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Lingasubramanian G, Hum CE, Hunter K, Mehta R, Bhandari V. Timing and risk factors associated with acute kidney injury in infants with necrotizing enterocolitis. J Perinatol 2024:10.1038/s41372-024-02003-4. [PMID: 38778205 DOI: 10.1038/s41372-024-02003-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVE To evaluate the prevalence, onset, risk factors, and mortality associated with acute kidney injury (AKI) in infants with necrotizing enterocolitis (NEC). DESIGN/METHODS Retrospective study at 2 centers in infants with NEC, with/without AKI. AKI assessed by serum creatinine and urine output. Statistical tests used included t, Mann-Whitney U, Chi-square, and Fisher Exact tests. RESULTS Among 80 eligible infants with NEC, 56 (70%) had AKI. Median onset of NEC was day 15, with median AKI onset two days (IQR, -5.75 to 0) prior to NEC onset. Vasopressors were significantly more likely to be used in infants with NEC and AKI (p = 0.009). Increased mortality (p = 0.01) was noted in infants with NEC and AKI. CONCLUSIONS The onset of AKI mostly precedes NEC onset, with moderate to severe AKI more prevalent than the milder form in infants with NEC. These infants are significantly more likely to be hemodynamically unstable and have increased mortality.
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Affiliation(s)
| | | | - Krystal Hunter
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Rajeev Mehta
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Vineet Bhandari
- Cooper Medical School of Rowan University, Camden, NJ, USA.
- The Children's Regional Hospital at Cooper, Camden, NJ, USA.
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2
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Zhong J, Doughty R, Thymann T, Sangild PT, Nguyen DN, Muk T. Insulin-like growth factor-1 effects on kidney development in preterm piglets. Pediatr Res 2024:10.1038/s41390-024-03222-3. [PMID: 38762663 DOI: 10.1038/s41390-024-03222-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Preterm birth disrupts fetal kidney development, potentially leading to postnatal acute kidney injury. Preterm infants are deficient in insulin-like growth factor 1 (IGF-1), a growth factor that stimulates organ development. By utilizing a preterm pig model, this study investigated whether IGF-1 supplementation enhances preterm kidney maturation. METHODS Cesarean-delivered preterm pigs were treated systemically IGF-1 or vehicle control for 5, 9 or 19 days after birth. Blood, urine, and kidney tissue were collected for biochemical, histological and gene expression analyses. Age-matched term-born pigs were sacrificed at similar postnatal ages and served as the reference group. RESULTS Compared with term pigs, preterm pigs exhibited impaired kidney maturation, as indicated by analyses of renal morphology, histopathology, and inflammatory and injury markers. Supplementation with IGF-1 reduced signs of kidney immaturity, particularly in the first week of life, as indicated by improved morphology, upregulated expression of key developmental genes, reduced severity and incidence of microscopic lesions, and decreased levels of inflammatory and injury markers. No association was seen between the symptoms of necrotizing enterocolitis and kidney defects. CONCLUSION Preterm birth in pigs impairs kidney maturation and exogenous IGF-1 treatment partially reverses this impairment. Early IGF-1 supplementation could support the development of preterm kidneys. IMPACT Preterm birth may disrupt kidney development in newborns, potentially leading to morphological changes, injury, and inflammation. Preterm pigs have previously been used as models for preterm infants, but not for kidney development. IGF-1 supplementation promotes kidney maturation and alleviates renal impairments in the first week of life in preterm pigs. IGF-1 may hold potential as a supportive therapy for preterm infants sensitive to acute kidney injury.
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Affiliation(s)
- Jingren Zhong
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Richard Doughty
- Department of Pathology, Akershus University Hospital, Lørenskog, Norway
| | - Thomas Thymann
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Per Torp Sangild
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
- Department of Pediatrics, Odense University Hospital, Odense, Denmark
- Department of Neonatology, Rigshospitalet, Copenhagen, Denmark
| | - Duc Ninh Nguyen
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark
| | - Tik Muk
- Section for Comparative Paediatrics and Nutrition, Department of Veterinary and Animal Sciences, University of Copenhagen, Frederiksberg, Denmark.
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DeFreitas MJ, Griffin R, Sanderson K, Nada A, Charlton JR, Jetton JG, Kent AL, Guillet R, Askenazi D, Abitbol CL. Maternal Hypertension Disorders and Neonatal Acute Kidney Injury: Results from the AWAKEN Study. Am J Perinatol 2024; 41:649-659. [PMID: 35196719 PMCID: PMC10981551 DOI: 10.1055/a-1780-2249] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE This study aimed to examine the association between maternal hypertension (HTN) exposure and neonatal acute kidney injury (AKI). STUDY DESIGN Retrospective cohort study of 2,162 neonates admitted to 24 neonatal intensive care units (NICUs). Neonates were classified into the following exposure groups: any maternal HTN, chronic maternal HTN, preeclampsia/eclampsia, both, or neither. Demographics, clinical characteristics, and AKI status were compared using Chi-square and analysis of variance. General estimating logistic regression was used to estimate adjusted odds ratios and included a stratified analysis for site of delivery. RESULT Neonates exposed to any maternal HTN disorder had a tendency toward less overall and early AKI. When stratified by inborn versus outborn, exposure to both maternal HTN disorders was associated with a significantly reduced odds of early AKI only in the inborn neonates. CONCLUSION Exposure to maternal HTN, especially preeclampsia/eclampsia superimposed on chronic HTN, was associated with less likelihood of early AKI in the inborn group. KEY POINTS · Maternal HTN is associated with less neonatal AKI.. · Maternal HTN category is variably associated with AKI.. · Inborn status is an important contributor to this association..
