Evaluation and management of children with acute kidney injury in emergency department

Acute kidney injury (AKI) is most important disorder in children who come to emergency department. Pathophysiology, epidemiology and treatment of children is different from adults due to differences in their anatomy and physiology. AKI is the abrupt loss of renal function and it is typically manifested by an increase in serum creatinine. It is result of hypoxic and or nephrotoxic injury to the renal tubules and glomeruli. In the early stages of AKI with a reduced glomerular filtration rate (GFR) may have a relatively normal or slightly elevated creatinine, so early recognition and management of AKI are crucial (1,2). The major causes of AKI may be divided into prerenal; intrinsic renal; and post renal, although may migrate from one category to another; prerenal or post renal for an extended period may result in intrinsic renal damage and AKI. Prerenal physiology is not an uncommon finding in emergency departments and often due to gastrointestinal losses and acute tubular necrosis (ATN) is usually the consequence of hypo-perfusion (3). The patients can be asymptomatic, although almost of the patients were symptomatic consist of nausea, vomiting, diarrhea, history of recently post-streptococcal infection, bloody diarrhea, change in urine output and edema (2,3). The emergency physician must perform a full physical examination and obtain accurate medical history particularly the medication used including herbal agents, sport supplements, non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and calcineurin inhibitors. Also the patient must be assessed accurately about the blood pressure, weight, hydration state, edema, skin manifestation, pulmonary and heart examination (3). AKI laboratory finding including blood urea nitrogen (BUN) and creatinine rising, although the increase will not necessarily cause the creatinine to be more than normal range. The international classification system, Kidney Disease: Improving Global Outcomes (KDIGO) (Table 1), is preferred. The system uses creatinine and urine output criteria and can be applied to both children and adults, minimizing practice variation. Analysis of the urine can distinguish between prerenal, renal and post-renal causes of acute renal failure, although may be normal in prerenal AKI, so it is necessary to obtain urine specimen by catheterization in non-toilet trained children. Additionally, complete blood cell is useful to identify infection, hemolysis, anemia, thrombocytopenia and eosinophilia (2-4). Electrolyte abnormalities is common in AKI due to renal function loss and decrease tubular secretion, cellular breakdown, dehydration and or volume overload. Electrolyte abnormality such as hyperkalemia, hyper or hyponatremia, etc, required emergent treatment, hence an ECG must be performed initially in all suspected AKI to identify 1Student Research Committee, Emergency department, Arak University of Medical Sciences, Arak, Iran 2Department of Pediatric Nephrology, Arak University of Medical Sciences, Arak, Iran