THE IPNA TEACHING COURSE IN VIETNAM

OCTOBER 16-19, 2023

Kim Reidy, MD
Associate Professor and Chief, Nephrology
Children’s Hospital at Montefiore
Albert Einstein College of Medicine
Bronx, NY USA
Introduction to Acute Kidney
Injury (AKI):

Kim Reidy, MD
October 2023
Learning objectives
• Recognize the risk factors for AKI
• Explain the stages of AKI
• Formulate a plan to determine the etiology
of AKI
• Develop an AKI management plan
• Identify complications of AKI
Case

It’s 3 am on Saturday.
A 5 year-old girl is being transferred to your
care for acute kidney injury.
Her BUN is 70 mg/dL and her creatinine is
4.5 mg/dL
What do you want to
know?
 What do you want to
know?
• What is the acuity? Obtunded?
• History: Volume depletion? Recent illnesses?
Hematuria? Changes in UOP? Medications?
Birth hx? Underlying disease? Family
history? Growth (is this acute or chronic?)
• Physical exam: Weight change? BP? HR and
volume status? Edema? Lungs wet?
• Initial labs? K? HCO3? Ca? Phos?
Hb?
What is AKI?

How do we classify severity of

AKI?
The 5 R’s of AKI

Kidney International, 2013

Is creatinine the
best marker for AKI?
Classification of AKI
Challenges in defining neonatal
AKI • At birth, creatinine = maternal function
• Creatinine has limitations as a marker of
GFR
= – Assay factors
• Jaffe assay altered by serum
bilirubin or albumin
• Preferred isotope dilution mass
spectrometry (IDMS) traceability
– Depends on muscle mass
– Passive tubular back leak rather than
secretion
– Hydration status
KDIGO modified Neonatal AKI
Definition
Stage Serum Creatinine (SCr) Urine Output (UOP)**

No change in SCr or rise < 0.3 mg/dL > 1 ml/kg/hour**

0
SCr rise ≥ 0.3 mg/dl within 48 hrs or
SCr rise ≥ 1.5- 1.9 X reference SCr* >0·5 and ≤ 1 mL/kg/hour
1
for 24
SCr rise ≥ 2 to 2.9 X reference SCr* < 0.5 ml/kg/hour for 24 h
2
SCr rise ≥ 3 X reference SCr * or <0.3 ml/kg/h for 24 h or
3 SCr ≥ 2.5 mg/dl or Receipt of dialysis Anuria for 12 h

*reference value is lowest previous value

**includes days #2-7 only (day of birth = day #1)

Zappitelli M et al Pediatr Res. (2017)

What does a slower creatinine decline mean?
• 31- 40 week GA
newborns (excluded
with KDIGO AKI)
• SCr decline <31%
by the seventh day
of life
• SCr threshold 0.7
mg/dl
• Associated with
increased mortality
Perazzo et al., KI 2020
 Should neonatal
AKI UOP criteria
vary by GA?
• Cutoff of 1 mL/kg/hour may
underestimation of AKI in very
preterm infants with known tubular
immaturity
• AKI in the very preterm (24-29 wk
GA) defined by higher UOP
threshold criteria was associated
with mortality
De Mul et al, CJASN 2022
Case: A 5 year-old girl is being
transferred to your care for
acute kidney injury.
Her BUN is 70 mg/dL and her
creatinine is 4.5 mg/dL

What studies do you

want to get?
 Causes of AKI?

Prerenal Intrinsic Postrenal

Renal-bladder
Urinalyses:
ultrasound
SG?
Protein, blood,
WBC?

Prerenal Acute Tubular Necrosis (ATN)

PUV,
High Urine SG SG 1.010 neurogenic
Low urine sodium Child/Adult FeNa >2% bladder, kidney
Low FeNa <3-6% FeUrea >35% stones, extrinsic
Low FeUrea<35%? 31 weeks GA-term FeNa > 3% compression
Child/Adult <1% 28-30 weeks GA FeNa > 6%

Other: glomerular disease (ANCA/vasculitis),

atypical HUS, interstitial nephritis, infection,
thrombosis, cortical necrosis, uric acid
nephropathy
What studies do you want
to get?
• Fe Na and/or Fe Urea
• Urinalysis
• Glomerular? ASLO, C3,C4, streptozyme,
ANA, AntiDNA Ab, ANCAs, Anti-GBM,
Hepatitis B/C, HIV
• HUS? Haptoglobin, LDH, STEC
• Renal bladder ultrasound
• How many children in the hospital get
AKI?

• What are the most common causes of the

AKI in children?