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Affiliation(s)
- Marissa J. DeFreitas
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami/Holtz Children’s Hospital, Miami, Florida
| | - Russell Griffin
- Department of Epidemiology, University of Alabama Birmingham, Birmingham, Alabama
| | - Keia Sanderson
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, North Carolina
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology & Hypertension Le Bonheur Children’s Hospital, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Jennifer R. Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia, Charlottesville, Virginia
| | - Jennifer G. Jetton
- Department of Pediatrics, Division of Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa
| | - Alison L. Kent
- Department of Pediatrics, University of Rochester, Rochester, New York
- Department of Pediatrics, Australian National University, ACT, Australia
| | - Ronnie Guillet
- Department of Pediatrics, University of Rochester, Rochester, New York
| | - David Askenazi
- Department of Pediatrics, Division of Nephrology, University of Alabama Birmingham, Birmingham, Alabama
| | - Carolyn L. Abitbol
- Department of Pediatrics, Division of Pediatric Nephrology, University of Miami/Holtz Children’s Hospital, Miami, Florida
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Slagle C, Askenazi D, Starr M. Recent Advances in Kidney Replacement Therapy in Infants: A Review. Am J Kidney Dis 2024; 83:519-530. [PMID: 38147895 DOI: 10.1053/j.ajkd.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/10/2023] [Accepted: 10/14/2023] [Indexed: 12/28/2023]
Abstract
Kidney replacement therapy (KRT) is used to treat children and adults with acute kidney injury (AKI), fluid overload, kidney failure, inborn errors of metabolism, and severe electrolyte abnormalities. Peritoneal dialysis and extracorporeal hemodialysis/filtration can be performed for different durations (intermittent, prolonged intermittent, and continuous) through either adaptation of adult devices or use of infant-specific devices. Each of these modalities have advantages and disadvantages, and often multiple modalities are used depending on the scenario and patient-specific needs. Traditionally, these therapies have been challenging to deliver in infants due the lack of infant-specific devices, small patient size, required extracorporeal volumes, and the risk of hemodynamic stability during the initiation of KRT. In this review, we discuss challenges, recent advancements, and optimal approaches to provide KRT in hospitalized infants, including a discussion of peritoneal dialysis and extracorporeal therapies. We discuss each specific KRT modality, review newer infant-specific devices, and highlight the benefits and limitations of each modality. We also discuss the ethical implications for the care of infants who need KRT and areas for future research.
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Affiliation(s)
- Cara Slagle
- Division of Neonatology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Starr
- Division of Nephrology and Division of Child Health Service Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.
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Dumoulin M, Pottel H, Mekahli D, Laenen A, Smits A, Allegaert K. Pharmacovigilance of nephrotoxic drugs in neonates: the Pottel method for acute kidney injury detection in ELBW neonates. Pediatr Nephrol 2024:10.1007/s00467-024-06335-3. [PMID: 38526762 DOI: 10.1007/s00467-024-06335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 01/28/2024] [Accepted: 02/20/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Extremely low birth weight (ELBW) neonates (birth weight ≤ 1000 g) are at high risk to develop drug-induced acute kidney injury (AKI). However, we lack a pragmatic detection tool to capture their time-dependent (patho)physiologic serum creatinine (Scr) patterns. Pottel et al. suggested rescaling Scr by dividing Scr with the mean Scr value of the age- and sex-specific reference population. We explored if this Pottel method can detect drug-related nephrotoxicity in ELBW neonates. METHODS A previously reported dataset on Scr changes in ELBW neonates exposed to ibuprofen, amikacin, or vancomycin was updated to calculate Pottel scores for every available Scr value in the first 28 postnatal days. We hereby used previously published postnatal age-specific 50th centile values in an ELBW population. Linear mixed models were applied, analyzing Pottel scores as response variable and continuous time (day), drug exposure, and interaction thereof in the explanatory model. RESULTS Serum creatinine (n = 3231) observations in 201 ELBW neonates were collected. A statistically significant rise of Pottel scores was observed with ibuprofen starting from postnatal day 4. In addition, a cumulative effect of treatment with mean Pottel scores on day 0 of 1.020 and on day 3 during treatment of 1.106 (95% CI 1.068-1.145, p < 0.001) was observed, corrected for effect of antibiotics. Antibiotic administrations showed a small but statistically significant difference up to postnatal day 5. CONCLUSIONS As rescaled Scr biomarker, the Pottel method showed a clear association with ibuprofen-exposed ELBW neonates, suggesting its applicability as a pragmatic bedside alternative tool to assess nephrotoxicity.
