Treatment of Acute Kidney Injury in Children: Conservative Management to Renal Replacement Therapy

Cause

The initial evaluation is straightforward, with assessment of patients' anamnesis, recent medical or surgical procedures, and received drugs. In the same line, volume status, cardiac output, and careful examination of volume depletion should be performed. Evaluation by hemodynamic monitoring as well as determination of the fractional excretion of sodium (FeNa) may be helpful to diagnose renal dysfunction in this etiologic category.

Other possible causes of AKI can be evaluated readily by renal ultrasound imaging at the bedside to look for an obstructive pattern, at the level of either the bladder or the ureters. Identifying whether the patient has solitary or bilateral kidneys or other major renal congenital malformations also is helpful.

The remaining causes of AKI are intrinsic processes. With advances in technology and medical care in Western medical centers, intrinsic kidney disease often is related to drug toxicity, sepsis, acute tubular necrosis (ATN), or an acute process with underlying chronic kidney disease (CKD). Another primary cause of intrarenal AKI continues to be hemolytic uremic syndrome. The diagnosis of hemolytic uremic syndrome can be made easily by evaluation of a peripheral smear, looking for subnormal cell counts and presence of schistocytes, with worsening anemia and uremia. This clinical picture should be distinguished from that in sepsis or disseminated intravascular coagulation (DIC), which can include the same findings. In the absence of hemolytic uremic syndrome, drug-induced AKI, or ATN, renal biopsy is indicated to identify the AKI cause and perhaps to direct therapy: however, this is rarely the case in the pediatric intensive care unit (PICU) setting.

General Approach to Conservative Management