Patient handout

Pediatric acute kidney injury (AKI)

PRODUCTION

1. Your condition

This handout is for pediatric acute kidney injury (aki). Your care team identified this based on: creatinine rise meeting kdigo criteria in a child (kdigo 2012 aki; kdigo 2024).

Other reasons your team may use this plan: oliguria <0.5 ml/kg/h × 6-12 h or anuria in a child (kdigo 2012 aki; kdigo 2024); edema or volume overload in a child (kdigo 2012 aki; aware kaddourah nejm 2017); acute hyperkalemia in a child (kdigo 2012 aki; aap 2022).

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
normal saline / lactated Ringer's 10-20 mL/kg	10-20 mL/kg over 30-60 min	IV	reassess after each bolus	Pre-renal AKI — judicious fluid; reassess for fluid overload (KDIGO 2012 AKI; AAP 2022)
furosemide	1-2 mg/kg IV	IV	q6-12 h titrated	For volume control only; does not improve mortality (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)
calcium_gluconate	100 mg/kg IV (max 3 g) over 5-10 min	IV	single dose; repeat if persistent ECG changes	Membrane stabilization; does not lower K+ (KDIGO 2012 AKI; AAP 2022)
insulin_regular	0.1 U/kg IV with dextrose 0.5 g/kg	IV	single, may repeat	Drives K+ intracellular (KDIGO 2012 AKI; AAP 2022)
albuterol	2.5-5 mg nebulised	inhaled	q20 min × 3	Drives K+ intracellular; tachycardia caution (KDIGO 2012 AKI; AAP 2022)
sodium_polystyrene_sulfonate	1 g/kg PO/PR	PO/PR	q4-6 h	Off-label in peds; bowel necrosis risk in neonates / post-op (AAP 2022)
sodium_bicarbonate	1-2 mEq/kg IV slow	IV	single	Reserve for severe acidosis or hyperkalemia adjunct (KDIGO 2012 AKI; AAP 2022)
eculizumab	600-900 mg/dose × 4-6 doses (per weight band)	IV	weekly initial then maintenance	IPNA 2016 HUS — first-line aHUS; mandatory meningococcal vaccination
ceftriaxone	50-100 mg/kg/day IV (max 2 g/day)	IV	daily	IDSA peds UTI / sepsis (AAP 2022)

Plan: Pediatric AKI — fluid resuscitation, nephrotoxin removal, etiology-directed (KDIGO 2012 AKI; KDIGO 2024; AAP 2022)

3. When to call your provider

Contact your care team if any of the following happen:

New Cr rise OR eGFR drop >= 25% from baseline -> ED + nephrology urgent (KDIGO 2024)
BP > 95th + 12 mmHg OR symptomatic HTN -> ED (Flynn AAP 2017)
New proteinuria UACR > 300 mg/g OR new hematuria -> nephrology urgent + glomerulonephritis workup (KDIGO 2012 AKI)
Recurrent AKI episode -> nephrology + pharmacy nephrotoxin audit + NINJA review (Goldstein 2016)
Growth percentile drop > 1 SD OR weight loss in CKD stage 3-5 -> nutrition + nephrology (KDIGO 2024)
New symptom of CKD-MBD (bone pain, fracture) -> bone-health workup + nephrology (KDIGO 2017)
Mental-health screen positive -> mental-health referral + family-impact assessment (KDIGO 2024)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

K+ ≥6.5 with peaked T waves, widened QRS, sine-wave (KDIGO 2012 AKI; AAP 2022)(life-threatening)
Fluid overload >10% of admit weight + respiratory distress (AWARE Kaddourah NEJM 2017; KDIGO 2012 AKI)
Confusion, asterixis, pericardial rub in setting of high BUN (KDIGO 2012 AKI)
Bloody diarrhea + AKI + hemolytic anemia + thrombocytopenia (IPNA 2016 HUS)
AKI + microangiopathic hemolysis + thrombocytopenia without diarrhea OR genetic complement defect (IPNA 2016 HUS)
Glomerular pattern + rapidly rising Cr + high-titer ANCA / anti-GBM / lupus serology (KDIGO 2012 AKI)
Hydronephrosis on US + AKI (KDIGO 2012 AKI; AAP 2022)
KDIGO peds stage 3 (Cr >= 3x baseline OR Cr >= 4.0 mg/dL OR UOP < 0.3 mL/kg/h x 24 h OR anuria x 12 h OR eGFR < 35 mL/min/1.73 m^2) with one or more classical RRT indications: refractory hyperkalemia (K+ > 6.5 despite medical management), refractory acidosis (pH < 7.15 despite bicarb), volume overload > 15% admit weight with respiratory compromise, uremic encephalopathy or pericarditis, dialyzable toxin (KDIGO 2012 AKI; STARRT-AKI NEJM 2020)(life-threatening)
Microangiopathic hemolytic anemia (schistocytes + thrombocytopenia + elevated LDH + low haptoglobin) + AKI WITHOUT bloody diarrhea — atypical HUS (aHUS) until excluded; complement-pathway defect (factor H/I deficiency, MCP/CD46, CFB/C3 gain-of-function); requires eculizumab + meningococcal vaccination + complement genetic evaluation (IPNA 2016 HUS)(life-threatening)
Microangiopathic hemolytic anemia (schistocytes + thrombocytopenia + elevated LDH + low haptoglobin) + AKI + bloody diarrhea — Shiga-toxin-producing E. coli (STEC) HUS; supportive care only; AVOID empiric antibiotics (may increase Shiga-toxin release and worsen HUS); plasmapheresis controversial (IPNA 2016 HUS; AAP 2022)
Proteinuria (UACR > 300 mg/g OR dipstick >= 2+) + hematuria (>= 5 RBC/hpf OR RBC casts) + hypertension (BP >= 95th percentile + 12 mmHg) in a child with AKI — glomerulonephritis pattern (PSGN / IgA / lupus / ANCA / anti-GBM / MPGN); requires renal biopsy planning + pediatric nephrology + rheumatology if serology-positive (KDIGO 2012 AKI; AAP 2022)
Active AKI in a child with concurrent exposure to >= 1 nephrotoxic medication (NSAIDs, aminoglycosides, vancomycin, iodinated contrast, chemotherapy, amphotericin, tacrolimus, cisplatin, methotrexate) — immediate discontinuation + substitution per NINJA stewardship + pharmacy review of all renal-dosed meds (KDIGO 2012 AKI; KDIGO 2024; NINJA Goldstein Pediatrics 2016)
Concurrent sepsis + AKI in a child — sepsis-AKI is the most common etiology in PICU (~50-60% of septic peds patients per AWARE Kaddourah NEJM 2017); presents with oliguria + rising Cr after fluid resuscitation; furosemide stress test predicts progression to KDIGO stage 3; routes to id.sepsis.peds.v1 with carryover state (KDIGO 2012 AKI; AWARE Kaddourah NEJM 2017; SSC peds 2020)(life-threatening)

5. Follow-up

Pediatric nephrology, growth tracking, BP screening, recurrence prevention, vaccination (esp. eculizumab → meningococcal) (KDIGO 2012 AKI; KDIGO 2024; AAP 2022; IPNA 2016 HUS)

6. Sources

Guideline: KDIGO 2012 AKI (PMID 22890468) + KDIGO 2024 AKI update + Schwartz 2009 (PMID 19158356) + AWARE Kaddourah NEJM 2017 (PMID 28076862) + AWAKEN Jetton Neonatology 2017 + STARRT-AKI NEJM 2020 (PMID 32668115) + IPNA 2016 HUS + AAP 2022 neonatal AKI