D, Mantan M, Upare S, Sethi GR. Acute renal failure in children in a tertiary care center. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2019 Nov 14];24:413-7. Available from: http://www.sjkdt.org/text.asp?2013/24/2/413/109620

   Introduction Top


Acute renal failure (ARF) is characterized by a rapid deterioration of renal function resulting in retention of nitrogenous wastes and other fluid and electrolyte derangements, which are usually reversible. [1] In the absence of a universally accepted definition, and in recognition that ARF actually includes a spectrum of clinical conditions, the term acute kidney injury (AKI) has recently been proposed for the entire spectrum of the syndrome. More recently, a classification of AKI has been proposed based on the serum creatinine and urine output [2] [Table 1]. The incidence of ARF in neonatal and pediatric units varies between 10 and 25%, depending on the criteria used for its definition. [3],[4] The etiology of ARF may be pre-renal, intrinsic renal or post-renal and has changed over the past decades from primary renal diseases to multi-factorial causes. Despite advances in therapy, mortality due to the condition is still high (30-40%) and a proportion of patients may progress to chronic kidney disease and dialysis dependency. [1] The present study was undertaken to identify the causes and short-term outcome of ARF in a pediatric tertiary care center located in Northern India.
Table 1: RIFLE staging of acute kidney injury/AKIN*.

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   Methods Top


This retrospective study was conducted in the pediatrics department of a tertiary care hospital. The study was approved by the institute's ethics committee. Records of all children aged one month to 12 years, diagnosed with ARF during the period of May 2005 to August 2010, were retrieved. ARF was diagnosed on the basis of acute worsening of renal function as evidenced by rising blood creatinine with or without decreased urinary output.

Neonatal and post-operative ARF were excluded as patients with these conditions were not admitted to the pediatric wards. Patients with dehydration, oliguria and deranged kidney function that corrected promptly on rehydration were also excluded.

Details of clinical features, etiology, biochemical parameters, treatment including the need for renal replacement therapy (RRT), duration of hospital stay and outcome were noted from the retrieved records. Presence of anemia, hypertension, edema, encephalopathy and seizures was recorded. The biochemical parameters noted were blood urea, serum creatinine, electrolytes, venous blood gas and bicarbonate levels. The causes of ARF were assigned using standard definitions and only the primary cause of ARF was included. Short-term outcome was defined as the condition at discharge. Data were analyzed using descriptive statistics of the excel program.


   Results Top


Clinical profile

The study included 230 children with ARF, either at admission or acquired during stay in the hospital. ARF was diagnosed based on pRIFLE criteria [Table 1]. [2] The median age of the study population was 30 months (5-144) and 120 patients (52.2%) were boys. Eighty-four patients (36.5%) were aged less than one year whereas 78 (34%) were aged between one and five years. Oliguria was present in 100 children (43.5%) with a mean duration of 82.5 ± 35.7 h. Hypertension was detected in 62 patients (27%) while encephalopathy or seizures was present in 24 patients (10.4%). The mean peak blood urea and serum creatinine concentrations were 155.3 ± 70.6 mg/dL and 4.3 ± 3.2 mg/dL, respectively. The mean urea and creatinine levels at discharge were, respectively, 79.3 ± 51.2 mg/dL and 2.12 ± 2.3 mg/dL. The mean duration of hospital stay was 17.8 ± 7.6 days.

Causes of ARF

The principal causes of ARF were acute tubular necrosis (ATN) in 121 (52.6%), glomerular disorders in 13 (5.7%), structural anomalies in 22 (9.6%), hemolytic uremic syndrome (HUS) in 27 (11.7%) and nephrolithiasis in eight patients (3.5%). The distribution of causes of ARF according to age is listed in [Table 2]. The major causes of ATN were sepsis in 71 (58.7%), acute gastroenteritis in 35 (28.9%) and Plasmodiumvivax malaria in seven patients (5.8%). Of the 71 patients with sepsis-related ATN, 37 patients (52.1%) were blood culture positive. The isolated organisms included  Escherichia More Details coli in 12 (32.4%), coagulase-negative Staphylococcus in two, Klebsiella species in nine, Pseudomonas in four and Staphylococcus aureus in ten patients.
Table 2: Distribution of etiology of acute renal failure according to age (n=230).