• What are the risk factors for AKI in this

patient?
• Almost 5,000 children admitted to PICUs

• Multicenter, international study

• 25% had AKI, almost 5% with stage 3

 Premature
Neonate

Cardiopulmonary Infant with Peri-

Bypass natal Asphyxia

Neonatal
ECMO & Pediatric Sepsis

AKI

Nephrotoxic Vasopressor
Medications Support

Hypotension
AKI Incidence by Gestational Age
What were risk factors
for severe AKI in PICU?
• Single center prospective QI project utilizing EMR based triggers
• Population: Non-ICU
– Aminoglycoside for ≥ 3 days or ≥ 3 nephrotoxin simultaneously
• Intervention: Rec. daily SCr monitoring
• Outcome: AKI
• Conclusion: The mean AKI intensity decreased by 42% with the
institution of EMR based triggers. Sustainable (Kidney Int. 2016)
 Case
She had fever, vomiting and diarrhea for 3 days. She
was given ibuprofen 4 times. She has had decreased
urine output. Ex full term infant with no prior
hospitalizations or surgeries. She lost 2 kg since her
last well child visit check up about 5 months ago and
is now 15 kg. HR 130s, BP 80/50. She is tired and
has dry mucous membranes. Exam is otherwise
normal.
K is 4 mEq/L, HCO3 17mEq/L, Ca 8.5mEq/L, phos
4.5 mg/dL
Hb 10 g/dl, normal platelets
Case cont
• She receives 3 x 20 cc/kg normal saline
boluses and her tachycardia resolves and
blood pressures improve. However, she
only makes 500 mL of urine output.

• What is the best rate for IVF?

• What other management is important?
AKI management
• What is the best rate for IVF in oliguric
patient?
– Insensible (400 mL/m2) plus UOP and other
losses
• What other management is important?
– Renal dose for eGFR
– Strict I/O, daily weight
– Avoid K, monitor serial electrolytes
– Avoid nephrotoxins (vancomycin/other
antibiotics, iv contrast, nsaids)
Can we predict who will get
severe AKI?
Renal Angina Index
• Prospective observational international multicenter study 3 consecutive
months in 2014 (32 PICU across Asia, Australia, Europe, and North America)

• All children between 90 days and 25 years with an expected ICU stay >48
hours were eligible

• Comparison: Renal angina (RAI ≥ 8) w/i 12 hours of admission vs. change

in SCR

• Outcomes: Severe AKI (Stage 2 or 3) at day 3 of admission

The Lancet Child & Adolescent Health, 2018

 • Results:
– 1590 patients, 286 met Renal Angina
– Severe AKI on Day 3 in 23% of patients

• Conclusion: “Compared with isolated, context-free changes in serum creatinine,

renal angina risk assessment improved accuracy for prediction of severe acute
kidney injury ….”
Basu et al.,The Lancet Child & Adolescent Health, 2018
Furosemide stress test
• Intravenous
administration of
furosemide
(1.0 mg/kg (furosemide
naive) –1.5 mg/kg)

• UOP <200 ml 2 h post

furosemide or
< 1 mL/kg/h predicts
severe AKI
Case cont
After 20 mg of furosemide, she makes 20 mL of
urine in the next 6 hours.

What would you do next?

When would you consider renal replacement

therapy?
IVF is a medicine!

Increased %FO at start of CRRT is

associated with mortality
INDICATIONS FOR DIALYSIS

Renal insufficiency GFR <15% with:

Hypertension
Metabolic acidosis
Hyperkalemia
Uremia
Fluid overload/ Pulmonary edema/CHF
Unable to be controlled by medical therapy
Continuous Renal Replacement Therapy
• Uninterrupted renal support to critically ill patients
• Intended to substitute for impaired renal function over an
extended period of time and intended to be utilized 24
hours/day
Advantages:
• Stable control of fluid, electrolyte and solute balance
• Improved cardiovascular stability
• Ability to administer greater fluid volume, including
hyperalimentation
Indications for CRRT
• Sepsis
Oligoanuria/
• Volume overload
Hemodynamic unstable/ hypotension
• Other usual
Sepsis syndrome
indication for dialysis (ie.
• Symptomatic
Large daily fluiduremia, severe acidosis, etc.)
requirement
• Unusuable peritoneum
•• AND
Inability to tolerate IHD
Prismaflex
Hemodiafiltration
to waste
Blood In

(from patient)
Dialysate
Solution Repl.
Solution

Blood Out

(to patient)

LOW PRESS HIGH PRESS

LOW CONC HIGH CONC
 ▪Diffusion ▪Convection

”coffee pot”

”tea bag”

Dialysis Hemofiltration
 New options in neonatal CRRT:
Carpediem
• Blood pump flow rate
ranges from 5 to 50 ml/min.

• The maximum ultrafiltration

and dialysate outlet rate
• 5 ml/min (300mL/hr) with
the biggest dialyzer
• 1 ml/min (60ml/hr) for
the smallest dialyzer.

Survival to CKRT termination was higher

for CARPEDIEM subjects (33/34 vs. 21/48,
p < 0.0001). Pediatric Nephrology (2022) 37:667–675
 Aquadex
2 pumps
• Blood pump (flow maximum of
40 mL/min)
• Ultrafiltration pump (maximum
of 500 mL/h when the blood
flow is 40 mL/min).
• Replacement fluid is infused
via the proximal pigtail of the
circuit

Pediatr Nephrol.
2016
What are the complications of
AKI?
AKI in PICU is associated with
increased LOS and mortality
 Outcomes by
neonatal AKI
status

Jetton and Askenazi, The Lancet Child & Adolescent Health, 2017
Thank you and Questions!