Management Strategies for Acute Renal Failure in Neonates
Immediate referral to a specialized pediatric nephrology unit is essential for managing acute renal failure (ARF) in newborns due to the complexity of the condition and the need for specialized fluid management. 1
Diagnosis and Initial Assessment
- Differentiate between prerenal, intrinsic renal, and postrenal failure
- Use fractional excretion of sodium (FENa) > 3% or renal failure index > 3 to confirm intrinsic ARF
- Perform diagnostic fluid challenge to differentiate prerenal from intrinsic renal failure
- Initial laboratory tests:
- Complete blood count
- Renal function tests
- Liver function tests
- Urinary protein quantification
- Electrolytes
Fluid Management
- Avoid intravenous fluids and saline unless clinically indicated for hypovolemia 1
- Concentrate oral fluid intake if necessary to manage edema
- Administer albumin infusions only based on clinical indicators of hypovolemia (oliguria, prolonged capillary refill time, tachycardia, hypotension) or failure to thrive, not based on serum albumin levels alone 1
- Monitor serum electrolytes every 4-6 hours initially
- Track daily weight and abdominal girth measurements
Medication Management
- Avoid nephrotoxic drugs, particularly aminoglycosides, unless no suitable alternatives exist 1
- If aminoglycosides are necessary, use as single daily dose rather than multiple doses
- Monitor drug levels when treatment exceeds 24-48 hours
- Use diuretics cautiously:
- Do not use furosemide to prevent AKI
- Consider furosemide for volume overload only in hemodynamically stable patients
- High doses of furosemide (>6 mg/kg/day) should not be given for periods longer than 1 week 2
- When using potassium-sparing diuretics, blockers of ENaC (amiloride) are preferable to spironolactone 2, 1
- Consider theophylline in neonates with severe perinatal asphyxia at high risk of AKI (single dose in first 60 minutes of life) 1
Nutritional Support
- Provide high protein requirements: 2-3 g/kg/day for infants 0-2 years 1
- Implement high energy diet (130 kcal/kg/day) with low salt content
- Consider enteral tube feeding if oral intake remains insufficient
- Supplement with:
Renal Replacement Therapy
- Initiate when conservative management fails to control:
- Fluid overload
- Electrolyte imbalances (particularly hyperkalemia)
- Metabolic acidosis
- Uremia
- Peritoneal dialysis is the preferred modality for neonates due to:
- Easier vascular access
- Better hemodynamic stability
- Preservation of central venous access 2
- Hemofiltration or hemodialysis may be considered in specialized centers with appropriate expertise 3
Monitoring and Follow-up
- Monitor vital signs, including blood pressure, every 1-2 hours initially
- Watch for signs of infection due to risk of immunosuppression
- Consider prophylactic anticoagulation if thrombocytosis >750,000/ml develops
- Follow recommended vaccination schedule for healthy children
- Regular follow-up with pediatric nephrology for:
- Growth and development monitoring
- Regular laboratory assessment (electrolytes, renal function, lipid profile)
- Renal ultrasound every 12-24 months to monitor for nephrocalcinosis 1
Common Pitfalls and Caveats
- Do not rely on serum creatinine alone for ARF diagnosis in the first days of life due to maternal influence 3
- Avoid excessive diuretic use, which can cause hypovolemia and worsen renal function
- Do not rely on total serum calcium levels to assess calcium status due to hypoalbuminemia
- Avoid central venous lines when possible due to high thrombosis risk 1
- Remember that transferrin saturation and ferritin levels are unreliable markers of iron status in nephrotic syndrome
- Nonoliguric ARF in neonates has a better prognosis than oliguric ARF 4
- Neonates who have suffered substantial loss of nephrons require lifelong monitoring of renal function, blood pressure, and urinalysis 5