Renal Failure in Children Flashcards
Acute renal failure (Acute Kidney Injury)
Defined as __________ but potentially __________ deterioration of __________ characterized by elevation of __________ and __________ and the Inability of the kidney to regulate fluid and electrolyte homeostasis.
Lsudden ; reversible
renal function ;serum creatinine
nitrogenous waste
Steps in Managing AKI
• Step One: _________ AKI
• Step Two: Determine the _________ of AKI • Step Three: Determine the _________ of AKI • Step Four: Treat the underlying cause
• Step One: Diagnose AKI
• Step Two: Determine the severity of AKI • Step Three: Determine the cause of AKI • Step Four: Treat the underlying cause
AKI is commonly recognized as reduction in ____________ and or increase in __________
urine output
serum creatinine
Kidney Disease: Improving Global Outcome (KDIGO) Criteria
AKI is defined as rise in S-cr ≥____μmol/L within ________ OR rise in S-cr to ≥____ times baseline S-cr known or presumed to have occurred within the past _____ OR urine output <_____ ml/kg/hr for at least ______
≥25μmol/L ; 48 hr
≥1.5 times ; 7 days
<0.5 ml/kg/hr ; 6 hr
Assessment of GFR
Measurement of GFR could be achieved by one of the following:
(a) _______________ of ____genous substance (e.g. ______) or _____genous substance (e.g. __________).
(b) _______ disappearance of substances such as _________, DTPA, Iothalamate
(c) Estimation of GFR from ______ value of _____genous substances such as ________, ____________.
plasma clearance ; exogenous
inulin ; endogenous ; creatinine
Plasma ;EDTA, ;serum
endogenous ; creatinine
cystatin C.
_________ is the best overall measure of kidney function.
GFR
GFR (ml/min/m2) = _____* ______/____
where U:????
V: ????
P: ?????
U*V/P
where U: Urine concentration of substance V: Volume of urine
P: plasma concentration of substance
_________ clearance is the gold standard measure of GFR
Inulin
Schwartz formula (ml/min/1.73m2) = (_______/serum _________)*____
height
creatinine
K
Classification of Causes of AKI
(A). Pre-renal: The kidney is normal. The insult results in __________ of the kidneys
•Hypovolemia: __________, __________, __________, haemorrhage
•Hypotension: cardiac __________, __________, cardiac __________
•Hypoalbuminemic state: __________ syndrome, __________
hypoperfusion
gastroenteritis ; diabetes insipidus
burns ; cardiac tamponade
shock ; cardiac failure
nephrotic syndrome ; liver cirhhosis
Classification of causes of AKI
(B). Intrinsic: the kidney is the seat of the pathology.
• Renal vessels: renal ________________ , renal ________________, cortical necrosis, ________________ syndrome
• Glomeruli: any cause of severe ________________
• Tubules (________________): the insult to the tubules could be hypoxic/ischaemic: malaria, bacterial infection or toxin mediated: haemoglobinuria, myoglobinuria, uric acids,
diethylene glycol, aminoglycosides, NSAIDs
• Interstitium: acute pyelonephritis, acute interstitial nephritis
renal vein thrombosis
renal artery thrombosis,
hemolytic uremic syndrome
glomerulonephritis
acute tubular necrosis
Classification of causes of AKI
C). Post renal:
•Bilateral __________
•______________ in a solitary kidney
•_____________
•______________
ureteric obstruction
Ureteric obstruction
Urethral obstruction
Bladder rupture
__________ , __________ or __________ BP and __________: suggest pre-renalAKI
Dehydration, normal or reduced BP and no oedema
————- , ____________ , ___________ : think intrinsic AKI
Oedema, hypertension, hematuria
_________, ____________ : think obstruction
Anuria, bladder mass
Clinical Features of AKI
•Features of the underlying cause: _______ , __________, vomiting/dehydration, ______ masses, ______, petechiae, ______, passage of ________ urine
•Features of AKI: _________ , _________, _________, _________tension, pallor, lethargy, nausea & vomiting, anorexia
•Features of AKI complications: ________ oedema, _______ & ________, __________ bleeding, metabolic acidosis, _____kalemia, _______natraemia
fever ; diarrhoea
flank masses ; rash
dysuria ; dark urine
oliguria ; anuria ; oedema ; hypertension,
pulmonary oedema ; seizures ; coma
gastrointestinal bleeding ; hyperkalemia
hyponatraemia
Investigations of AKI
URINE
A. Urinalysis: __________ , __________
B. Urine microscopy: __________, dysmorphic red cells, eosinophils
C. Urine __________
D. Urine __________
haematuria ; proteinuria
red cell cast
Urine electrolytes
Urine culture
Investigations of AKI
Blood
A. _________________________
B.__________, _________ , _________
C. _________ and _________
D. Full blood count: anaemia, blood film for schistocytes,
thrombocytopaenia,
E. Blood film for ______________ ; _________ if sepsis is suspected
F. C3/C4 level, ASO titre, ANCA, anti double stranded DNA antibodies (when suspected)
Electrolytes, urea and creatinine
Calcium, magnesium, phosphate
Arterial blood gases and PH
malaria parasite; blood culture
Other Investigations for AKI
(3) Imaging
A. ____________ scan: initial imaging investigation
B. ____________ if renal vein or artery is
suspected
C. ____________/_________ : for renal stones
(4) Renal ___________:
Where the cause of the renal failure is not known or in case of rapidly progressive glomerulonephritis
KUB ultrasound scan
Doppler ultrasound
X-rays/CT scan
Renal biopsy
Treatment of AKI
The following strategies are employed:
a. Treatment of the ____________
b. Correct ________ abnormalities
c. Avoid/manage ___________________
d. Avoid further ________
e. Provision of adequate _________
f. _____________ dosing in renal failure
g. Renal replacement therapy
a. Treatment of the underlying cause
b. Correct electrolyte abnormalities
c. Avoid/manage fluid derangements
d. Avoid further renal injury
e. Provision of adequate nutrition
f. Tailor drug dosing in renal failure
g. Renal replacement therapy
Treatment of AKI
(a) Fluid management:
Correct _________ if present.
