‫بسم الله‬ ‫الرحمن الرحيم‬

‫“قالوا ل علم لنا ال ما علمتنا‬ ‫انك انت العليم الحكيم”‬

ANALYSIS OF CLINICAL AND LABORATORY DATA OF INFANTS AND CHILDREN ADMITTED WITH ACUTE RENAL FAILURE TO DIALYSIS UNIT OF ALEXANDRIA UNIVERSITY CHILDREN’S HOSPITAL: TEN YEARS EXPERIENCE (1995-2004)

Definition of Acute Renal Failure:
ARF is a syndrome with multiple causes; defined as a sudden loss of renal functions (over several hours to several days). ARF results in derangement in extracellular fluid balance, acid base, electrolytes and divalent cation regulation. An increase in serum creatinine concentration, accumulation of other nitrogenous waste products and often a decline in urinary output are the hall marks of ARF.

Classification of ARF
Acute Renal Failure

Pre-renal

Intrinsic

Post-renal

Glomerular

Interstitial

Tubular

Vascular

Pre-renal Causes
• Intravascular volume depletion • Low cardiac output. • Impaired renal autoregulatory responses.

Specific Renal Diseases That May Lead to Acute Renal Failure: I-Vascular Causes of Intrinsic ARF:
Small vessel vascular diseases that cause renal failure e.g: Hemolytic-uremic syndrome

II- Acute Nephritis  e.g: Acute post-streptococcal glomerulonephritis

(APSGN), Rapidly progressive glomerulonephritis . Urinary findings including proteinuria ,erythrocytes, leukocytes and erythrocyte casts with dysmorphic erythrocytes are characteristic features.

RBCs casts

WBCs Casts

Renal tubular epithelial cells casts

Muddy brown granular casts

Broad casts (form in dilated, damaged tubules

III-Renal Interstitial Diseases:
• Acute tubulointerstitial nephritis (ATIN) is a clinical syndrome characterized by inflammation of the renal interstitium accompanied by interstitial edema and renal tubular injury. • ATIN may be caused by numerous drugs, infectious agents and systemic illnesses. • Clinically apparent disease usually develops days to weeks after exposure to the inciting drug or agent but may be immediate.

IV-Acute Tubular Necrosis
• Most common cause of intrinsic ARF • Tubules are damaged by ischemia or toxins resulting in desquamation of tubular cells, intraluminal tubule obstruction, and back leakage of glomerular filtrate

Urinary Tract Obstruction

:

Obstruction of urine flow may result in ARF. Various clinical causes of urinary tract obstruction are:calculi, ureteropelvic junction obstruction, posterior urethral valves, prune bel ureterocele, neurogenic bladder, duplicated ureters. The most important factors determining recovery of renal and tubular function are the degree and severity of obstruction.

Post-Renal ARF

ARF: Signs and Symptoms
• • • • • • • • • • • Hyperkalemia Nausea/Vomiting HTN Pulmonary edema Ascites Asterixis Encephalopathy Pruritus Seizures Chest pain Shortness of breath

Diagnosis
•Physical examination

•Laboratory Diagnosis

•Radiological Evaluation

Physical Examination
• Vital signs: espec temp and BP • Fluid status: mucous membranes, JVP, peripheral edema • CVS: murmur, pericardial rub, CHF • Resp: rales consistent with edema • Abdo: bladder distension, masses, ascites, CVA tenderness • Derm: rash – Maculopapular: interstitial nephritis – Purpura: vasculitis – Petechiae: HUS/TTP.

Laboratory investigation

• Blood – CBC-D – Lytes, Ca, Mg, P – Urea – Creatinine • Urine – Urine sodium – Urine osmolality – Urinalysis Consists of: – dipstick for heme pigment, protein, glucose, ketones, pH, leukocytes, and nitrites – Microscopic examination of urine

Radiological Investigations
• Radiology – CXR – Renal U/S – CT – IVP – Retrograde pyelogram

Other investigations
– – – – ECG serum C3 Antineutrophil cytoplasmic antibodies. Glomerular basement membrane antigens.

