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(Pediatrics in Review. 2008;29:299-307.)
© 2008 American Academy of Pediatrics

Acute Renal Failure in Children

The first 300 words of the full text of this article appear below.

	Objectives

 
After completing this article, readers should be able to:

1. Define acute renal failure (ARF).
   
2. Differentiate the three forms of ARF.
   
3. Initiate treatment, including stabilization, of a patient who has ARF.
   
4. Discuss the various medications necessary for treating a patient who has ARF.
   

	Introduction

 
Acute renal failure (ARF) is defined as an acute decline in renal function characterized by an increase in blood urea nitrogen (BUN) and serum creatinine values, often accompanied by hyperkalemia, metabolic acidosis, and hypertension. Significant morbidity and mortality can accompany ARF. Patients who have ARF recover their renal function either partially or completely or they develop end-stage renal disease. They also may develop associated multiorgan disease.

ARF is divided into three forms: prerenal failure (most common), intrinsic renal failure, and postrenal failure. Treatment ranges from conservative medical management to dialysis or renal transplantation, depending on the severity of kidney disease and degree of renal function recovery. Worldwide, most cases of ARF in children are due to hemolytic-uremic syndrome or volume depletion.

	Prerenal Failure

 
     Causes
Prerenal failure refers to hypoperfusion of the kidneys. There are a variety of causes for such hypoperfusion, the most common of which is hypovolemia due to gastrointestinal (GI) diseases, congenital heart disease, and sepsis (Table 1).

Table 1. Causes of Prerenal Acute Renal Failure

Extracellular Fluid Volume Deficits Gastrointestinal losses –Vomiting –Diarrhea –Decreased oral intake of fluids –Loss of fluids via intestinal stoma –Nasogastric loss of fluids Increased urinary loss of fluids –Osmotic diuresis (mannitol, glucosuria) –Diabetes insipidus (central, nephrogenic) –Loss of urinary concentrating ability –Renal insufficiency –"Medullary washout" –Diuretic use –Adrenal insufficiency Blood losses –Hemorrhage Redistribution of extracellular fluid –Hypoalbuminemia –Nephrotic syndrome –Liver disease Vasodilation –Sepsis –Anaphylaxis Skin losses of fluids –Excessive sweating –Cystic fibrosis –Inflammatory skin disease –Burns –"Third space" fluid loss –Edema (any cause) –Intestinal injury –Peritonitis –Pancreatitis Cardiac Dysfunction Congenital heart disease Cardiomyopathy Arrhythmia Acquired valvular disease Tamponade

     Pathophysiology
Prerenal ARF may result from a sudden decline in renal perfusion due to a sudden decline in intravascular volume. Decreased perfusion can lead to ischemic or toxic injury to the renal cells, with a subsequent decrease in the glomerular filtration rate (GFR). To compensate, the body tries to re-establish renal perfusion and restore intravascular volume in several ways. Afferent arterioles attempt to maintain renal blood flow by relaxing vascular tone, thereby decreasing renal vascular resistance. Decreased renal perfusion also stimulates increased catecholamine and vasopressin secretion and activation of the renin-angiotensin system that, in turn, . . . [Full Text of this Article]