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Affiliation(s)
- Mathilde Dumoulin
- Department of Paediatrics, Leuven University Hospitals, Louvain, Belgium
| | - Hans Pottel
- Department of Public Health and Primary Care, KU Leuven Campus Kulak, Kortrijk, Belgium
| | - Djalila Mekahli
- Department of Pediatric Nephrology, Leuven University Hospitals, Louvain, Belgium
- PKD Research Group, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Annouschka Laenen
- Leuven Biostatistics and Statistical Bioinformatics Center (L-BioStat), KU Leuven, Louvain, Belgium
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000, Louvain, Belgium
- Neonatal Intensive Care Unit, Leuven University Hospitals, Louvain, Belgium
| | - Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Herestraat 49, 3000, Louvain, Belgium.
- Neonatal Intensive Care Unit, Leuven University Hospitals, Louvain, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Louvain, Belgium.
- Department of Hospital Pharmacy, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Sanderson K, Griffin R, Anderson N, South AM, Swanson JR, Zappitelli M, Steflik HJ, DeFreitas MJ, Charlton J, Askenazi D. Perinatal risk factors associated with acute kidney injury severity and duration among infants born extremely preterm. Pediatr Res 2024:10.1038/s41390-024-03102-w. [PMID: 38438550 DOI: 10.1038/s41390-024-03102-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/29/2024] [Accepted: 02/03/2024] [Indexed: 03/06/2024]
Abstract
BACKGROUND We evaluated time-varying perinatal risk factors associated with early (≤7 post-natal days) and late (>7 post-natal days) severe acute kidney injury (AKI) occurrence and duration. METHODS A secondary analysis of Preterm Erythropoietin Neuroprotection Trial data. We defined severe AKI (stage 2 or 3) per neonatal modified Kidney Disease: Improving Global Outcomes criteria. Adjusted Cox proportional hazards models were conducted with exposures occurring at least 72 h before severe AKI. Adjusted negative binomial regression models were completed to evaluate risk factors for severe AKI duration. RESULTS Of 923 participants, 2% had early severe AKI. In the adjusted model, gestational diabetes (adjusted HR (aHR) 5.4, 95% CI 1.1-25.8), non-steroidal anti-inflammatory drugs (NSAIDs) (aHR 3.2, 95% CI 1.0-9.8), and vancomycin (aHR 13.9, 95% CI 2.3-45.1) were associated with early severe AKI. Late severe AKI occurred in 22% of participants. Early severe AKI (aHR 2.5, 95% CI 1.1-5.4), sepsis (aHR 2.5, 95% CI 1.4-4.4), vasopressors (aHR 2.9, 95% CI 1.8-4.6), and diuretics (aHR 2.6, 95% CI 1.9-3.6) were associated with late severe AKI. Participants who had necrotizing enterocolitis or received NSAIDs had longer severe AKI duration. CONCLUSION We identified major risk factors for severe AKI that can be the focus of future research. IMPACT STATEMENT Time-dependent risk factors for severe acute kidney injury (AKI) and its duration are not well defined among infants born <28 weeks' gestation. Over 1 in 5 infants born <28 weeks' gestation experienced severe AKI, and this study identified several major time-dependent perinatal risk factors occurring within 72 h prior to severe AKI. This study can support efforts to develop risk stratification and clinical decision support to help mitigate modifiable risk factors to reduce severe AKI occurrence and duration.
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Affiliation(s)
- Keia Sanderson
- University of North Carolina Department of Medicine-Nephrology, Chapel Hill, NC, USA.
