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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA-AFRICA  
Year : 2011  |  Volume : 22  |  Issue : 5  |  Page : 1072-1076
Acute renal failure in the pediatric age group - Single center prospective study of 180 cases


1 Department of Nephrology and Clinical Transplantation, Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) - Smt Gulabben Rasiklal Doshi and Smt Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre (IKDRC), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India
2 Department of Pathology, Laboratory Medicine, Transfusion Services and Immunohematology, Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) - Smt Gulabben Rasiklal Doshi and Smt Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre (IKDRC), Civil Hospital Campus, Asarwa, Ahmedabad, Gujarat, India

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Date of Web Publication6-Sep-2011
 

   Abstract 

Acute renal failure (ARF) is one of the common emergencies in pediatric practice. In the Indian subcontinent, its etiology, clinical features and outcome vary from other parts of the world. We decided to perform a prospective study of ARF in 180 pediatric patients admitted to our institute between August 2006 and March 2008. Our study included children, neonates 7.8%, <1 year 16.7%, 1-5 years 30.5% and >5 years comprised 52.8%. The male:female ratio was 2.3:1. Acute tubular necrosis remains the major cause of ARF; other intrinsic renal disease accounted for almost 30% of the patients. In all patients of ARF who required dialysis, peritoneal dialysis was offered as the first-line management. Six patients were offered hemodialysis. Mortality below one year age was higher compared with those who were more than one year of age (40% vs 11.3%). The overall mortality in the present study was 17.7%. ARF in pediatric nephrology is not uncommon. In our setup, peritoneal dialysis (PD) is an effective and safe modality of renal replacement therapy in most of the cases. Delayed referral, malnutrition, infections, age less than one year and multiorgan involvement were bad prognostic features.

How to cite this article:
Shah P R, Falodia J, Kute V B, Kanodia K V, Vanikar A V, Goplani K R, Gera D N, Trivedi H L. Acute renal failure in the pediatric age group - Single center prospective study of 180 cases. Saudi J Kidney Dis Transpl 2011;22:1072-6

How to cite this URL:
Shah P R, Falodia J, Kute V B, Kanodia K V, Vanikar A V, Goplani K R, Gera D N, Trivedi H L. Acute renal failure in the pediatric age group - Single center prospective study of 180 cases. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2022 May 20];22:1072-6. Available from: https://www.sjkdt.org/text.asp?2011/22/5/1072/84572

   Introduction Top


Acute renal failure (ARF) is one of the common emergencies in pediatric practice. In the Indian subcontinent, its etiology, clinical features and outcome vary from other parts of the world. [1] It is a syndrome of diverse etiology characterized by rapid deterioration of renal function resulting in accumulation of harmful nitrogenous wastes in the body and perturbation of extracellular fluid volume as well as electrolyte and acid base homeostasis. Most of the ARF in this group were due to acute gastroenteritis or were infection related, as found in developing countries like India, while in the developed world, complications of surgery and hemolytic uremic syndrome (HUS) are important causes of ARF. [2] We decided to perform a prospective study of ARF in the pediatric age group at our institute.


   Materials and Methods Top


All children with ARF in the age group from 0 to 14 years were included who were admitted to the pediatric nephrology department during the period August 2006 to March 2008. All these patients were studied by obtaining a detailed history, a thorough physical examination and necessary investigations. Acute glomerulonephritis was diagnosed when patients presented with acute nephritic syndrome, urine analysis showing red cells and protenuria of variable degrees with or without suggestive immunological parameters like low levels of complement (C3) and raised ASO titer. The diagnosis of HUS was based on the presence of clinical presentation with or without thrombocytopenia and microangiopathic hemolytic anemia. C-ANCA and P-ANCA were performed in patients with rapidly progressing glomerulonephritis (RPGN) and diagnosis was confirmed by histo-pathological examination when considered necessary. Acute tubular necrosis was diagnosed based on initial presentation of the disease with typical history and bland urinary sediment and exclusion of other causes. Kidney biopsy was performed in 30 patients in the following conditions:

  1. Clinical presentation of acute glomerulonephritis (AGN but having s. creatinine >2 mg%, to rule out crescentic GN.
  2. Rapidly deteriorating renal function with or without oliguria.
  3. Delayed recovery of renal function.
  4. Prolonged hematuria.
  5. Clinical suspicious of illness other then acute tubular necrosis.
  6. Suspicious of systemic lupus erythematosis (SLE) with positive serological markers.
Management of patients included correction of electrolyte balance, fluid management, anuria correction and control of hypertension. For indicated patients, IV steroids, cyclophosphamide and plasmapheresis were given. Dialysis was performed in situations like:

  1. Uremic symptoms, mainly vomiting, convulsions, drowsiness and coma along with biochemical changes.
  2. Volume overload with pulmonary edema.
  3. Uncontrolled metabolic acidosis. Blood pH<7.3.
  4. Hyperkalemia S.K. + >6.0 mEq/L.
  5. Oligoanuria of more than 48 hours.
  6. Complex electrolyte disturbances.
  7. To plan renal biopsy in patients with rapidly deteriorating renal function.


