Post on 22-May-2020
The Journey from AKI to RRT
Loai Eid, MD, MSHS, FAAP, FASPN
Consultant Pediatric Nephrologist
Pediatric Nephrology & Hypertension Division Chief
Dubai Hospital – DHA
21st March, 2019
Outline
• The Acute kidney injury (AKI)
• The Chronic Kidney Diseases (CKD)
• The Renal Replacement Therapies (RRT)
Case
• 4 yr male admitted with gram negative septic
shock. He is oliguric, 20% fluid overload, K of
6.8 meq/dl, Urea of 85 mg/dl, pH of 7.18.
Intubated on 85% FIO2, Peep of 10. BP is
80/40 on 0.6 mic/kg/min of norepinephrine
• He has AKI and needs RRT; How?
Pediatric AKI: Definition
Past: So many definitions…. Risk Injury Failure End-Stage Kidney Disease (RIFLE) Pediatric RIFLE (pRIFLE) Acute Kidney Injury Network definition
Crit Care. 2005; 9(5): 523–527
Vaidya et al. Annu Rev Pharmacol Toxicol. 2008 ; 48: 463–493. doi:10.1146
Vaidya et al. Annu Rev Pharmacol Toxicol. 2008 ; 48: 463–493. doi:10.1146
Pediatric AKI: Incidence in PICU
Population & Definition-dependent
0
5
10
15
20
25
30
35
40
45
50
No AKI R I F
58%
16% 17%
9%
0%
10%
20%
30%
40%
50%
60%
70%
No AKI Stage 1 Stage 2 Stage 3
Anesth Analg 2009;109:45–52
(Aprotinin study) Al-Kandari et al, ASN, 2008 Kid Int 2007; 71: 1028-35
82% AKI 21% AKI 42% AKI
Most Critically ill children
Vasopressors/Ventilated
Urinary catheter
pRIFLE
N=395
Cardiac Surgery
All PICU stay>48hrs
pRIFLE
0
10
20
30
40
50
60
70
80
90
No AKI R I F
Pediatric AKI:
Changing Epidemiology
Pediatric ARF Causes
Nu
mb
er o
f P
atie
nts
0
10
20
30
40
50
60
Un
kn
ow
n
AG
N
Hem
og
lob
inu
ria
Sep
sis
Hem
Cy
stit
is
AT
N-D
ehy
rdat
ion
Co
ng
enit
al H
eart
Flu
id O
ver
load
Neo
pla
sm
Lo
w A
lb
HU
S
Ch
ron
ic R
enal
Dz
Co
ng
esti
ve
hea
rt
Rh
abd
om
yo
lysi
s
AR
DS
Py
elo
nep
hri
tis
Vas
culi
tis
Nep
hro
tox
ic M
ed
Stickle SH et al: Am J Kid Dis 45:96-101, 2005
Previously: Primary renal diseases
Clinical Issues in AKI
• Oliguria:
– Volume overload and hypertension
– Inability to provide nutrition, therapy
• Diminished renal clearance:
– Electrolyte imbalance
– Acidosis
– Uremia
Conservative Management of AKI:
Traditional Methods
• Limit fluid intake
– Can reduce volume overload problems
– Can’t address issues of nutrition
• Limit input of retained substances
– Can reduce risks for hyperkalemia
– Can’t address imbalances from metabolism
• Adjustment of drug dosages in AKI
• Try not to mess up; wait and Hope
Do Diuretics Help in AKI?
1. Majority of
ICU patients
get diuretics
2. But no
improvement
in clinical
outcomes
Bagshaw CCM 2008 36(4)
8 non-randomized studies
6 randomized studies
Effect of Low-Dose Dopamine on Mortality
Friedrich JO, Adhikari N, Herridge MS et al. Ann Intern Med 2005; 142: 510–524
Low-dose dopamine increases urine output but
does not prevent renal dysfunction, the need for
RRT or death
Case
• Antenatal US: A male child with hypo-dysplastic kidneys and normal amniotic fluid
• Post-natal: Bilateral grade 4 VUR
• RFT: Creatinine continued to increase in first few months (4.5mg/dl at 6 months), UO normal-high
• PD started at 6 months, supplemental feeding + CKD - Meds; GH started at 1 year due to poor growth
• Transplant from Mom at 1.5 yrs. of age
• Currently: 6.5 years old, growing and thriving well, creatinine 0.6 mg/dl
Transplant
CKD: Impact on All Organs
• Bones can break, muscles can atrophy, glands can loaf, even the brain can go to sleep, and not endanger our survival; but should the kidneys fail in their task neither bone, muscle, gland nor brain could carry on.
