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Chapter 14: Renal Failure

Poyyapakkam R. Srivaths

ACUTE RENAL FAILURE

The term “acute renal failure” (ARF) for alteration in kidney function in an acute setting was first introduced by Smith1 to define changes in kidney function due to traumatic injuries. Since the kidney's physiological role is the excretion of water-soluble solutes and urine production, changes in these parameters are often included in the definition of ARF. However, since the magnitude of changes is not uniformly defined, there is a large ascertainment bias when epidemiology of ARF is examined. For example, in a pediatric intensive care unit (PICU) study that defined ARF as doubling of serum creatinine (Cr), the incidence of ARF in all children admitted to the PICU was reported as 4.5%. However, in another PICU study that defined ARF as elevation of serum Cr to 1.5 times the normal value, the incidence of ARF was 82% in children with severe illness .2,3 This discrepancy led to the adoption of a consensus definition of ARF by the Acute Dialysis Quality Initiative. The objective was to arrive at a definition of ARF that uses standardized terminology and includes a broad range of acute impairment of renal function. This definition is referred by the acronym RIFLE,4 which stands for risk, injury, failure, loss of function, and end-stage renal disease (ESRD). These criteria have been modified in children to account for normal variations in serum Cr with somatic growth, referred to as pRIFLE (Table 14-1).3

Table 14-1.

Pediatric RIFLE (pRIFLE) Criteria3

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Table 14-1.

Pediatric RIFLE (pRIFLE) Criteria3
Category Estimated Creatinine Clearance (eCCl) Using Schwartz Formula Urine Output
Risk eCCl decrease by 25% Less than 0.5 mL/kg per hr for 8 hours
Injury eCCl decrease by 50% Less than 0.5 mL/kg per hr for 16 hours
Failure eCCl decrease by 75% or eCCl <35 mL/min/1.73 m2 Less than 0.5 mL/kg per hr for 24 hours or anuric for >12 hours
Loss of function Persistent failure for >4 weeks
End-stage renal disease Persistent renal failure >3 months

Etiology

In the past, the etiologies of ARF in the pediatric hospital setting were limited to primary renal diseases such as hemolytic uremic syndrome and acute glomerulonephritis. However, ARF is now more likely secondary to systemic illness or its treatment, such as sepsis, nephrotoxic medications, and ischemia due to other organ involvement.3,5 Acute renal failure in the current intensive care setting is due to multiple organ dysfunction syndrome (MODS) following cardiopulmonary bypass surgery for congenital heart disease, liver failure, or stem cell transplantation. This poses difficult challenges in prescribing fluid and meeting nutrition needs, since each of these conditions has unique requirements.

Outcome

Pediatric ARF has a definite and serious impact on both short-term and long-term outcomes. Previous thinking was that children in the PICU ...

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