Intermittent peritoneal dialysis was performed using a pediatric PD catheter or an infant feeding tube. Patients were followed and monitored for distension of abdomen, hydration status and hypothermia. Urine output, symptomatology, changes in renal function, progression of disease, time taken for recovery and outcome of the patient were monitored. An attempt was made to determine the prognostic factor for ultimate outcome. Statistical analysis was performed to deduce age, sex and demographic prevalence and other risk factors for occurrence of renal failure, and positive factors for recovery were studied.


   Results Top


During the period August 2005 to March 2008, we studied 180 children admitted with ARF to our institute. Children less then one year of age were 16.7%; neonates comprised almost 7.8% of the group. Children between one and five years comprised 30.5%, while children more than five years of age comprised the maximum: 52.8%. The male:female ratio was 2.3:1. Etiology of various renal disorders are depicted in [Table 1].
Table 1: Etiological classification of ARF.

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Ours being a tertiary care center, only 9.4% of the cases were due to pre-renal cases because most of the pre-renal cases are treated at primary or secondary care centers. In the present study, acute tubular necrosis remains the major cause of ARF; other intrinsic renal disease accounted for almost 30% of the patients. Post-renal cases were 15%. Thirty-eight cases were anuric, 93 cases were oliguric and 49 cases were non-oliguric.

In all patients of ARF who required dialysis, peritoneal dialysis was offered as the first-line management, except in patients having volume overload, bleeding tendency and those with a provisional diagnosis of HUS, where plasma exchange and dialysis were to be performed together. Six patients were offered hemodialysis.

Renal biopsy was performed in 30 patients (16.7%). Majority 14 (7.8%) cases were having post-infectious glomerulonephritis (PIGN), while the second common causes were HUS and crescentic GN.

Extent of recovery and follow-up is shown in [Table 2]. All pre-renal cases recovered. Of 76 acute tubular necrosis (ATN) cases, 93% patients required dialysis. Three cases had partial recovery and six patients expired due to poor nutrition combined with paralytic ileus and postfeeding (tube feeding) problem.

[Table 3] shows the various prognostic factors. This table shows that mortality in the below one year age group was higher (40% vs 11.3%). This can be due to underlying septicemia, prematurity, feeding problems, associated congenital anomalies, etc. in neonates. Of 32 expired patients, ten patients were late arrivals for dialysis and were with severe pulmonary edema and acidosis, which could not be reverted, and those patients expired.
Table 2: Extent of recovery and follow-up.

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Table 3: Prognostic factors of ARF.

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Mortality in the present study was 17.7%, which is comparable with other studies [Table 4].
Table 4: Comparison of outcome with other studies.

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Acharya et al had encountered a high mortality (73.2%) due to late referral and severe ARF in their patients.


   Discussion Top


ARF is a serious condition in critically ill children. [3] ARF may have an impact on morbidity and mortality of the affected patients. [4],[5] The etiology of ARF seems to differ in different countries. [6] Srivastav et al and Shah et al [7] reported that AGE was responsible for 27% and 48% of ARF, respectively. We reported 18.3%, which is similar to that reported by others. [8],[9] Sepsis was the most common cause of ARF in the pediatric population. [10],[11] In the present study, 7.7% of the cases had sepsis leading to ARF. HUS and cardiovascular surgeries are prominent causes of ARF in high-income countries. [2],[12],[13] In this study, HUS was responsible for 2.5% of the cases with poor outcome. In the Western countries, the incidence of post-infectious glomerulonephritis, like that which follows post-streptococcal infection, has considerably declined due to better hygienic conditions, but this still remains a common disorder in developing countries. [14] In our study, 16.7% of the cases had PIGN.

Mortality below one year of age was higher compared with that in more than one year of age (40% v/s 11.3%). The overall mortality in the present study was 17.7%. Mortality rates of 17.3-73.2% have been reported in other studies depending on the underlying disorder. [8],[15] Poor nutrition, infection, central nervous system complications and prolonged anuria were poor prognostic factors. In patients with glomerular disease, 33% had rapidly progressive renal failure (RPRF) and, despite treatment with immunosuppression and plasma exchange, had either no recovery or partial recovery and, ultimately, became dialysis dependant.