From Dr. Homer. W. Smith: Fish to
Philosopher
Definition of CKD
• Kidney damage: Pathologic abnormalities or
markers of damage (abnormalities in blood
or urine tests or imaging studies)
or
• GFR <60 ml/min/1.73m2
Persistent for 3 months with implications for health
Renal Pathology in Progressive CKD
Regardless of the cause,
kidney in CKD shows:
Glomerulosclerosis
Vascular sclerosis
Tubulo-interstitial
fibrosis
Olson, Lab Invest 59:564-578, 1988
CKD: Incidence & Prevalence
• A serious public health problem, poor outcomes and high cost
• Increasing incidence with poor and ethnic minority disproportionately affected
• Rising incidence of obesity and type II DM in youth
• Prevalence of CKD: 18.5-58.3 per million children
Age, gender and racial differences:
Prevalence increases with age
Obstructive uropathies more common in males
CKD and ESRD: Higher in blacks
Stages of CKD
KDOQI KDIGO
Stage Description GFR (ml/min/1.73m2)
1 Kidney damage with
normal or ↑ GFR
≥90
2 Kidney damage with
mild ↓ GFR
60-89
3a
3b
Mild-Moderate ↓ GFR
Moderate-severe ↓ GFR
45-59*
30-44
4 Severe ↓ GFR 15-29*
5 Kidney failure <15*
Stage Description GFR (ml/min/1.73m2)
1 Kidney damage
with normal or ↑ GFR
≥90
2 Kidney damage
with mild ↓ GFR
60-89
3 Moderate ↓ GFR 30-59*
4 Severe ↓ GFR 15-29*
5 Kidney failure <15*
* Complications of CKD surface
All Transplant patients have CKD regardless of GFR
Causes of Pediatric ESRD: 2012-2016
CAUSE Incidence
(Percentage)
CAKUT/Cystic 40%
Glomerular Disease (e.g. FSGS) 20.1%
Secondary Glomerular Disease/Vasculitis 10.3%
Interstitial nephritis/pyelonephritis
(chronic)
5.2%
Hypertensive/large vessel disease 5%
Neoplasms/Tumors 2%
Diabetes Mellitus 2%
Complications of transplant 1.1%
Miscellaneous (e.g. SCD, HIVAN) 6.3%
Unknown 9.7%
Missing data 3.9%
Source: USRDS (usrds.org)-2018
eGFR in Children
Old Schwartz:
K x Length in cm/S. Creat (mg/dl)
0.45 in children <2 years
0.55 in female children 2-18 and pre-pubertal boys
0.7 in pubertal boys
New Schwartz:
K= 0.413 x Length in cm/S. Creat,
Creatinine measured by enzymatic method standardized to IDMS
Evaluation of CKD
• Diagnosis: R/O CKD in a child with poor growth, anemia, excessive thirst, polyuria, nocturnal enuresis, HT
• Assess severity: eGFR
• Complications: of CKD
• Comorbidities: CVD, growth and nutrition, sexual, neurocognitive and psychosocial development
• Risks: for progression of CKD and CVD
Signs of CKD
• Proteinuria-early
• Hypertension-early
• Increasing serum creatinine (decreasing GFR)-late
• Poor height growth-late
• Fatigue-very late
• Anorexia-very late
• Nausea/vomiting-very late
Risk Factors for Progression
Well Known
• Ongoing disease
(GN, Obstruction)*
• AKI *
• Albuminuria *
• Hypertension *
• Diabetes, insulin resistance *
• Nephrotoxic agents *
• Contrast *
• Puberty
Less well studied
• Anemia *
• Chronic inflammation
• Genetics
• Metabolic acidosis *
• Obesity *
• Hyperuricemia *
• Access to health care*?
• Lower SES
Chronic Disease Model for CKD
Renal Replacement Therapy
Indications
• Volume overload
• Metabolic imbalance
• Toxins (endogenous or
exogenous)
• Inability to provide
needed daily fluids due
to insufficient urinary
excretion
Goals
• Restore fluid, electrolyte
and metabolic balance
• Remove endogenous or
exogenous toxins as
rapidly as possible
• Permit needed therapy
and nutrition
• Limit complications
RRT Options AKI/CKD
• Hemodialysis, Peritoneal Dialysis, & CRRT
– Each has advantages & disadvantages
• Modality Choice guided by
1) Patient Characteristics
• Disease/Symptoms
• Hemodynamic stability
2) Goals of therapy
• Fluid removal, electrolyte correction, or both
3) Availability, expertise and cost
Walters et. al. Pediatr Nephrol 2008
Peritoneal Dialysis (PD)
• Continuous
• Low cost, easy application
• Low ultrafiltration
• Good CV tolerance
• Preferred in infants, especially
with congenital heart disease
• No extracorporeal circuit
• No anticoagulation
• Intermittent
• Blood perfuses
extracorporeal circuit
• High efficiency system
• Poor CV tolerance
• High level of complexity
• Vascular access/heparin
• Quick depuration of small
molecules and water
HemoDialysis (HD)
Continuous Renal Replacement
Therapy (CRRT)
• Continuous • Technically similar to HD • SLOW: depuration of small
molecules and water • Good CV tolerance
• High level of complexity
• Vascular access/heparin
RRT Options
Liao, Z et al. Artificial Organs 2003; 27: 802-807
Trends in Pediatric RRT
0%
10%
20%
30%
40%
50%
60%
1995 1999 2003
CRRT
PD
HD
Warady et al, Pediatr Neph 2000, 15:11-3
CRRT Increasing
Renal Replacement Therapy
USRDS 2018 Annual Data Report
Conclusions
Born: February 8, 1968
Died: May 28, 2010
Height: 4' 8" (1.42 m)
Contact information:
Loai Eid, MD, MSHS, FAAP, FASPN
Consultant Pediatric Nephrologist
Dubai Hospital - DHA
Mediclinic City, Al Zahra PVT & Saudi German Hospitals
Email: LaEid@dha.gov.ae
Loaieid@hotmail.com
Mobile: 0562704271