Pediatric acute kidney injury: Indications, timing, and choice of modality for renal replacement therapy (RRT)
- Patrick D Brophy, MD
Patrick D Brophy, MD
- University of Iowa, Carver College of Medicine
- Jennifer G Jetton, MD
Jennifer G Jetton, MD
- Clinical Associate Professor
- University of Iowa, Carver College of Medicine
Acute kidney injury (AKI) is characterized by the acute failure of the kidneys to maintain adequate electrolyte, acid-base, and fluid homeostasis along with a reduction in glomerular filtration rate (GFR) [1,2]. Clinically, AKI is manifested by increases in nitrogenous waste products (blood urea nitrogen [BUN]) and serum creatinine (SCr), and, in some cases, a concomitant reduction in urine output (less than 0.5 to 1 mL/kg per hour) that may be refractory to diuretic therapy [1-3]. (See "Acute kidney injury in children: Clinical features, etiology, evaluation, and diagnosis".)
AKI is increasingly recognized as an important and independent risk factor of morbidity and mortality in critically ill children [4-7]. With at least 30 different definitions of AKI reported in the literature , generalizations across studies and comparisons of different data sets are challenging. As a result, the lack of evidence-based guidelines regarding the management of the pediatric patient with AKI has led to uncertainty and controversy regarding the appropriate timing for the initiation of renal replacement therapy (RRT), as well as the most appropriate RRT modality.
The indications, timing, and modalities for RRT for children with AKI will be reviewed here. RRT in adults is discussed separately. (See "Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose", section on 'Timing of elective initiation'.)
INDICATIONS FOR AND TIMING OF RRT
Retrospective reviews of large databases of critically ill children demonstrate that children tend to develop organ failure, including AKI, early in their hospital course, and children with AKI have a greater mortality risk and longer length of stay than those without AKI [9,10]. RRT may prevent and correct the adverse and potentially life-threatening complications of AKI including symptomatic uremia, metabolic and electrolyte imbalance, and severe fluid overload, thereby reducing the mortality and length of stay of children with AKI.
Indicators for the provision of RRT in pediatric AKI have been traditionally extrapolated from the following parameters used for dialysis initiation for end-stage renal disease (ESRD) :
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- INDICATIONS FOR AND TIMING OF RRT
- Severity of AKI
- Fluid overload
- Renal angina
- Our approach
- MODALITY CHOICE
- Peritoneal dialysis
- - Contraindications and complications
- Intermittent hemodialysis
- Continuous renal replacement therapy
- Comparisons of modalities
- SUMMARY AND RECOMMENDATIONS