In conclusion, ARF in pediatric nephrology is not uncommon. In our setup, PD seems to be an effective and safe modality of renal replacement therapy in most of the cases. Delayed referral, malnutrition, infections, age less than one year and multiorgan involvement were all bad prognostic features. Aggressive approach in the form of early dialysis, early renal biopsy and prompt treatment with immunosuppression and plasma exchange when necessary can favorably affect the outcome. [17]

 
   References Top

1.Mehta KP. Acute renal failure in India, Pakistan and Bangladesh. In: Holiday M A, Barratt TM, Avner ED (eds). Pediatric Nephrology, 3 rd edn. Baltimore, Williams and Wilkins, 1994;1440-1.  Back to cited text no. 1
    
2.Srivastva RN, Modugil A, Bagga A, Vasudev AS. Hemolytic uremic syndrome in children in northen India. Pediatr Nephrol 1991;5:284-8.  Back to cited text no. 2
    
3.Bailey D, Phan V, Litalien C, et al. Risk factors of acute renal failure in critically ill children: A retrospective epidemiological study. Pediatr Crit Care Med 2007;8(1):29-35.  Back to cited text no. 3
    
4.Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous venovenous hemofiltraion on outcome of acute renal failure: a prospective randomized trial. Lancet 2000;356 (9223):26-30.  Back to cited text no. 4
    
5.Lowrie L. Renal replacement therapies in pediatric multiorgan dysfunction syndrome. Pediatr Nephrol 2000;14(1):6-12.  Back to cited text no. 5
    
6.Otukesk H, Hoseini R, Hooman N, Chalian H, Tabarroki A. Prognosis of acute renal failure in children. Pediatr Nephrol 2006;21(12):1873-8.  Back to cited text no. 6
    
7.Srivastava RN. Pediatric renal disease in India. In: Pediatric Nephrology, 2 nd edn. Eds Holiday MA, Barratt TM, Vernier RI. Baltimore, Williams and Wilkins, 1987;354-8.  Back to cited text no. 7
    
8.Choudhry VP, Srivastava RN, Vellodi A, Bhuyan UN, Ghai OP. A study of acute renal failure. Indian Pediatr 1980;17:405-10.  Back to cited text no. 8
[PUBMED]    
9.Shah BV, Almeida AF, Chawla KP, et al. Acute renal failure in pediatric population in tropics. J Postgrad Med 1985;31:134-9.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.Kandoth PW, Agrawal GJ, Dharnidharka VR. Acute renal failure in children requiring dialysis therapy. Indian Pediatr 1994;31:305-9.  Back to cited text no. 10
    
11.Deb B, Banerjee S, Lilia S. Renal failure in non-ICU set up. In: Conferences Abstracts, 30 th National Conference Indian Academy of Pediatr, 1993;75-6.  Back to cited text no. 11
    
12.Ghani AA, Al Helal B, Hussain N. Acute renal failure in pediatric patients: Etiology and predictors of outcome. Saudi J Kidney Dis Transpl 2009;20(1):69-76.  Back to cited text no. 12
    
13.Flynn JT. Causes, management approaches and outcome of acute renal failure in children. Curr Opin Pediatr 1998;10(2):184-9.  Back to cited text no. 13
    
14.Spizzirri FD, Rahman RC, Bibiloni N, Ruscasso JD, Amoreo OR. Childhood hemolytic uremic syndrome in Argentina: Long term follow-up and prognostic features. Pediatr Nephrol 1997; 11(2):156-60.  Back to cited text no. 14
    
15.Mogal NE, Brocklebank JT, Meadow SR. A review of acute renal failure in children: incidence, etiology and outcome. Clin Nephrol 1998; 49(2):91-5.  Back to cited text no. 15
    
16.Acharya UT, Singla PN, Singh RG, Usha, Mishra OP. Outcome of dialysed patients with acute renal failure. Indian Pediatr 1996;33:387-90.  Back to cited text no. 16
[PUBMED]    
17.Shaheen IS, Watson AR, Harvey B.Acute renal failure in children: etiology, treatment and outcome. Saudi J Kidney Dis Transpl. 2006;17: 153-8.  Back to cited text no. 17
    

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Correspondence Address:
P R Shah
Department of Nephrology and Clinical Transplantation, Dr. H. L. Trivedi Institute of Transplantation Sciences (ITS) - Smt Gulabben Rasiklal Doshi and Smt Kamlaben Mafatlal Mehta Institute of Kidney Diseases and Research Centre (IKDRC), Civil Hospital Campus, Asarwa, Ahmedabad 380016, Gujarat
India
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]

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