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nekayla Anderson
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew M South
- Department of Pediatrics, Section of Nephrology, Brenner Children's, Wake Forest University School of Medicine, Winston Salem, NC, USA
| | - Jonathan R Swanson
- Division of Neonatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
- Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Heidi J Steflik
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Marissa J DeFreitas
- Division of Pediatric Nephrology, Department of Pediatrics, University of Miami, Miami, FL, USA
| | - Jennifer Charlton
- University of Virginia, Department of Pediatrics, Division of Nephrology, Charlottesville, VA, USA
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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Rutledge AD, Griffin RL, Vincent K, Askenazi DJ, Segar JL, Kupferman JC, Rastogi S, Selewski DT, Steflik HJ. Incidence, Risk Factors, and Outcomes Associated With Recurrent Neonatal Acute Kidney Injury in the AWAKEN Study. JAMA Netw Open 2024; 7:e2355307. [PMID: 38329754 PMCID: PMC10853837 DOI: 10.1001/jamanetworkopen.2023.55307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 12/15/2023] [Indexed: 02/09/2024] Open
Abstract
Importance The incidence and associated outcomes of recurrent acute kidney injury (rAKI) in neonates remain largely unknown. Objective To determine the incidence, risk factors, and clinical outcomes associated with rAKI in critically ill neonates. Design, Setting, and Participants This cohort study was a secondary analysis of the multicenter, international Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates retrospective study. Comparisons were made among neonates with no AKI, a single AKI episode (sAKI), and rAKI. All neonates younger than 14 days who were admitted between January 1 and March 31, 2014, to 24 participating level II to IV neonatal intensive care units and received intravenous fluids for at least 48 hours were considered for inclusion. Neonates with congenital heart disease requiring surgery within the first week of life, lethal chromosomal anomalies, death within 48 hours of admission, or severe congenital kidney abnormalities were excluded. Data were analyzed from May 23, 2022, to December 8, 2023. Exposure Recurrent AKI using the neonatal Kidney Disease: Improving Global Outcomes criteria. Determination of each rAKI required a complete return to the baseline serum creatinine level that defined the prior AKI episode. Main Outcomes and Measures Incidence and risk factors of rAKI and associations of rAKI with length of stay (LOS; ie, birth to hospital discharge) and mortality. Results The study cohort (n = 2162) included 1233 male neonates (57.0%). Gestational age distribution was less than 29 weeks for 276 neonates (12.8%), 29 to less than 36 weeks for 958 (44.3%), and 36 weeks or older for 928 (42.9%). Of 605 neonates with AKI, 133 (22.0%) developed rAKI with risk factors including younger gestational age, lower birthweight, and higher stage of initial AKI. Infants with rAKI experienced longer median LOS (no AKI, 17 [IQR, 8-34] days; sAKI, 18 [IQR, 9-45] days; rAKI, 60 [IQR, 25-109] days; P < .001). Time-varying Cox proportional hazards regression models suggest rAKI is independently associated with a lower hazard of discharge (adjusted hazard ratio, 0.7 [95% CI, 0.6-0.9]; P = .01) when compared with sAKI, but mortality did not differ between groups (adjusted hazard ratio, 1.4 [95% CI, 0.6-3.0]; P = .44). Conclusions and Relevance In this cohort study, neonatal rAKI was independently associated with longer LOS when compared with sAKI, suggesting that rAKI in neonates may be an important clinical distinction warranting further study and careful monitoring after an initial AKI episode.
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Affiliation(s)
- Austin D. Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | | | - Katherine Vincent
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | | | - Jeffrey L. Segar
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee
| | - Juan C. Kupferman
- Department of Pediatrics, Maimonides Medical Center, Brooklyn, New York
| | - Shantanu Rastogi
- Department of Pediatrics, Children’s Hospital at Montefiore, Bronx, New York
| | - David T. Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston
| | - Heidi J. Steflik
- Department of Pediatrics, Medical University of South Carolina, Charleston
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Haynes N, Bell J, Griffin R, Askenazi DJ, Jetton J, Kent AL. Receipt of high-frequency ventilation is associated with acute kidney injury in very preterm neonates. Pediatr Nephrol 2024; 39:579-587. [PMID: 37594576 DOI: 10.1007/s00467-023-06077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 06/25/2023] [Accepted: 06/26/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND High-frequency ventilation (HFV) is frequently used in critically ill preterm neonates. We aimed to determine the incidence of acute kidney injury (AKI) in neonates less than 29 weeks gestation who received HFV in the first week of life and to determine if the rates of AKI differed in those who received other forms of respiratory support. METHODS This retrospective cohort study of 24 international, level III/IV neonatal intensive care units (NICUs) included neonates less than 29 weeks gestation from the AWAKEN study database. Exclusion criteria included the following: no intravenous fluids ≥ 48 h, admission ≥ 14 days of life, congenital heart disease requiring surgical repair at < 7 days of life, lethal chromosomal anomaly, death within 48 h, severe congenital kidney abnormalities, inability to determine AKI status, insufficient data on ventilation, and when the diagnosis of early AKI was unable to be made. Subjects were grouped into three groups based on ventilation modes (CPAP/no ventilation, conventional ventilation, and HFV). RESULTS The incidence of AKI was highest in the CPAP/no ventilation group, followed by HFV, followed by conventional ventilation (CPAP/no ventilation 48.5% vs. HFV 42.6% vs. conventional ventilation 28.4% (p = 0.009). An increased risk for AKI was found for those on HFV compared to CPAP/no ventilation (HR = 2.65; 95% CI:1.22-5.73). CONCLUSIONS HFV is associated with AKI in the first week of life. Neonates on HFV should be screened for AKI. The reasons for this association are not clear. Further studies should evaluate the relationship between ventilator strategies and AKI in premature neonates. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Nicholas Haynes
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA
| | - Jeremiah Bell
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russel Griffin
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - David J Askenazi
- Pediatric and Infant Center for Acute Nephrology, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Jetton
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Alison L Kent
- School of Medicine and Dentistry, University of Rochester, Rochester, NY, USA.
- University of Adelaide Medical School, Women's and Children's Hospital, Adelaide, SA, Australia.
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia.
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14624, USA.
