Pediatric emergency medicine trisk 2914 2914
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be controlled gradually over the next several days or longer. ACE inhibitors
are generally well tolerated in early stages of CKD and may slow the
progression of CKD over time, especially in those with proteinuria. There is
limited data to support the use of ARB therapy in children, but these may be
considered as an alternative in patients who have difficulty tolerating ACE
inhibitors. However, when GFR is <40 to 60 mL/min/1.73 m², use of either
ACE inhibitors or ARBs may result in dangerous elevations of serum
potassium and further decline in GFR, and these medications may need to
be temporarily held during periods of acute deterioration of renal function.
Electrolyte and acid–base abnormalities are common in CKD and include
hyperkalemia, hypocalcemia, hyperphosphatemia, and metabolic acidosis.
The treatment of these electrolyte and acid–base disturbances was
previously discussed. Of note, the metabolic disturbances associated with
CKD generally develop gradually, and therefore, immediate correction may
not be warranted and may, in fact, be deleterious. However, given the
potential for cardiac dysrhythmias, hyperkalemia should be addressed
urgently. In clinically stable patients with concurrent hypocalcemia and
acidosis, the potential risk for tetany with alkali therapy should be
considered. If clinically reasonable, hypocalcemia should be treated
initially, and this can be achieved with oral calcium if the patient is
asymptomatic.
For some children with severe CKD or AKI superimposed on CKD,
supportive medical management will be insufficient, and RRT will be
required. Accepted indications for RRT include severe fluid overload,
refractory hyperkalemia, and severe uremia. Modalities of dialysis include
continuous renal replacement, intermittent hemodialysis, and peritoneal
dialysis. The modality utilized will depend on the clinical circumstances,
local resources, and clinician preference.
Suggested Readings and Key References
Hypovolemia and Disorders of Sodium Homeostasis
Feld LG, Neuspiel DR, Foster BA, et al. Clinical practice guideline:
maintenance
intravenous
fluids
in
children.
Pediatrics
2018;142(6):e20183083.
