Acute renal failure is common in the seriously ill neonate requiring surgery. It may be prerenal as a result of severe dehydration, hypotension, abdominal distension, or sepsis.
It may result from congenital severe intrinsic renal disease.
It may be obstructive and result from severe obstruction in the urinary collecting system, e.g. urethral valves.85,86
Prerenal failure is the most common form of acute renal failure in the surgical neonate and results from a severe decrease in renal perfusion, usually as a result of profound hypotension from blood loss, sepsis, severe necrotizing Acute renal failure 141
enterocolitis. or intestinal obstruction with loss of fluid into dilated intestinal loops.
Primary fascial closure of omphalocele or gastroschisis carries the risk of placing the abdominal contents under pressure which may cause a reduction in cardiac output, hypotension, bowel ischemia, venostasis, and postoperative renal failure. Limited data suggest that an intragastric pressure 20 mmHg or an increase in central venous pressure of 4 mmHg or more indicate the need of a staged repair using a pouch.87 Additionally, newborn infants with abdominal wall defects have significantly increased fluid requirements preoperatively as major insensible water losses occur when eviscerated bowel is exposed to air and a perioperative third space is frequently associated. These conditions also favor hypovolemia, hypoperfusion of the kidney, and postoperative renal failure.
Renal vein or renal artery thrombosis, if bilateral, may be associated with acute renal failure. Treatment is by early aggressive fluid replacement until blood pressure normalizes and then by meticulous adjustment of fluid and electrolyte balance, until recovery of renal function occurs. Peritoneal dialysis may be required until renal function recovers.
Recovery is associated with a polyuric phase which also requires ongoing care with replacement of large amounts of water, potassium, and sodium via the kidneys.
Renal failure due to obstruction and due to congenital malformations is often associated with severe irreversible renal diseases not compatible with normal extrauterine life. The focus of care must initially be to decide on the appropriateness of active management. Further discussion of renal failure management is outside the scope of this chapter.
CONCLUSION
Major changes in body composition and in fluid and electrolyte balance occur during the transition to extrauterine life. These changes are even more marked in the preterm infant. The newborn infant who has a disorder requiring surgery has additional possible disorders of fluid and electrolyte balance. Future research and audit of fluid management strategies are vital to prevent hypernatremia, hyperglycemia and hyponatremia, and adverse neurodevelop- mental sequelae.
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