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9
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Starr MC, Gilley SP, See EJ, Slagle C, Soranno DE. Adults are just big kids: pediatric considerations for adult critical care nephrology. Curr Opin Crit Care 2023; 29:580-586. [PMID: 37861193 DOI: 10.1097/mcc.0000000000001100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW In recent years, there has been growing attention to pediatric kidney health, especially pediatric acute kidney injury (AKI). However, there has been limited focus on the role of pediatric AKI on adult kidney health, specifically considerations for the critical care physician. RECENT FINDINGS We summarize what is known in the field of pediatric AKI to inform adult medical care including factors throughout the early life course, including perinatal, neonatal, and pediatric exposures that impact survivor care later in adulthood. SUMMARY The number of pediatric AKI survivors continues to increase, leading to a higher burden of chronic kidney disease and other long-term co-morbidities later in life. Adult medical providers should consider pediatric history and illnesses to inform the care they provide. Such knowledge may help internists, nephrologists, and intensivists alike to improve risk stratification, including a lower threshold for monitoring for AKI and kidney dysfunction in their patients.
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Affiliation(s)
- Michelle C Starr
- Indiana University School of Medicine, Department of Pediatrics, Pediatric Nephrology
- Child Health Service Research Division, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie P Gilley
- University of Colorado School of Medicine, Department of Pediatrics, Section of Nutrition, Aurora, Colorado, USA
| | - Emily J See
- Royal Melbourne Hospital, Departments of Intensive Care and Nephrology, Melbourne, VIC, Australia
| | - Cara Slagle
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, Department of Pediatrics, Cincinnati, Ohio
| | - Danielle E Soranno
- Indiana University School of Medicine, Department of Pediatrics, Pediatric Nephrology
- Purdue University, Weldon School of Bioengineering, Department of Bioengineering, West Lafayette, Indiana, USA
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10
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Chen CC, Chu CH, Lin YC, Wang ST, Huang CC. Preceding risks and mortality outcomes of different neonatal acute kidney injury in preterm infants. Pediatr Res 2023; 94:1530-1537. [PMID: 37208430 DOI: 10.1038/s41390-023-02650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/19/2023] [Accepted: 05/01/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND The aim of the study was to examine preceding risks and mortality outcomes of oliguric and non-oliguric acute kidney injury (AKI) in very preterm infants. METHODS Infants born ≤30 weeks' gestation were included. AKI was diagnosed based on neonatal Kidney Disease: Improving Global Outcomes criteria and was classified as oliguric and non-oliguric according to the urine-output criteria. We used modified Poisson and Cox proportional-hazards models for statistical comparisons. RESULTS Of 865 enrolled infants (gestational age 27.2 ± 2.2 weeks and birth weight 983 ± 288 gm), 204 (23.6%) developed AKI. Before AKI, the oliguric AKI group had significantly higher prevalence of small-for-gestational age (p = 0.008), lower 5-min Apgar score (p = 0.009) and acidosis (p = 0.009) on admission, and hypotension (p = 0.008) and sepsis (p = 0.001) during admission than the non-oliguric AKI group. Oliguric (adjusted risk ratio 3.58, 95% CI 2.33-5.51; adjusted hazard ratio 4.93, 95% CI 3.14-7.72) instead of non-oliguric AKI had significantly higher mortality risks than no AKI. Oliguric AKI showed significantly higher mortality risks than non-oliguric AKI, irrespective of serum creatinine and severity of AKI. CONCLUSIONS Categorizing AKI as oliguric and non-oliguric was crucial because of the distinct preceding risks and mortality outcomes of these two types of AKI in very preterm neonates. IMPACT The differences of the underlying risks and prognosis between oliguric and non-oliguric AKI in very preterm infants remain unclear. We found that oliguric AKI, but not non-oliguric AKI, carries higher mortality risks than infants without AKI. Oliguric AKI possessed higher mortality risks than non-oliguric AKI, irrespective of concomitant serum creatinine elevation and severe AKI. Oliguric AKI is more associated with prenatal small-for-the-gestational age and perinatal and postnatal adverse events, while non-oliguric AKI is associated with nephrotoxins exposures. Our finding highlighted the importance of oliguric AKI and is helpful in developing future protocol in neonatal critical care.
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Affiliation(s)
- Chih-Chia Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Hsiang Chu
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Tair Wang
- Graduate Institute of Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Division of Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
- Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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11
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Chen CC, Chu CH, Lin YC, Huang CC. Neurodevelopment After Neonatal Acute Kidney Injury in Very Preterm-Birth Children. Kidney Int Rep 2023; 8:1784-1791. [PMID: 37705902 PMCID: PMC10496073 DOI: 10.1016/j.ekir.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/31/2023] [Accepted: 06/26/2023] [Indexed: 09/15/2023] Open
Abstract
Introduction This study aimed to assess head circumference (HC) growth and neurodevelopmental outcomes in very preterm-birth children after neonatal acute kidney injury (AKI). Methods This longitudinal follow-up cohort included 732 very preterm neonates of gestational age <31 weeks admitted to a tertiary center between 2008 and 2020. AKI was categorized as nonoliguric and oliguric AKI based on the urine output criteria during admission. We compared the differences in death, z scores of HC (zHC) at term-equivalent age (TEA) and at corrected ages of 6, 12, and 24 months, and the neurodevelopmental outcomes at corrected age of 24 months after neonatal nonoliguric and oliguric AKI. Results Among the 154 neonates who developed AKI, 72 had oliguric AKI and 82 had nonoliguric AKI. At TEA, oliguric AKI, but not nonoliguric AKI, was independently associated with lower zHC than non-AKI (mean differences, -0.49; 95% confidence interval [CI], -0.92 to -0.06). Although the 3 groups were comparable in zHC at corrected ages of 6, 12, and 24 months, the oliguric AKI group, but not the nonoliguric AKI group, had a higher rate of microcephaly by corrected age of 24 months. In addition, the oliguric AKI group, but not the nonoliguric AKI group, was more likely to die (61% vs. 9%) and have neurodevelopmental impairment (41% vs. 14%) compare with the non-AKI group. After adjustment, oliguric (adjusted odds ratio [aOR], 8.97; 95% CI, 2.19-36.76), but not nonoliguric, AKI was associated with neurodevelopmental impairment. Conclusion Neonatal oliguric AKI is associated with neurodevelopmental impairment in very preterm-birth children. Long-term head-size and neurodevelopmental follow-up after neonatal AKI is warranted.
