Management of Acute Kidney Injury in Critically Ill Children

Abstract

Acute kidney injury (AKI) is common in critically ill patients, affecting almost one in four critically ill children and one in three neonates. Higher stages of AKI portend worse outcomes. Identifying AKI timely and instituting appropriate measures to prevent and manage severe AKI is important, since it is independently associated with mortality. Methods to predict severe AKI should be applied to all critically ill patients. Assessment of volume status to prevent the development of fluid overload is useful to prevent adverse outcomes. Patients with metabolic or clinical complications of AKI need prompt kidney replacement therapy (KRT). Various modes of KRT are available, and the choice of modality depends most on the technical competence of the center, patient size, and hemodynamic stability. Given the significant risk of chronic kidney disease, patients with AKI require long-term follow-up. It is important to focus on improving awareness about AKI, incorporate AKI prevention as a quality initiative, and improve detection, prevention, and management of AKI with the aim of reducing acute and long-term morbidity and mortality.

Keywords: AKI; Dialysis; Kidney replacement therapy; Pediatric.

Fig. 1

Circuit diagrams for the various modes of continuous kidney replacement therapy (CKRT). Blood flows from left to right from the patient to the blood pump and then to the filter, from which it is returned to the patient. a Slow continuous ultrafiltration (SCUF): In this modality, there is no diffusive clearance and only ultrafiltrate (UF) is generated across the filter; this method is preferred for isolated UF removal when kidney function is normal. b Continuous venovenous hemofiltration (CVVH): Replacement fluid is run either pre- or post-filter in a volume to replace the effluent; excess effluent is removed to ensure the UF desired for negative fluid balance; clearance is convective rather than diffusive. c Continuous venovenous hemodialysis (CVVHD): Blood flows across the filter in a countercurrent fashion with the dialysate fluid, and the effluent predominantly consists of dialysate fluid with minimal, if any, UF, as in intermittent hemodialysis. d Continuous venovenous hemodiafiltration (CVVHDF): This modality combines CVVH with CVVHD, such that the blood and dialysis fluid run in counter-current directions, the replacement fluid is either pre- or post-filter, and the effluent comprises the dialysate and replacement fluids