ACUTE KIDNEY INJURY IN

PEDIATRIC SEPSIS

Sitti Aizah Lawang

OVERVIEW
• Pathophysiology sepsis AKI
• Diagnosis sepsis AKI
• Biomarker AKI- NGAL
INTRODUCTION
• Sepsis  risk factor for AKI
• Acute Kidney Injury (AKI)  high morbidity and
mortality

Crit.care Med.2008 April:36(4):1297-1303

EPIDEMIOLOGY
• Incidence AKI  up to 20% (ICU)  mortality
rate 25-80%.
• The Beginning and Ending Supportive Therapy
(BEST) study in 23 country  sepsis cause AKI
(47,5%)

Blood Purif, 2012;33:131-7

PATHOPHYSIOLOGY OF SEPSIS AKI

www:cjasn.asnjournal.org
PATHOPHYSIOLOGY OF SEPSIS AKI

Nature Reviews Nephrology 5, 629-640 (November 2009)

DIAGNOSE AKI

• Current clinical practice  serum creatinin (RIFFLE)

• Creatinin  unreliable & insensitive  early acute
change
• Neutrophil Gelatinase Associated Lipocalin (NGAL) 
sensitive, specific and predictive early biomarker for
AKI

Crit Care Med,2008 April:36(4):1297-1303

RIFFLE CRITERIA FOR AKI
Neutrophil Gelatinase Associated Lipocalin

• NGAL is a 25-kD protein, small molecule of 178 amino

acid  superfamily of lipocalin
• NGAL  important role in host defense, reducing
apoptosis and proliferation of renal tubules.
• In stress condition (infection, inflammation, ischemic,
neoplasm) the NGAL level will increase

Ann Intern Med.2008 June 3;148(11)

Clin J Am Soc Neprol 3;531-44
Pacificbiomarker2012
Figure . Possible mechanisms for increased urinary (NGAL) levels in proteinuric diseases. (A)
Under physiological conditions, almost totally reabs in tubular by megalin transporter (B) In
proteinuric diseases damage glomerular, NGAL ↑ (C) Megalin reabs ↓ cause by damage
tubular (megalin located) (D) Injured tubular cells NGAL↑ defence mech against oxidative
stress

. Journal of Medical Research and Science.2012;1:30-6

NGAL as Biomarker AKI

• Reference value for uNGAL in pediatric (25 healthy newborns &

308 children  pediatric normal ( mean 10.2 ng/mL, median 4.6
ng/mL, range 0.2-146.7 ng/mL; p<0.0001).
• uNGAL values for neonates ( mean 44.2 ng/mL, median 30.3
ng/mL, range 5.2-137.4 ng/mL)

Clin Chem Lab Med. 2013 May;51(5):

• Observation Jan-Maret 2014 on 29 sepsis children in
RSCM Jakarta and RS. Wahidin Makassar (sepsis 17,
shock sepsis 12) showed:
• Urine NGAL according to severity of illness: PELOD
score <10 (N:14) median 26,31 (2,64-678,42), score 10-
20 (N:9) median 485,66 (81,58-5999,84), score > 20
(N:6) median 2209,8 (3,2 – 6353)
 THERAPY

• Renal Replacement Therapy

• Non dialysis:
1. Hydration and volume loading
2. Maintaining renal perfusion pressure
3. Low dose dopamine  no benefit
4. Loop diuretic  controversy
5. Osmotic diuretic-manitol  risk of AKI↑

Rajapakse et.al SLJCC.vol 1 no 1

Clin J Am Soc Neprol 3;533-44
 PROGNOSIS

• AKI  higher risk of death than without AKI.

• Increased risk of death rises incrementally with the
severity of AKI

Nat Rev Nephrol.April 2011;7(4):209-217

 CONCLUSION

• AKI is common and serious problem

• The diagnosis of AKI is often delayed
• Preventive and therapeutic measures are delayed
due to lack of early biomarker