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Affiliation(s)
- Chih-Chia Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chi-Hsiang Chu
- Department of Statistics, Tunghai University, Taichung, Taiwan
| | - Yung-Chieh Lin
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan
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12
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Elgendy MM, Adisa A, Farghaly M, Ali M, Mohamed MA, Aly H. Acute kidney injury in infants diagnosed with congenital diaphragmatic hernia. Pediatr Res 2023; 94:1083-1088. [PMID: 36949287 DOI: 10.1038/s41390-023-02545-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 02/01/2023] [Accepted: 02/09/2023] [Indexed: 03/24/2023]
Abstract
BACKGROUND To assess the association and outcomes of acute kidney injury (AKI) in infants diagnosed with congenital diaphragmatic hernia (CDH). METHODS We analyzed the National Inpatient Sample dataset for the years 2010 through 2018. We evaluated the prevalence and outcomes associated with AKI in infants diagnosed with CDH. Outcomes were assessed using regression analysis while controlling for variables. RESULTS A total of 32,042,481 term infants were identified, of them 10,804 had CDH. Prevalence of AKI in infants with CDH was 6.5% compared to 0.05% in those without CDH (aOR = 14.7, CI: 13.0-16.6). ECMO was utilized at 62% of CDH infants that had AKI compared to 17% in infants without AKI (aOR = 4.22, CI: 3.38-5.27). Mortality was greater in CDH infants who developed AKI when compared to those without AKI (57.3 vs. 16.7%, aOR = 3.65, CI: 2.99-4.46). The trend of mortality in CDH infants who developed AKI decreased overtime, p < 0.001, while the trends for mortality in the overall CDH infants and in CDH infants without AKI did not change during the study period, p = 0.12. CONCLUSION AKI is not uncommon in infants diagnosed with CDH. ECMO utilization and mortality are substantially increased in CDH infants when they develop AKI. IMPACT Mortality in infants diagnosed with congenital diaphragmatic hernia (CDH) is relatively high despite advances in neonatal care. Infants with CDH are potentially at increased risk of acute kidney injury (AKI). Within CDH population, infants diagnosed with AKI are at increased risk for ECMO use and mortality. This is the largest study to address the association and outcomes of AKI in term infants diagnosed with CDH.
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Affiliation(s)
- Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, Ohio & Department of Pediatrics, University of Florida, Jacksonville, FL, USA.
| | - Afeez Adisa
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Mohsen Farghaly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Mahmoud Ali
- Department of Pediatrics, MetroHealth Medical center, Cleveland, OH, USA
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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13
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Plumb L, Casula A, Sinha MD, Inward CD, Marks SD, Medcalf J, Nitsch D. Epidemiology of childhood acute kidney injury in England using e-alerts. Clin Kidney J 2023; 16:1288-1297. [PMID: 37529656 PMCID: PMC10387403 DOI: 10.1093/ckj/sfad070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 08/03/2023] Open
Abstract
Background Few studies describe the epidemiology of childhood acute kidney injury (AKI) nationally. Laboratories in England are required to issue electronic (e-)alerts for AKI based on serum creatinine changes. This study describes a national cohort of children who received an AKI alert and their clinical course. Methods A cross-section of AKI episodes from 2017 are described. Hospital record linkage enabled description of AKI-associated hospitalizations including length of stay (LOS) and critical care requirement. Risk associations with critical care (hospitalized cohort) and 30-day mortality (total cohort) were examined using multivariable logistic regression. Results In 2017, 7788 children (52% male, median age 4.4 years, interquartile range 0.9-11.5 years) experienced 8927 AKI episodes; 8% occurred during birth admissions. Of 5582 children with hospitalized AKI, 25% required critical care. In children experiencing an AKI episode unrelated to their birth admission, Asian ethnicity, young (<1 year) or old (16-<18 years) age (reference 1-<5 years), and high peak AKI stage had higher odds of critical care. LOS was higher with peak AKI stage, irrespective of critical care admission. Overall, 30-day mortality rate was 3% (n = 251); youngest and oldest age groups, hospital-acquired AKI, higher peak stage and critical care requirement had higher odds of death. For children experiencing AKI alerts during their birth admission, no association was seen between higher peak AKI stage and critical care admission. Conclusions Risk associations for adverse AKI outcomes differed among children according to AKI type and whether hospitalization was related to birth. Understanding the factors driving AKI development and progression may help inform interventions to minimize morbidity.
