Hospital pediatrics. Postrenal acute renal failure (most important)

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Hospital pediatrics. Postrenal acute renal failure (most important)

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21. Postrenal acute renal failure. Diagnostics. Treatment

Etiology. Urinary tract obstruction develops with congenital valve anomalies, structural abnormalities of the urethra, hematuria, tumor or retroperitoneal fibrosis.

Examination and diagnostics. Obstruction of the urinary tract is established on the basis of anamnesis (congenital anomalies in the development of the urinary tract, genital organs, injuries of the lower abdomen); palpated volumetric formation in the lateral parts of the abdomen, overflowing bladder. Anuria may indicate bilateral ureteral obstruction. Conduct ultrasound and scintigraphy of the kidneys. If these methods cannot be carried out, determine the level of creatinine in serum, less than 5 mg /% - excretory urography is indicated.

Treatment. Pathogenetic therapy is prescribed based on the cause of acute renal failure. Plasmapheresis should be performed, the volume of which can be determined by the severity of the patient’s condition and the degree of intoxication. In case of hemodynamic disorders, anti-shock therapy is prescribed, replacement of blood loss with transfusion of blood components, blood substitutes (100-400 mg of prednisolone is administered intravenously). In case of hypotension (after replenishing blood loss), an intravenous drip of 1 ml of a 0,2% solution of norepinephrine in 200 ml of an isotonic sodium chloride solution is prescribed.

In case of poisoning, measures are used to remove the poison from the body. With large intravascular hemodialysis, if the hematocrit is below 20%, an exchange transfusion of blood or plasma is performed.

If the cause is bacterial shock, then anti-shock therapy and antibiotics are prescribed. In the initial period of oligurianuria, furosemide is prescribed intravenously at a dose of 160 mg 4 times a day to stimulate diuresis.

Further therapy should be aimed at regulating homeostasis. Assign a diet with limited intake of protein and potassium, but with sufficient calories from carbohydrates and fats. The amount of fluid injected should be more than diuresis, the amount of water lost with vomiting and diarrhea, no more than 500 ml, this volume should include 400 ml of a 20% glucose solution with 20 units of insulin, with hyperkalemia, 10- 20 ml of a 10% solution of calcium gluconate, also in / in drip 200 ml of a 5% solution of sodium bicarbonate (after establishing the degree of acidosis and under the control of blood pH). Indications for hemodialysis and peritoneal dialysis: if the level of urea in plasma is more than 2 g / l, potassium - more than 6,5 mmol / l; if there is decompensated metabolic acidosis; if there are clinical manifestations of acute uremia.

Contraindications are cerebral hemorrhage, gastric bleeding, intestinal bleeding, severe hemodynamic disorders, lowering blood pressure. A contraindication to peritoneal dialysis is a recent operation on the abdominal organs, adhesive process in the abdominal cavity. Treatment includes surgery or urinary diversion. Obstruction of the lower urinary tract is detected and eliminated by catheterization of the bladder, obstruction of the ureters is detected by ultrasound.

After restoration of the patency of the urinary tract, polyuria develops, which leads to dehydration; in these cases, 0,45% NaCl is injected.

Author: Pavlova N.V.

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