MANAGEMENT

Just as the true incidence of pediatric AKI is unclear, so is the optimal therapy for
this condition. Most of the interventions that have been used are based on data
from adults.
Conservative therapy
A randomized trial in adults with AKI found no difference in urine output or need
for RRT between those who received renal-dose dopamine and those who were
given placebo.14 Several meta-analyses have confirmed that renal-dose
dopamine has no benefit in adult AKI;1517 indeed, it may even be harmful.18 No
study of this agent has been performed in the pediatric setting, although many
clinicians have assumed that the adult data also apply to children. A resurgence in
the use of norepinephrine in animal models of AKI and in adults with the disease
has raised the question of whether there is a role for renal doses of this agent in
children with AKI.19,20 Insufficient data exist to answerthis question at present.
Reports on the use of diuretics before RRT in adults with oliguria are conflicting,
and there are no data regarding this treatment in children. However, a study of
26 critically ill neonates with oliguria after cardiac surgery showed that those who
were given a continuous infusion of furosemide had the same urine output as
those who were given bolus injections every 4 h for 24 h, despite the former
group having received a lower total dose of furosemide.21 Thus, continuous
infusion could decrease the ototoxicity and nephrotoxicity of this medication
Other agents, such as nesiritide (recombinant B-type natriuretic peptide), have
been tested in adults
with AKI, but they have shown no impact on urine output, glomerular filtration
rate, or need for RRT; however, these data are not necessarily applicable to
pediatric patients.22,23 Fenoldopam might improve urine output in pediatric AKI,
but it has no effect on serum creatinine levelThese interventions might have a
greater beneficial effect on AKI if they are initiated early in the disease course, the
timing of which could be measured by increases in the levels of biomarkers of AKI.
Delivery of nutrition in pediatric AKI can be difficult in the oliguric patient, as the
volume associated with the nutrition might exceed the urine output of the child.
Specialized renal formulas developed for infants and children with acute or
chronic renal failure might provide adequate nutrition without causing volume
excess (J Gast, personal communication). The optimal strategy for identifying the

needs and extent of nutrition required in the pediatric AKI setting is an ongoing
debate,
but measurement of resting energy expenditure by use of the metabolic cart
continues to be a reasonable way to determine the amount of nutrition necessary
for children in the intensivecare unitRenal replacement therapy
Initiation
At what point should conservative management be abandoned in favor of RRT?
Studies indicate that it is best to begin RRT in children as soon as fluid overload
occurs, unless there is excessive solute load.2630 The first such study, which
included 30 children who underwent intermittent hemodialysis for AKI after bone
marrow
transplantation, showed that those with volume excess of 10% or less at the time
of RRT initiation had improved survival at discharge from hospital.26 In a
subsequent study of 21 children on continuous RRT, mean volume excess was
16% in those who survived and 33% in those who did not survive.27 In a study by
Goldstein et al., 116 children with AKI of various causes underwent continuous
RRT at 1 of 13 different centers. Despite variations between centers in the timing
of RRT initiation and the definition of AKI, the major predictor of survival was
initiation of RRT before substantial fluid excess. The patients who survived had an
average volume excess of 14% above dry weight at the time of initiation of
continuous RRT, as opposed
to an average excess of 25% in those who did not survive. Blood urea nitrogen
level (solute clearance) at initiation of RRT was not associated with survival,
although it was increased in non-survivors. Based on the published studies, a
reasonable threshold for initiation of RRT would be a fluid overload of 15%.