พรช ย ก งว ฒนก ล ภาคว ชาก มารเวชศาสตร คณะแพทยศาสตร จ ฬาลงกรณ มหาว ทยาล ย

Transcription

1 พรช ย ก งว ฒนก ล ภาคว ชาก มารเวชศาสตร คณะแพทยศาสตร จ ฬาลงกรณ มหาว ทยาล ย

2 We are detectives.

3 Frame of thought Clinical or Lab Medical vs. Surgical Supportive care only? Refer?

4 Frame of thought Onset Clinical Signs/Symptoms Surgical vs. Medical Surgical: Post renal Medical: Renal, pre-renal Supportive: general, replacement Rx Care Specific: Medications Diagnosis Referral reason Treatment

5 A 5-month-old girl History: Oliguria for 2 days 3 days: low grade fever, mild diarrhea Physical Exam: T 37.2 C, BP 110/70, PR 120/min, RR 44/min, Wt 5 kg, Lt 64 cm Pale, not icteric, puffy eyelids, 2 days: decreased urine output Chest : labor breathing, fine crepitation Today: dyspnea and edema Ext: mild edema

6 Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents (2017) P Stage 2 Hypertension Stage 1 Hypertension P 95 Elevated Blood Pressure P 90 or 120/80 Normal Blood Pressure

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9 How to remember? BP Classification Systolic BP Diastolic BP Elevated blood pressure 96 + (2 x age) or Stage 1 hypertension (2 x age) or SBP - 40 Stage 2 hypertension (2 x age) or

10 A 5-month-old girl History: Oliguria for 2 days 3 days: low grade fever, mild diarrhea Physical Exam: T 37.2 C, BP 110/70, PR 120/min, RR 44/min, Wt 5 kg, Lt 64 cm Pale, not icteric, puffy eyelids, 2 days: decreased urine output Chest : labor breathing, fine crepitation Today: dyspnea and edema Ext: mild edema

11 Problems Diarrhea Oliguria Hypertension Hypervolemia: Pulmonary congestion

12 Initial investigations CBC: Hb 8.8 g/dl, Hct 26.2%, WBC 5,720. plt 146,000 UA: spgr 1.007, ph 6, blood 2+, protein 1+, RBC 10-20/hpf BUN 45, Cr 2.7 mg/dl, Na + 132, K + 4.8, Cl - 92, CO 2 10 mmol/l Ca 8.2, PO4 8.6 mg/dl

13 Frame of thought Onset Clinical Signs/Symptoms Surgical vs. Medical Surgical: Post renal Medical: Renal, pre-renal Supportive: general, replacement Rx Care Specific: Medications Diagnosis Referral reason Treatment

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16 Frame of thought Onset Clinical Signs/Symptoms Surgical vs. Medical Surgical: Post renal Medical: Renal, pre-renal Supportive: general, replacement Rx Care Specific: Medications Diagnosis Referral reason Treatment

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19 Primary hyperoxaluria type I American Journal of Kidney Diseases , DOI: ( /j.ajkd ) Copyright 2008 National Kidney Foundation, Inc. Terms and Conditions

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21 A 1 year-2-month-old boy History: Seizure for 5 min 1 week: low grade fever, clear nasal discharge, productive cough 3 days: diarrhea 1 day: yellow-red stool, vomiting, poor appetite Today: fever, vomiting, decreased urine, bloody diarrhea and seizure Physical Exam: T 37.7 C, BP 120/85, PR 123/min, RR 44/min, Wt 10 kg, Lt 77 cm Pale, not icteric, puffy eyelids, petechiae at chest and left calf no localizing sign

22 Problems Fever with diarrhea Seizure Anemia with petechiae Oliguria Hypertension

23 Frame of thought Onset Clinical Signs/Symptoms Surgical vs. Medical Surgical: Post renal Medical: Renal, pre-renal Supportive: general, replacement Rx Care Specific: Medications Diagnosis Referral reason Treatment

24 Initial investigations CBC: Hb 8.8 g/dl, Hct 26.2%, WBC 25,720. plt 46,000 UA: spgr 1.007, ph 6, blood 4+, protein 2+, RBC 3-5/hpf BUN 87, Cr 1.6 mg/dl, Na + 130, K + 4.4, Cl - 94, CO 2 13 mmol/l Ca 9.2, PO4 6 mg/dl Stool: soft, yellow, few RBC, no WBC. PT 10 sec (11), aptt 27 sec (28)

25 Peripheral smear

26 Thrombotic Microangiopathy (TMA) Clinical syndrome Microvascular thrombosis Thrombocytopenia Microangiopathic hemolytic anemia (MAHA)

