Çocuklarda Akut Böbrek Hasarı ve Yönetimi
Synopsis
Acute kidney injury (AKI) in children is a sudden loss of kidney function characterized by a reduction in glomerular filtration rate, accumulation of waste products, and fluid-electrolyte imbalance. Currently, the use of the KDIGO classification based on serum creatinine and urine output is primarily recommended for the diagnosis and staging of AKI. Etiologically, the conditions are divided into three groups: prerenal (60%), intrinsic renal (35%), and postrenal (5%) causes. Prerenal AKI stems from intravascular volume depletion such as dehydration, hemorrhage, or shock, whereas renal AKI develops secondary to glomerulonephritis, acute tubular necrosis, and nephrotoxic agents, and postrenal AKI arises from urinary tract obstructions. For diagnosis, detailed anamnesis, physical examination, eGFR calculation using the Schwartz formula, urinalysis, ultrasonography, and novel biomarkers such as NGAL and cystatin-C are utilized. The core principles of management consist of achieving hemodynamic stabilization, maintaining intravascular volume, establishing targeted fluid-electrolyte balance (management of hyperkalemia, hyponatremia, metabolic acidosis, and hypertension), and providing nutritional support for the catabolic state. In cases of anuria/oliguria unresponsive to medical therapy, severe acidosis, persistent hyperkalemia, uremia, or fluid overload, renal replacement therapies such as peritoneal dialysis, intermittent hemodialysis, or continuous renal replacement therapy (CRRT) are initiated. The prognosis of the disease depends on the underlying etiology, and fluid overload exceeding 20% at the initiation of renal replacement therapy is directly associated with high mortality.
References
Devarajan P. (2020). Acute Kidney Injury. Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor (Eds.), Nelson Textbook of Pediatrics, (21nd ed., Chapter 550-1, pp. 2769-2774). Philadelphia: Elsevier
Devarajan P, Goldstein SL. (2017). Acute kidney injury. Karrwal K. Kher, H. William Schnaper, Larry A. Greenbaum (Eds.), Clinical Pediatric Nephrology. (3nd ed., Chapter 30, pp.571-601). New York: Taylor & Francis Group
Bellomo R, Ronco C, Kellum JA, et al. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Group. Crit Care. 2004.8(4):204-12. doi: 10.1186/cc2872.
Improving global outcomes (KDIGO) acute kidney injury work group: KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2: 1-138.
Goldstein SL. Urine Output Assessment in Acute Kidney Injury: The Cheapest and Most Impactful Biomarker. Front Pediatr. 2020;7:565. doi: 10.3389/fped.2019.00565.
Sutherland SM, Kwiatkowski DM. Acute Kidney Injury in Children. Adv Chronic Kidney Dis. 2017;24(6):380-387. doi: 10.1053/j.ackd.2017.09.007.
Akcan-Arikan A, Zappitelli M, Loftis LL, et al. Modified RIFLE criteria in critically ill children with acute kidney injury. Kidney Int. 2007;71(10):1028-35. doi: 10.1038/sj.ki.5002231.
Chung KK, Stewart IJ, Gisler C, et al. Acute Kidney Injury Network (AKIN) criteria applied in burns. J Burn Care Res. 2012;33(4):483-90. doi: 10.1097/BCR.0b013e31825aea8d.
Andreoli SP. Acute kidney injury in children. Pediatr Nephrol. 2009;24(2):253-63. doi: 10.1007/s00467-008-1074-9.
Duzova A, Bakkaloglu A, Kalyoncu M, et al. Turkish Society for Pediatric Nephrology Acute Kidney Injury Study Group. Etiology and outcome of acute kidney injury in children. Pediatr Nephrol. 2010;25(8):1453-61. doi: 10.1007/s00467-010-1541-y.
Breyer MD, Hao C, Qi Z. Cyclooxygenase-2 selective inhibitors and the kidney. Curr Opin Crit Care. 2001;7(6):393-400. doi: 10.1097/00075198-200112000-00005.
Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81(9):819-25. doi: 10.1038/ki.2011.339.
