Çocuklarda Akut Böbrek Hasarı ve Yönetimi
Özet
Çocuklarda akut böbrek hasarı (ABH); glomerüler filtrasyon hızında azalma, atık maddelerin birikmesi ve sıvı-elektrolit dengesizliği ile seyreden ani böbrek fonksiyon kaybıdır. Günümüzde ABH tanısında ve evrelemesinde serum kreatinini ile idrar çıkışını esas alan KDIGO sınıflandırmasının kullanılması öncelikli olarak önerilmektedir. Etiyolojik açıdan hastalıklara prerenal (%60), intrensek renal (%35) ve postrenal (%5) faktörler neden olmaktadır. Prerenal ABH; dehidratasyon, kanama veya şok gibi intravasküler hacim yetersizliğinden kaynaklanırken, renal ABH glomerülonefrit, akut tübüler nekroz ve nefrotoksik ajanlara bağlı gelişmekte, postrenal ABH ise üriner sistemdeki tıkanıklıklar sonucu ortaya çıkmaktadır. Tanıda detaylı anamnez, fizik muayene, Schwartz formülü ile eGFR hesabı, idrar tahlili, ultrasonografi ve NGAL ile sistatin-C gibi biyobelirteçlerden yararlanılmaktadır. Tedavinin temel prensiplerini hemodinamik stabilizasyonun sağlanması, intravasküler hacmin korunması, özgül sıvı-elektrolit dengesinin kurulması (hiperkalemi, hiponatremi, metabolik asidoz ve hipertansiyon tedavisi) ile katabolik sürece yönelik beslenme desteği oluşturmaktadır. Tıbbi tedaviye yanıt vermeyen anüri/oligüri, şiddetli asidoz, dirençli hiperkalemi, üremi veya aşırı sıvı yükü varlığında periton diyalizi, aralıklı hemodiyaliz veya sürekli renal replasman tedavisi (CRRT) gibi renal replasman yöntemleri uygulanır. Hastalığın prognozu altta yatan etiyolojiye bağlıdır ve renal replasman tedavisi başlangıcında %20'nin üzerindeki sıvı yükü yüksek mortalite ile doğrudan ilişkilidir.
Referanslar
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.