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28 Acute kidney injuries (AKI) Previously known as acute renal failure 2004 Acute Dialysis Quality Initiative (ADQI) RIFLE criteria prifle criteria KDIGO criteria

29 RIFLE Criteria Risk of renal dysfunction Injury to the kidney Failure of kidney function Loss of kidney function End-stage kidney disease

30 RIFLE criteria RIFLE criteria GFR criteria Urine output criteria Risk of renal dysfunction Injury to the kidney Scr เพ มข น 1.5 เท า หร อ GFR ลดลง มากกว าร อยละ 25 Scr เพ มข น 2 เท า หร อ GFR ลดลง มากกว าร อยละ 50 ป สสาวะ < 0.5 ml/kg/hr เป นเวลา 6 ชม. ป สสาวะ < 0.5 ml/kg/hr เป นเวลา 12 ชม. Failure of kidney function Scr เพ มข น 3 เท า หร อ GFR ลดลง มากกว าร อยละ 75 หร อ Scr มากกว า 4 mg/dl ป สสาวะ < 0.3 ml/kg/hr เป นเวลา 24 ชม. หร อ ไม ม ป สสาวะออกเป นเวลา 12 ชม. Loss of kidney function End-stage kidney disease ไตวายฉ บพล น มากกว า 4 ส ปดาห ไตวาย มากกว า 3 เด อน

31 AKIN staging Stage GFR criteria Urine output criteria I SCr > 0.3 mg/dl or SCr > % from baseline < 0.5 ml/kg per hour 6 h II SCr % from baseline < 0.5 ml/kg per hour >12 h III SCr > 300 % from baseline or SCr > 4.0 mg/dl with an acute rise of at least 0.5 mg/dl < 0.3 ml/kg per hour >24 h or anuria for > 12 h

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33 Biomarkers of AKI Functional Cystatin C Damage NGAL (neutrophil gelatinase-associated lipocalin) IL-18 (interleukin-18) KIM-1 (kidney injury molecule-1)

34 Management of AKI General measures Preventive measures Volume replacement in gastroenteritis IV theophylline in severe asphyxiated neonate? Diuretics and dopamine agonists Promote urine output with no effect on the cause of renal failure Therapies to decrease injury and promote recovery Animal studies Specific measures Immunosuppressive for glomerulonephritis and vasculitis Plasma exchange for TMA

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36 Common causes of acute kidney injuries in children Neonate Birth asphyxia Infancy Dehydration, HUS Childhood Others Acute glomerulonephritis Post-op complication Sepsis

37 Fluid & Electrolyte abnormalities Volume Hypervolemia Osmolality Dilutional Hyponatremia Acid-Base Acidosis Potassium Hyperkalemia

38 Rational of Therapy Volume TF = IL + UO Osmolality Acid-Base Na + restriction Alkaline Therapy Renal Replacement Therapy Potassium K + restriction K + cocktail

39 Indication of dialysis treatment Medical treatment failure Inability to control fluid and electrolyte abnormalities Uremic symptoms Multi-organ dysfunction

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41 Childhood RRT Patients Small size Vascular access Abdominal condition Availability Unit setup Supply Personnel Mode of Rx

42 Mode of RRT in children Peritoneal dialysis Hemodialysis Continuous renal replacement therapy

43 Peritoneal dialysis Cardio-vascular stability Easy, low technology Slow clearance, Multiple exchanges in small children

44 Continuous Renal Replacement Therapy (CRRT) Cardio-vascular stability Good clearance Limitation of vascular access, Complexity of procedure

45 Which modalities? Patient Availability Team

46 PD

47 HD

48 CRRT Machine Manual Aquarius PrismaFlex Infomed

49 Critical care nephrology Application of renal replacement therapy modalities in intensive care setting Blood purification technique Hemofiltration Hemodiafiltration Slow continuous therapy Therapeutic plasma exchange Liver dialysis Treatment of sepsis and inborn error of metabolism

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51 Human resources for Ped RRT นนทบ ร เช ยงราย เช ยงใหม ลาปาง ขอนแก น กร งเทพฯ established potential พ ษณ โลก นครราชส มา ส ร นทร สระบ ร จ นทบ ร ชลบ ร ส ราษฎร ธาน ภ เก ต สงขลา

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54 Frame of thought Clinical or Lab Medical vs. Surgical Supportive care only? Refer?

55 Frame of thought Onset Clinical Signs/Symptoms Surgical vs. Medical Surgical: Post renal Medical: Renal, pre-renal Supportive: general, replacement Rx Care Specific: Medications Diagnosis Referral reason Treatment

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