Abstract
Management of acute liver failure (ALF) and acute on chronic liver failure (ACLF) in the pediatric population can be challenging. Kidney manifestations of liver failure, such as hepatorenal syndrome (HRS) and acute kidney injury (AKI), are increasingly prevalent and may portend a poor prognosis. The overall incidence of AKI in children with ALF has not been well-established, partially due to the difficulty of precisely estimating kidney function in these patients. The true incidence of AKI in pediatric patients may still be underestimated due to decreased creatinine production in patients with advanced liver dysfunction and those with critical conditions including shock and cardiovascular compromise with poor kidney perfusion. Current treatment for kidney dysfunction secondary to liver failure include conservative management, intravenous fluids, and kidney replacement therapy (KRT). Despite the paucity of evidence-based recommendations concerning the application of KRT in children with kidney dysfunction in the setting of ALF, expert clinical opinions have been evaluated regarding the optimal modalities and timing of KRT, dialysis/replacement solutions, blood and dialysate flow rates and dialysis dose, and anticoagulation methods.
Highlights
The management of acute kidney injury (AKI) in the setting of acute liver failure (ALF) can be challenging, especially in the pediatric population
These practice points have been developed in conjunction with the Pediatric Continuous Renal Replacement Therapy (PCRRT) workgroup and are designed to provide provisional, time-sensitive answers, based on the best available evidence to questions related to AKI in PALF
The baseline characteristics of PALF with AKI (n = 19) compared to just PALF (n = 65) shows a correlation with: (1) higher baseline bilirubin (mean difference (MD) AKI vs. no AKI: 8.5 mg/dl, 95% CI 3.3–13.8, p = 0.002), (2) higher International Normalized Ratio (INR) (MD AKI vs. no AKI: 0.98, 95% CI: 0.1–1.8, p = 0.029), (3) higher Model for (Pediatric) End-Stage Liver Disease (M(P)ELD) (MD AKI vs. no AKI: 5.9, 95% CI: 1.5–10.3, p = 0.009), (4) higher incidence of systemic inflammatory response and (5) higher incidence of spontaneous bacterial peritonitis (19)
Summary
The management of acute kidney injury (AKI) in the setting of acute liver failure (ALF) can be challenging, especially in the pediatric population. Current guidelines in the treatment of kidney dysfunction secondary to liver failure includes conservative management, intravenous fluids, and kidney replacement therapy (KRT), based primarily on adult literature (1). There is a lack of randomized controlled trials in the pediatric subset to design a diagnostic algorithm. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) provide clinical practice points for children with AKI in the setting of ALF
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