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Four patients with congenital heart disease presented with cardiogenic shock and ARF. Intravascular hemolysis was the cause of ATN in two patients and both were G-6-PD deficient. Of the 27patients with HUS, 19 had dysentery (D+). Stool cultures were positive in 18 patients, and organisms isolated included E. coli in eight (44.4%), Klebsiella spp. in four, Proteus in three and Shigella dysentriae in three patients. Common associations with D-HUS were pneumonia in four and meningitis in two patients.

Renal replacement therapy and outcome

RRT was required in 54 patients (23.5%) and 49 patients (90.7%) underwent peritoneal dialysis (PD). The average duration of dialysis was 65.3 ± 38.7 h and the main complication of PD was peritonitis, seen in 11/49 patients (22.4%). Dialysis was more frequently required in patients with acute on chronic renal failure, 8/18 (44.4%); urolithiasis, 6/8 (75.0%); HUS, 16/27 (59.3%); vasculitis, 3/3 (100%); and structural anomalies of the urinary tract, 5/16 (23.8%). Complete recovery was seen in 99 patients (43.2%) with ARF and sequelae such as persistent deranged renal functions, hypertension or proteinuria were present in 84 patients (36.7%). Forty-six patients (20.1%) with ARF died. The short-term outcome based on the etiology of ARF is summarized in [Table 3].
Table 3: Etiology of acute renal failure and survival rates.

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Higher mortality (26.2%) was observed in children below one year of age. Also, mortality was higher in children with HUS (40.7%), sepsis (37.3%) and those managed in the intensive care setting (39.0%).

Radiological findings

Of the 230 patients with ARF, information on renal ultrasound was available for 199 patients. One hundred patients (50.3%) had normal kidneys on ultrasound. Dilated renal collecting systems were seen in 20 patients (10.1%), normal sized kidneys with altered corticomedullary differentiation (CMD) in 45 (22.6%), enlarged kidneys with altered CMD in seven (3.5%) and enlarged kidneys with maintained CMD were seen in three patients (1.5%). Twelve patients had bilateral small kidneys on sonography (those with acute on chronic renal failure). Two patients had nor-mal sized single kidneys, two children each had renal tumors and multiple renal abscesses and six children had nephrolithiasis. In the two children with nephrolithiasis, X-ray (KUB) also showed renal calculi.


   Discussion Top


Because of the lack of a uniform definition of ARF until recently, most studies of the past are relatively heterogeneous and the incidence of ARF has varied from 10 to 40% among hospitalized children. The causes of ARF have changed in the last decade. Studies in the 1970s and 1980s demonstrated that intrinsic renal diseases including HUS and glomerulonephritis were the most common causes of ARF in children. Most studies from the developed world presently report ARF from surgical, transplant and intensive care units. [2] Information on pediatric ARF is relatively scant from our country. Hence, this study was conducted aimed at identifying changes in the etiology of pediatric AKI in the recent years as well as its short-term outcome.

Of the 230 subjects studied, 162 (70.4%) were below five years of age. In the previous studies also, ARF had a maximal incidence in children under five years of age. [2],[5] Increased occurrence of diarrhea and septicemia in young patients could be the major reason for this age distribution.

The most common cause of ARF in this study was ATN, seen in 52.6% of the patients. The primary cause of ATN was sepsis, seen in 58.7% of the patients and acute gastroenteritis in 28.9% patients. These results are compa rable to other studies from developing countries. It seems that even with passing decades, the etiology of ARF in our country has changed little. [5],[6] In a recent study from North India, sepsis was the cause of ARF in 33% patients. [7] This could be due to poor hygiene and lack of sanitation, still prevalent in a large proportion of the population.

The incidence of HUS has decreased as compared with previous decades. In a previous study from the same city, the reported prevalence was 36% as against 11.7% in the present study. [8] Availability of better antibiotics and an overall decrease in the incidence of dysentery in the population could be responsible for this change. Most cases of HUS (70.4%) were associated with dysentery, and E. coli was the most common causative agent.

Sonographic findings were abnormal in 49.7% patients and the most common abnormality detected was altered CMD, seen in 22.6% patients. Utility of sonography in ARF is primarily limited to the identification of obstruction, urolithiasis and differentiation from chronic kidney disease. [9] The implications of altered echo texture in an acute setting are not known.