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Affiliation(s)
| | - Anna Casula
- UK Renal Registry, UK Kidney Association, Bristol, UK
| | - Manish D Sinha
- Evelina London Children's Hospital, Guys and St Thomas’ NHS Foundation Trust, London, UK
- British Heart Foundation Centre, Kings College London, London, UK
| | - Carol D Inward
- Department of Paediatric Nephrology, University Hospitals Bristol & Weston NHS Foundation Trust, Bristol, UK
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, UK
| | - James Medcalf
- UK Renal Registry, UK Kidney Association, Bristol, UK
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Dorothea Nitsch
- UK Renal Registry, UK Kidney Association, Bristol, UK
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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14
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Elgendy MM, Othman HF, Mohamed MA, Matar RB, Aly H. Kidney replacement therapy in neonates: utilization trends and outcomes. Pediatr Nephrol 2023; 38:867-876. [PMID: 35790647 DOI: 10.1007/s00467-022-05575-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND We aimed to assess prevalence and clinical characteristics of newborns receiving kidney replacement therapy (KRT). METHODS We used the National Inpatient Sample (NIS) dataset for the years 2000-2017. Newborns treated with peritoneal dialysis (PD), hemodialysis (HD), and continuous KRT (CKRT) were included. Trend analysis using the Cochran-Armitage test was used to assess prevalence over the years. RESULTS A total of 64,532,552 hospitalized newborns were included. Among the 4281 infants treated with KRT, 2501 (58.4%) were treated with PD, 997 (23.3%) had HD, and 783 (18.3%) used CKRT. Associated diagnoses included congenital kidney anomalies (37.4% vs. 15% vs. 9.5%), urinary tract anomalies (35% vs. 12.5% vs. 6.3%), and congenital heart disease (68% vs. 25.7% vs. 72.3%). Median length of stay was longest in PD patients (39 days vs. 18 days vs. 26 days), respectively. However, cost of hospitalization was greatest in CKRT patients (US $490,916 vs. US $218,514 vs. US $621,554), respectively. In the entire cohort, 54,424 newborns had acute kidney injury (AKI); of them 16,999 (31%) died. KRT was used in 2,688 (4.9%) of infants with AKI. Over the study period, trends for utilization of PD (from 0.042 to 0.06%) and CKRT (from 0.03 to 0.21%) increased whereas the hemodialysis trend decreased (from 0.021 to 0.013%). CONCLUSIONS Congenital heart disease (CHD) and congenital anomalies of the kidneys and urinary tract (CAKUT) are the major diagnoses in newborns receiving KRT. Utilization of PD was greater than HD and CKRT. Trends of PD and CKRT utilization increased over time. Less than 5% of infants diagnosed with AKI received KRT.
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Affiliation(s)
- Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA.
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, MI, USA
| | - Mohamed A Mohamed
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Raed Bou Matar
- Center for Pediatric Nephrology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, Cleveland, OH, USA
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15
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Al Gharaibeh FN, Mohan S, Santoro MA, Slagle CL, Goldstein SL. Acute kidney injury and early fluid load in a retrospective cohort of neonatal sepsis. Pediatr Nephrol 2022; 38:1971-1977. [PMID: 36525082 DOI: 10.1007/s00467-022-05840-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Sepsis and acute kidney injury (AKI) are associated with mortality in the newborn intensive care unit (NICU). There is a paucity of studies that describe AKI and fluid overload in neonatal sepsis and their association with mortality. METHODS Retrospective study of neonates with culture positive sepsis admitted to the NICU between June 2020 and June 2021 was conducted. Primary outcome was in-hospital mortality according to AKI as defined by the neonatal modified Kidney Diseases Improving Outcomes criteria. Secondary outcomes were early fluid overload and vasopressor use. RESULTS Thirty-three percent of neonates had AKI with sepsis, and 57% of cases were severe AKI. AKI was associated with mortality after adjusting for variables that were different between survivors and non-survivors (aOR 5.7 [95% CI 1.1-36], p = 0.04). Early fluid overload occurred in 27% of neonates who were at higher risk of having AKI with sepsis (OR 7.4 [95% CI 1.6-26.0], p = 0.01) and higher risk of mortality (aOR 17.8 [95% CI 2-7545], p = 0.02). CONCLUSIONS AKI and early fluid overload are associated with mortality in sepsis in our retrospective cohort. Mitigating AKI and early fluid overload in sepsis might be a fruitful strategy in reducing mortality with sepsis. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Faris N Al Gharaibeh
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.