The most urgent aspects of ARF are:
• Hyperkalaemia • Severe hypertension • Severe plasma and extracellular volume expansion leading to heart failure and pulmonary edema. • Unremitting metabolic acidosis. • Hypocalcemia / hyperphosphatemia. • Uremia.

Therapy
y ic therap on-dialyt N

Dialysis:

Growth factor. Atrial Natriuretic Peptide (ANP) Intra Cellular Adhesion Molecules  Anti oxidant therapy Dopamine • Mannitol  Diuretics • Adjuvant Measures has to include
cardiorespiratory support, nutrition, prevention and treatment of sepsis, and treatment of the condition that precipitated the ARF.

Non-dialytic therapy

Dialysis:
Indications of dialysis:  Severe derangements in electrolyte concentrations .  Volume overload.  Acid-base imbalance.  Pronounced azotemia; blood urea nitrogen >100mg/dl  Florid symptoms of uremia (pericarditis,encephalopathy, bleeding, nausea, vomiting or pruritus).

Dialysis:
• Hemodialysis :

Peritoneal Dialysis
Indications for Peritoneal Dialysis in Acute Renal Failure • • • • • Hemodynamically unstable patients Bleeding diathesis Acute necrotizing pancreatitis Difficulty obtaining vascular access High molecular weight toxin removal (contrast) • Hypothermia • Children with ARF

AIM OF THE WORK
The aim of this work was to study acute renal failure (ARF) in infants and children admitted to dialysis unit of Alexandria University Children’s Hospital in 10 years (January 1995 - December 2004).

MATERIAL
This study was conducted on the files of all infants & children who presented with ARF and have already undergone dialysis in Alexandria University Children’s Hospital (AUCH) during the period from 1/1/1995 - 31/12/2004.

METHODS
Files of dialysis patients who attended the dialysis unit of Alexandria University Children’s Hospital (AUCH) during the period from 1/1/1995 to 31/12/2004 were reviewed. Recorded data from the history, clinical examination, laboratory investigations, and treatment given, including the type of dialysis as well as the follow up were summarized.

Demographic data of studied cases
250 200 150 No. of cases 100 50 0

Neonate

infant

preschool

school

adolescent

Distribution of cases according to their age

Demographic data of studied cases
0% Female 40% Male 60%

Distribution of cases according to their sex.

Family history
positive family history

negative family history

Distribution of cases according to their family history.

Residency.

35% urban rural 65%

Distribution of cases according to their residency

Clinical findings at presentations of ARF
500 450 400 350 300

Oliguria or anuria

Volume overload

Gastrointestinal bleeding

No. of cases

250 200 1 50 1 00 50 0

In this study it was demonstrated that 88 % of cases at presentation had oligo / anuria (most frequent clinical presentation), followed in frequency by volume overload (73.9 %) .
.

Hypertension

Bleeding diasthesis

Heart failure

Convulsions

Coma

Clinical presentations in different age groups.
1 00 90 80

Oligo/anuria % V. overload % Hypertension % Heart failure % GIT. Bleeding % Bl. Diasthesis % Convulsions % Coma % %

70 60 50 40 30 20 10 0

Neonate

Infant

Preschool

School

Adolescent

  Hepatitis profile of the patients
600 500 400 300 200 100 0 HBs Ag negative HBs Ag positive HCV Ab positive HCV Ab negative

Results of renal biopsy in patients with ARF.