RRT was required in 23.5% patients, and the main modality of dialysis used was PD in 90.7% of the cases. The catheter used for peritoneal access in all these patients was a stiff catheter. The reasons for greater use of PD were its easy availability, requirement of lesser expertise and also a younger age group of patients (almost 70% were below 5 years of age). The higher incidence (22.4%) of peritonitis among these patients could be due to use of stiff catheters and prolonged duration of acute dialysis. Patients who underwent hemodialysis were older and also required dialysis for prolonged periods. While continuous RRTs are being increasingly used in intensive care patients in the western world, its usage in the pediatric population in our country is extremely low due to nonavailability at most centers. [2],[9],[10]

The overall mortality was 20.1% in this study. The factors associated with higher mortality were age at onset below one year, HUS as the underlying diagnosis and admission to intensive care unit. Other studies on AKI have also shown a mortality of 20-30% and a better survival beyond infancy. [5],[7],[11]

The eventual recovery and the long-term outcome of patients with ARF chiefly depends on the underlying condition. While the prognosis in ATN, acute interstitial nephritis and glomerulonephritis, is satisfactory, patients with multi-organ failure and cortical necrosis fare poorly. [12],[13]

A major limitation of our study is the lack of information regarding the occurrence of ARF from the pediatric surgical and cardiothoracic units. It is possible that with the rising number of pediatric surgeries, the incidence of ARF has increased in these settings as well.

To conclude, ATN consequent to septicemia was the most common cause of ARF in this study. RRT was required in 23.5% patients and PD was the mainstay of RRT in our patients.

 
   References Top

1.Moghal NE, Brocklebank JT, Meadow SR. A review of acute renal failure in children: Incidence, etiology and outcome. Clin Nephrol 1998;49:91-5.  Back to cited text no. 1
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2.Hui-Stickle S, Brewer ED, Goldenstein SL. Pediatric ARF Epidemiology at a Tertiary Care Center from 1999-2001. Am J Kidney Dis 2005;45:96-101.  Back to cited text no. 2
    
3.Agras PI, Tarcan A, Baskin E, Cengiz N, Gurakan B, Saatci U. Acute renal failure in the neonatal period. Renal Failure 2004;26:305-9.  Back to cited text no. 3
    
4.Srivastava RN, Bagga A, Moudgil A. Acute renal failure in north Indian children. Indian J Med Res 1990;92:404-8.  Back to cited text no. 4
    
5.Agarwal I, Kirubakaran C, Markandevulu V. Clinical profile and outcome of acute renal failure in South Indian children. J Indian Med Assoc 2004;102:353-4.  Back to cited text no. 5
    
6.Srivastava RN, Moudgil A, Bagga A, Vasudev AS. Hemolytic uremic syndrome in children in northern India. Pediatr Nephrol 1991;5:284-8.  Back to cited text no. 6
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7.Nasir SA, Bhat MA, Hijaz SW, Charoo BA, Sheikh BA. Profile of acute renal in children in Kashmir. Indian Pediatr 2011;48:491-2.  Back to cited text no. 7
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8.O'Neill WC. B-mode sonography in acute renal failure. Nephron Clin Pract 2006;103: C19-23.  Back to cited text no. 8
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9.Ronco C, Bellomo R, Ricci Z. Continous renal replacement therapy in critically ill patients. Nephrol Dial Transplant 2001;16(suppl 5):67-72.  Back to cited text no. 9
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10.Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005;67:653-8.  Back to cited text no. 10
[PUBMED]    
11.Pundziene B, Dobiliene D, Rudaitis S. Acute kidney injury in pediatric patients: Experience of a single center during an 11 year period. Medicina (Kaunas) 2010;46:511-5.  Back to cited text no. 11
    
12.Radhakrishnan J, Kiryluk K. Acute renal failure outcomes in children and adults. Kidney Int 2006;69:17-9.  Back to cited text no. 12
[PUBMED]    
13.Arora P, Kher V, Rai PK, Singhal MK, Gulati S, Gupta A. Prognosis of acute renal failure in children: A multivariate analysis. Pediatr Nephrol 1997;11:153-5.  Back to cited text no. 13
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Correspondence Address:
Mukta Mantan
Department of Pediatrics, Maulana Azad Medical College, Delhi 110002
India
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DOI: 10.4103/1319-2442.109620

PMID: 23538377

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    Tables

  [Table 1], [Table 2], [Table 3]

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