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Acute renal failure is the sudden loss of renal function necessary to maintain normal fluid and electrolyte balance and clear metabolic waste.1,2 The most common causes of acute renal failure in children are glomerulonephritis, sepsis, hemolytic uremic syndrome (HUS), and postoperative complications. Taken as a whole, the mortality of children with acute renal failure is reported in the literature to range from 8% to 89% and varies by cause.1


Acute renal failure is the result of nephrotoxic and/or hypoxic injury to the glomeruli and renal tubules. About 70% of cases result from nephrotoxic insults and 30% from ischemia.1 Reduced renal blood flow causes hypoxic injury and damages the proximal tubular cells. Medications such as amoxicillin, acyclovir, gentamicin, and cephalosporins also contribute to renal tubular injury. Inflammatory mediators intensify renal tubular damage.2

Table 128-1 lists common causes of renal failure in infants and children.

Table 128-1 Causes of Renal Failure in Infants and Children

Clinical Features


The presentation of acute renal failure is variable and depends on the cause. Many symptoms and signs relate to the underlying disorder (e.g., bloody diarrhea in HUS), whereas symptoms of renal failure itself include nausea and anorexia (secondary to uremia), changes in urine output or color, edema (which may be dependent, periorbital, scrotal/labial, or generalized), and headache (from hypertension). Perform a full review of systems and obtain the medical history and pertinent family history.1,2 Identify all medications used, including prescription and nonprescription drugs, herbals, and sport supplements.

Physical Examination

The physical examination should be thorough with special emphasis on vital signs (especially blood pressure), weight, hydration status, and joint and skin findings.1 Note the presence or absence of edema. Auscultate the lungs for rales, which suggests fluid overload, and the heart for uremic rubs. Palpate the abdomen for masses.


Laboratory Evaluation

Analysis of the urine can distinguish prerenal, renal, and postrenal causes of acute renal failure. Obtain a specimen via catheterization for infants and children in diapers and for those with decreased or absent urine output. Hematuria, presence of casts, and proteinuria characterize the “active sediment” ...

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