 

14

Membranoproliferative GN
12

Rapidly progressive GN Lupus nephritis End stage renal disease Nephronophthisis ATN Mesangioproliferative GN Focal segmental GN Acute interstitial nephritis Renal tumour Not adequate Alport syndrome Uric acid nephropathy HUS

10

8

6

4

2

0

Ultrasonographic data of cases.
Increased cortical echogenicity 200 180 160 140 120 Normal Bilateral hydroureteronephrosis Increased cortical echogenicity w ith loss of CMD Bilateral hypoplastic kidney Single hypoplastic/singlehydronephrotic kidney Unilateral/bilateral renal stones w ith or w ithout hydronephrotic changes Renal tumour/mass Increased cortical echogenicity w ith loss of CMD w ith unilateral/bilateral renal cysts Bilateral polycystic kidney Nephrocalcinosis

No. of cases 100
80 60 40 20 0 ultrasonographic finding

Results of VCUG done for some cases with obstructive and/or reflux nephropathy
.
50 45 40 35 30

No. of cases 25
20 15 10 5 0

normal

VUR

PUV

Results of DMSA scan done for some cases with obstructive and/or reflux nephropathy.
60 50 40

No. of cases 30
20 10 0

normal

renal scarring

Diagnosis of cases dialyzed for ARF
Acute tubular/cortical necrosis Acute on top of chronic renal f ailure Obstructive/ref lux nephropathy HUS Congenital anomaly Nephrotic syndrome Unknow n Rapidly progressive GN Bilateral nephrolithiasis Tumour lysis syndrome SLE Hepatorenal syndrome Juvenile/f amilial nephronophthisis Bilateral polycystic kidney Renal tumour Uric acid nephropathy Acute interstitial nephritis Alport syndrome Nephrocalcinosis Renal trauma/nephrectomy

Distribution of cases with acute tubular or cortical necrosis
90 80 70 60 50 No. of cases 40 30 20 10 0 sepsis gastroenteritis others

Fate of cases dialyzed for ARF
31.1%
died chronic follow up

39.7%
100 90 80 70 60

29.2%

Follow up % Died % Chronic %

% 50
40 30 20 10 0

Neonate

Infant

Preschool

School

Adolescent

Type of dialysis done for cases with ARF
6%
Peritoneal dialysis Peritoneal/hem odialys is Hem odialysis

1%

93%

Distribution of cases as regards their origin
450 400 350

Community acquired Hospital acquired ICU NICU

300 250 200 150 100 50 0

Morbidity and mortality of cases with ARF regarding their origin.
100 90 80 70 Community acquired Hospital acquired PICU NICU 60

 

%

50 40 30 20 10 0 Follow up % Died % Chronic %

From this study we concluded that: ARF occured with an average of 50 cases / year.  Most of cases who presented with ARF were infants (37.9 % of cases ), followed by school age group (25 %). Male patients out numbered female patients and patients from rural areas out numbered those from urban areas.  Presence of family history of renal problems or renal failure was absent in most of the studied patients.  The most common clinical findings at presentation in all age groups were oligu/anuria and volume overload . Most cases were HCV antibody negative and HBV surface antigen negative at time of initiation of dialysis.

 Most cases of ARF due to obstructive uropathy, had primary VUR.  The most common causes of ARF were ATN, obstructive uropathy, and hemolytic uremic syndrome.  Mortality rate of acute renal failure is high specially in neonates and in cases dialyzed in PICU.  Mortality rate in cases presenting with ARF due to hepatorenal syndrome and renal tumours were the highest.

 APD was the standered modality of dialysis in our unit, and it proved to have a highly accepted efficacy.  Most cases which community acquired. presented with ARF were

RECOMMENDATIONS
 ARF in most cases occur as a complication of preventable causes hence more efforts and more resources should be directed towards prevention,early detection and treatmeant of such causes.  Primary health care doctors should be taught how to prevent occurrence of renal failure in cases of gastroenteritis, merely by timely volume repletion.  Renal failure secondery to urinary tract obstruction was seen in many cases, more attention should be paied for early detection and treatment of such cases.

RECOMMENDATIONS
 All children with ARF need life-long monitoring of their renal functions, blood pressure, and urinalysis.  Finally, we recommend that medical records should be up graded to make it complete, easily accessible and easily analyzed and modern tecnology should be employed in such process.

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