Avoid ______________ by restricting fluid intake to _____________ plus ______________.
Manage polyuria by providing __________ fluid plus + _______________
hypovolemia ; fluid overload
insensible loss ; previous day’s output.
maintenance fluid plus ; on going losses
Treatment of AKI
(b) Metabolic acidosis: correct if ____________ or <____mmol/l
Hypocalcemia: treat with ______________ if symptomatic or <1.8mmol/l
Hyperphosphatemia: decrease ______ ± _______________
symptomatic ; <12mmol/l
IV calcium gluconate ; intake
phosphate binders
Treatment of AKI
(c). Correct electrolyte abnormalities:
Hyponatremia: correct if less than 125meq/l or symptomatic
Hyperkalemia: severe hyperkalemia (>____meq/l) is a medical emergency and requires the following prompt actions sequentially:
• I.V ______________: 0.5-1ml/kg (slowly or rapidly?) over _______
• I.V __________ 2-3mmol/kg
• I.V _________ 0.5ml/kg of 50%DW ± 1 unit of soluble insulin for every 5g of glucose
• ___________ via nebulisation
• Ion exchange resin (______ or ________)
• Dialysis
7
calcium gluconate
NaHCO3
glucose
Salbutamol via nebulisation
rectally ; orally
Chronic Kidney Disease
Defined as abnormalities of kidney ________ or _________, which has lasted _____________ with implication for health.
structure
function,
> 3 months
Criteria for chronic kidney disease (any of these present for >3 months)
A. _______________________ could be:
1. _____________
2. Urine sediment abnormalities
3._________ and other abnormalities due to tubular disorders
4. Abnormalities detected by histology
5. Structural abnormalities detected by imaging 6. History of kidney transplantation
B. GFR <____ml/min/1.73m2
Evidence of kidney damage
Albuminuria; Electrolyte
60
Classification of CKD based on the cause
•___________: SLE, HIV, HBV, HCV, Sickle cell
disease, minimal change dx, FSGS
•___________: systemic infections, UTI,
obstruction
•_________: systemic vasculitis, thrombotic
microangiopathy, renal limited vasculitis
•__________: polycystic kidney disease, renal dysplasia
Glomerular
Tubulointerstitial
Vascular
Congenital
Common causes of CKD
Any condition that leads to ________________ can cause CKD.
The commonest causes in children are _____________ in origin
significant loss of nephrons
congenital
Common causes of CKD
(a) Obstructive uropathies: __________ , __________ obstruction __________ obstruction, __________ bladder
(b) Renal __________, __________ or __________
(c) __________:focal segmental glomerulosclerosis, membranoproliferative GN, SLE, Henoch-schonlein purpura etc (d) Reflux nephropathy
(e) Hereditary conditions: __________ disease, __________ disease, nephronophthisis
(f) Others such as HIVAN, HBV, HCV
(g) Causes of severe acute kidney injury
posterior urethral valve ; pelvi-ureteric junction obstruction
vesicoureteric junction obstruction; neurogenic bladder
agenesis, aplasia or hypoplasia
Glomerulonephritis
polycystic kidney ; sickle cell disease
Progression of CKD
• CKD is a condition in which an initial kidney injury is followed by a more _________ and chronic ___________________
With loss of nephrons there is compensatory increase in _________ across the remaining nephrons leading to increased _________ and after a long time _________ & _________. The compensatory increase is partly mediated by the ______________________ system. On the long term this leads to further loss of nephron ultimately culminating in ________________
gradual ; loss of kidney function
filtration pressure ; GFR
glomerulomegaly ; sclerosis.
renin angiostensin system.
end stage renal disease
Predictors of progression of CKD
Non-Modifiable
•Underlying cause of CKD
•_________ birth
•______ birth weight
•Growth spurt
•______________
•Low _________ _____
Preterm
Low
Previous AKI
background GFR
Predictors of progression of CKD
Modifiable
•________tension
•__________
•________
•Anaemia
•Acidosis
•Dyslipidemia
•Hyper_________
•Hyper_________
Hypertension
Proteinuria
Obesity
Hyperphosphatemia
Hyperuricemia