Kellum JA, Angus DC. Patients are dying of acute renal failure. Crit Care Med. 2002;30(9):2156-7. doi: 10.1097/00003246-200209000-00041.
Basile DP. The endothelial cell in ischemic acute kidney injury: implications for acute and chronic function. Kidney Int. 2007;72(2):151-6. doi: 10.1038/sj.ki.5002312.
Phan V, Brophy PD, Fleming GF (2008). Acute Renal Failure: Prevention, Causes, and Investigation. Geary DF, Schaefer F (Eds.), Comprehensıve Pedıatrıc Nephrology (1nd ed., Chapter 39, pp. 607-627). Philadelphia, Elsevier.
Hoschek JC, Dreyer P, Dahal S, et al. Rapidly progressive renal failure in childhood. Am J Kidney Dis. 2002;40(6):1342-7. doi: 10.1053/ajkd.2002.37394.
Himmelfarb J, McMonagle E, Freedman S, et al. The PICARD Group. Oxidative stress is increased in critically ill patients with acute renal failure. J Am Soc Nephrol. 2004;15(9):2449-56. doi: 10.1097/01.ASN.0000138232.68452.3B.
Yılmaz, FH. "Çocuklarda Akut Böbrek Hasarı." Pediatric Practice and Research. 2020.8;2: 62-68. doi:10.21765/pprjournal.763418
Schwartz GJ, Muñoz A, Schneider MF, et al. New equations to estimate GFR in children with CKD. J Am Soc Nephrol. 2009;20(3):629-37. doi: 10.1681/ASN.2008030287.
Düzova A (2017). Akut Böbrek Yetmezliği. Yurdakök M. (Ed.), PEDİATRİ içinde, (s. 3789-3796). Ankara: Güneş Tıp Kitabevleri
Çivilibal M, Aksu BY."Acute Kidney Injury and the Current Guidelines." Haseki Tıp Bülteni. 2015;53(2):116-19. DOI: 10.4274/haseki.2579
Gharaibeh KA, Hamadah AM, El-Zoghby ZM, et al. Cystatin C Predicts Renal Recovery Earlier Than Creatinine Among Patients With Acute Kidney Injury. Kidney Int Rep. 2017.3;3(2):337-342. doi: 10.1016/j.ekir.2017.10.012.
Schiffl H, Lang SM. Update on biomarkers of acute kidney injury: moving closer to clinical impact?. Mol Diagn Ther. 2012;16(4):199-207. doi: 10.1007/BF03262209.
Fahimi D, Mohajeri S, Hajizadeh N, et al. Comparison between fractional excretions of urea and sodium in children with acute kidney injury. Pediatr Nephrol. 2009;24(12):2409-12. doi: 10.1007/s00467-009-1271-1.
Bagshaw SM, Bellomo R, Kellum JA. Oliguria, volume overload, and loop diuretics. Crit Care Med. 2008;36(4 Suppl):S172-8. doi: 10.1097/CCM.0b013e318168c92f.
Lassnigg A, Donner E, Grubhofer G, et al. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol. 2000;11(1):97-104.
Lauschke A, Teichgräber UK, Frei U, et al. 'Low-dose' dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int. 2006;69(9):1669-74. doi: 10.1038/sj.ki.5000310.
Sutherland SM, Alexander SR. Continuous renal replacement therapy in children. Pediatr Nephrol. 2012;27(11):2007-2016. doi: 10.1007/s00467-011-2080-x.
Sutherland SM, Goldstein SL, Alexander SR. The prospective pediatric continuous renal replacement therapy (ppCRRT) registry: a critical appraisal. Pediatr Nephrol. 2014;29:2069-2076.
Hayes LW, Oster RA, Tofil NM, et al. Outcomes of critically ill children requiring continuous renal replacement therapy. J Crit Care. 2009;24(3):394-400. doi: 10.1016/j.jcrc.2008.12.017.
Bunchman TE, McBryde KD, Mottes TE, et al. Pediatric acute renal failure: outcome by modality and disease. Pediatr Nephrol. 2001;16(12):1067-71. doi: 10.1007/s004670100029.
