A new article published in Blood Purification reported that children are less severely affected by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) compared to adults. However, scarce data exists regarding the prevalence and pathogenesis of acute kidney injury (AKI) in children affected by SARS-CoV-2.

The authors discussed that in children with novel coronavirus infection (COVID), dehydration seems to be the most common trigger factor for AKI, and attentionmust be given to the fluid status. Meanwhile, the principles of initiation, prescription and complications related to renal replacement therapy are the same for COVID patients as for non-COVID patients. Continuous renal replacement therapy (CRRT) remains the most common modality of treatment. Nevertheless, when to initiate treatment and what modality to use depends on the available resources.

It was stated that although children are less often and less severely affected, diversion of all hospital resources to manage the adult surge might lead to limited CRRT resources. These shortages can be mitigated as – where machines are limited, one CRRT machine can be used for multiple patientsproviding a limited number of hours of CRRT per day—in this case, increased exchange rates can be used to compensate for the decreased duration of CRRT; if consumables are limited – lower doses of CRRT (15-20 mL/kg/h) for 24 h may be feasible. Hpercoagulability leading to frequent filter clotting is an important issue in these children. Increased doses of unfractionated heparin, combination of heparin and regional citrate anticoagulation, or combination of prostacyclin and heparin may be used. If infusion pumps to deliver anticoagulants are limited, the administration of low-molecular-weight heparin can be considered. While in children, acute peritoneal dialysis (PD) can successfully control both fluid and metabolic disturbances. Intermittent hemodialysis can also be used in patients who are hemodynamically stable. Moreover, the keys to successfully managing pediatric AKI in a pandemic are flexible use of resources, good understanding of dialysis techniques, and teamwork.

The article summarized that the incidence of AKI in children affected by SARS-CoV-2 is unknownand it is probably lower than in adults. In cases presenting with the same severity of illness as adults, the same clinical picture of renal involvement may be expected. Reports of AKI in COVID-19 patients are already alerting that the mortality is significantly increased when the renal dysfunction is severe. Early diagnosis and timely treatment of potential triggers of renal injury—for example – dehydration, fluid overload and drug toxicity, are crucial and currently largely unexplored in COVID-19 children. Furthermore, in established anuric pediatric AKI, RRT remains the mainstay of renal support. On the other hand, specific aspects to be considered in COVID-19 children requiring dialysis include the utilization of PD – the shortage of resources due to overutilization in adult centers, the occurrence of particularly frequent filter clotting, and need for addressing specific anticoagulation strategies.

It was inferred that although pragmatic utilization of available resources and safety of health-care workers is important in these challenging circumstances, particular attention should be posed not to avoid or delay RRT in a COVID-19 child with severe AKI. The delay to provide this kind of treatment in severely ill children may cause an unacceptable increase in the mortality of such frail patients.

Source: Blood Purification.2020 Jul 14;1-11.doi: 10.1159/000509677.