Is the clinical syndrome in which sudden decreasing in 
renal function result in inability of kidney to maintain
fluid and electrolyte homeostasis, 2-3% in children, 8%
in neonatal ICU.
CRITERIA
ESTIMATED CCl
URINE OUTPUT
Risk
eCCl decrease by 25%
<0.5 mL/kg/hr for 8 hr
Injury
eCCl decrease by 50%
<0.5 mL/kg/hr for 16 hr
Failure
eCCl decrease by 75% or eCCl
<35 ml/min/1.73 m2
<0.3 mL/kg/hr for 24 hr
or anuric for 12 hr
Loss
Persistent failure >4 wk
End-stage
End-stage renal disease
(persistent failure >3 mo)
eCCl, estimated creatinine clearance;
pRIFLE, pediatric risk, injury, failure, loss
and end-stage renal
Causes
A-prerenal causes1- dehydration
2- hemorrhage
3- hypoalbunimia 
4- heart failure
B- intrinsic causes , glomeruler 
diseases
1- post infectious GN

2- lupus GN, HSP,
3- HUS
4- acute tubuler necrosis
5- RVT



C- post renal 1- posterior urethral 
valve
2- uretro-pelvic 
junction obstruction
3- stone, neurogenic 
bladder
- vomiting, diarrhea 3 days
prerenal
6
years
child
with
recent
pharangitis+edema+HT=PSGN
- critical ill child with protracted HT and HX of
exposure to nephrotoxin
ATN
- neonate with hydronephrosis in prenatal U/S
congenital P UJ obstruction.
Physical examination
- volume status, tachycardia, dry mouth, poor
peripheral circulation,
prerenal cause
- peripheral edema, basal creptation, gallop
rythem, suggest GN, ATN
- rash +nephritis=SLE, HSP
anemia due to 1- hemolytic(SLE, RVT, HUS)
2- delutional
- leucopenia(SLE)
- thrombocytopenia((SLE, RVT, HUS)
- hyponatremia(delutional)
-metabolic acidosis
-BUN, S.Cre
increase
-uric acid , K+, Ph++, increase
- CA++ low
- C3 level low in(SLE, PSGN, radiation GN, 
membarenoprolefrative)
- Abs in PSGN
-GUA 1- RBC, protienurea, granuler cast,
internsic 
cause
2- WBC, WBC cast, low grade protienurea, 
RBC, tubulointerstesial disease
Indices
Pre renal
Sp.gravity
>1.020
Ur.osmolality
>500
Ur.NA+(Mag/L)
<20
FENA+
<1
BUN/S.cre
>20
FENA+=Una X Pcre/P na X Ucre
- CXR cardiomegaly, pulmonary edema.
- Renal U/S
hydronephrosis, hydroureter, obstruction
- Renal biopsy may needed.
Intrinsic
<1.010
<350
>40
>2
<20
1- infant and children with obstruction or non ambulatory child

bladder catheter, to collect UOP
2- fluid therapy according to volume status 
A- in case of Hypovolemia, N/S 20 CC/kg within 30 min may be 
repeted 2 or 3 times and watch the UOP in 2 hour , if no possible
of internsic or post renal.
Diuretics indicated provided that good volume status Frusamide 
2-4 mg/kg+MANITOL 0.5g/kg , if no UOP within 30 min , consider
diuretic infution , if no UOP, consider
Dopamin 23Mig/kg/min with diuretic , if no UOP, stop diuretic and fluid
should be restricted.
B-in case of normal volemia
consider(insensible water loss) 400 
cc/m2 /day + the fluid equal to the UOP.
C- in case of Hypervolemia insensible water loss and UOP 
should be omitted.
Type of the fluid is glucose-containing solution 10-30% as 
maintaince .
Input, output, UOP, chemistry should be checked daily. 
3- Hyperkalemia >6mg/dl
may lead to cardiac
arrythemia (ECG=tent
T wave , widing QRS, ST
depression, and arrest).
Indication
of withholding of K+(fluid, diet)+Resin
1g/kg orally or rectally by enema every 2-4 hour.
If >7mg/dl give the flowing
1- Ca.gluconate 10% 1cc/kg within 3-5min
2- NACO3 1-2cc/kg over 5-10min
3- Reguler insulin 0.1U/kg with glucose 50% 1cc/kg
over 1hour.
If inspite of all these measure , still persistent
hyperkalemia
consider dialysis.
4- Acidosis if mild rarely need treatment , if sever PH
<7.15 NAHCO3 <8 with hyperkalemia need NAHCO3
infusion (desire PH 7.2, NAHCO3 12).
5- Hypocalcemia primarily treated by lowering S.PH++
, and Ca++ sh be not given I-V unless with tetany to
ovoid Ca . deposition in tissue, use Ca. carbonate 1-3
tab with meal.
6- Hyponatremia
delutional
need
fluid
restriction
,
if
<120
or
symptomatic(seizure,
lethargy
)need
3%NACL .
NACL in m.ag required=0.6XBwt X (125s.NA)
7- Bleeding due to platelet dysfunction,
stress, heparin(dialysis), need oral or I.V
H2 blocker ranitidine
8- HT in GN, HUS, need salt and water
restriction, Nefidipine 0,25-0,5mg/kg
every 2-6hour(max 10mg), B.blocker,long
acting Ca.cannel blocker., if sever crisis
need NA nitropruside or Labetalol
infusion.
9- Anemia
mild, delutional , packed
RBC, 10 cc/kg within 4-6hour if Hb
<7g/dl(better fresh)
10- nutrition NA, PH, K, should be
restricted in most cases, protein should
be moderately decrease, increase calorie
intake.
Intermittent hemodialysis is useful in patients with 
relatively stable hemodynamic status. 3 to 7 times per
week .
Peritoneal dialysis is most commonly employed in 
neonates and infants with ARF, Cycles are repeated for 824 hr/day , contraindicated in patients with significant
abdominal pathology.
Continuous renal replacement therapy (CRRT) is useful in
patients with unstable hemodynamic status, concomitant
sepsis, or multiorgan failure in the intensive care setting.
