Address For Correspondence:
R Bhimma, Department of Paediatrics & Child Health, Nelson R Mandela School of Medicine, University of Kwazulu-Natal, Private Bag 7, Congella, 4013, South Africa.
Email: bhimma@ukzn.ac.za

Management of AKI in children

Preventive Measure

In asphyxiated neonates, intravenous infusion of theophylline given within the first hour was associated with improved fluid balance, creatinine clearance and reduced serum creatinine levels in some studies. The potential mechanism that theophylline could protect from AKI in this setting may be by blocking of the adenosine receptor [53-55]. However, additional studies are needed to determine the significance of these findings and the potential side-effects of theophylline.

Diuretics and 'renal dose' dopamine are commonly used to prevent or limit AKI [56-63]. Although, stimulation of urine output aids in improving fluid management in AKI, conversion of oliguric to non-oliguric AKI has not been shown to alter the cause of renal failure. Furosemide may decrease intra-tubular obstruction by increasing urine flow rate. Also inhibition of Na+-K+-ATPase will limit oxygen consumption in already damaged tubules with a low oxygen supply [3]. Continuous infusion of furosemide may be associated with less toxicity than bolus administration [57]. 'Renal-dose' dopamine (0.5-5mcg/kg/min) may increase renal blood flow by promoting vasodilation and may improve urine output by promoting natriuresis. However, the use of dopamine has not been shown to decrease the need for dialysis or improve survival in patients with AKI. [59-63].

Fenoldopam is a potent, short-acting, selective, dopamine-1 receptor agonist that decreases vascular resistance while increasing renal blood flow [64] Several trials in adults have shown that the use of fenoldopam decreases the incidence of AKI, need for renal replacement therapy, length of hospital stay and the number of deaths from any cause [65]. Large scale paediatric studies are still outstanding.

All nephrotoxic agents should at best be avoided or used with extreme caution. Similarly, all medications cleared by renal excretion should be avoided or their doses should be adjusted appropriately.

A prophylactic therapy shown to decrease the incidence of contrast nephropathy is the intravenous administration of fluids. Normal saline or isotonic sodium bicarbonate given in a dose of 1ml/kg/hour 12 hours before and then 12 hours after the procedure is recommended.

N-acetylcysteine is another prophylactic agent used with varying success in high-risk patients and is given a day before a contrast study is performed and is continued on the day of the procedure [66].