| | - Shruthi Mohan
- Pediatric Residency Program, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Cara L Slagle
- Division of Neonatology, Perinatal Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.,College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Stuart L Goldstein
- College of Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA.,Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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16
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Abstract
PURPOSE OF REVIEW The purpose of this review is to describe acute kidney injury (AKI) phenotypes in children. RECENT FINDINGS AKI is a heterogenous disease that imposes significant morbidity and mortality on critically ill and noncritically ill patients across the age spectrum. As our understanding of AKI and its association with outcomes has improved, it is becoming increasingly apparent that there are distinct AKI subphenotypes that vary by cause or associated conditions. We have also learned that severity, duration, and repeated episodes of AKI impact outcomes, and that integration of novel urinary biomarkers of tubular injury can also reveal unique subphenotypes of AKI that may not be otherwise readily apparent. SUMMARY Studies that further delineate these unique AKI subphenotypes are needed to better understand the impact of AKI in children. Further delineation of these phenotypes has both prognostic and therapeutic implications.
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17
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Massa-Buck B, Rastogi S. Recent Advances in Acute Kidney Injury in Preterm Infants. CURRENT PEDIATRICS REPORTS 2022. [DOI: 10.1007/s40124-022-00271-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Nada A, Askenazi D, Kupferman JC, Mhanna M, Mahan JD, Boohaker L, Li L, Griffin RL. Low albumin levels are independently associated with neonatal acute kidney injury: a report from AWAKEN Study Group. Pediatr Nephrol 2022; 37:1675-1686. [PMID: 34657971 PMCID: PMC9986677 DOI: 10.1007/s00467-021-05295-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/09/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Data from adult and pediatric literature have shown an association between albumin levels and AKI. Whether hypoalbuminemia and neonatal AKI are associated has not been studied. METHODS We evaluated the association of albumin with early (during the first postnatal week) and late (after the first postnatal week) AKI for 531 neonates from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database and for 3 gestational age (GA) subgroups: < 29, 29 to < 36, and ≥ 36 weeks GA. RESULTS Low albumin levels were associated with increased odds of neonatal AKI; for every 0.1 g/dL decrease in albumin, the odds of late AKI increased by 12% on continuous analysis. After adjustment for potential confounders, neonates with albumin values in the lowest quartiles (< 2.2 g/dL) had an increased odds of early [Adjusted Odd Ratio (AdjOR) 2.5, 95% CI = 1.1-5.3, p < 0.03] and late AKI [AdjOR 13.4, 95% CI = 3.6-49.9, p < 0.0001] compared to those with albumin in the highest quartile (> 3.1 g/dL). This held true for albumin levels 2.3 to 2.6 g/dL for early [AdjOR 2.5, 95% CI = 1.2-5.5, p < 0.02] and late AKI [AdjOR 6.4, 95% CI = 1.9-21.6, p < 0.01]. Albumin quartiles of (2.7 to 3.0 g/dL) were associated with increased odds of late AKI. Albumin levels of 2.6 g/dL and 2.4 g/dL best predicted early (AUC = 0.59) and late AKI (AUC = 0.64), respectively. Analysis of albumin association with AKI by GA is described. CONCLUSIONS Low albumin levels are independently associated with early and late neonatal AKI. Albumin could be a potential modifiable risk factor for neonatal AKI.
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Affiliation(s)
- Arwa Nada
- Department of Pediatrics, Division of Nephrology & Hypertension, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, 49 North Dunlap St FOB 326, Memphis, TN, 38105, USA.
| | - David Askenazi
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Juan C Kupferman
- Department of Pediatrics, Division of Pediatric Nephrology & Hypertension, Maimonides Medical Center, Brooklyn, NY, USA
| | - Maroun Mhanna
- Department of Pediatrics, Division of Neonatology, Louisiana State University Health in Shreveport, Shreveport, LA, USA
| | - John D Mahan
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Louis Boohaker
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Linzi Li
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell L Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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19
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Recurrent acute kidney injury in preterm neonates is common and associated with worse outcomes and higher mortality. Pediatr Res 2022; 92:284-290. [PMID: 34593979 DOI: 10.1038/s41390-021-01740-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/24/2021] [Accepted: 09/05/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in preterm neonates is associated with poor outcomes that may worsen in the setting of recurrent episodes of AKI. This study defines and studies the incidence, risk factors, and outcomes of recurrent AKI (rAKI). METHODS Retrospective chart review of the neonates born at a gestational age of ≤28 weeks admitted to the neonatal intensive care unit (NICU) between January 2014 and December 2018. We identified AKI based on the serum creatinine (Scr) concentrations using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. rAKI was defined as the occurrence of AKI after Scr from the prior AKI had returned to baseline. RESULTS Forty-nine of the 205 (24%) preterm neonates developed rAKI. An earlier diagnosis (<7 days old) and a higher KDIGO stage (stage 3) at the initial episode of AKI was associated with rAKI (p = 0.03). Preterm neonates with rAKI had higher mortality as compared to those with a single episode of AKI (sAKI) (adjusted odds ratio (aOR) 4.55, 95% confidence interval (CI), 1.12-18.51). Length of stay (LOS) was longer among neonates with rAKI as compared to those with sAKI by 36 days (95% CI 24.9-47.1). CONCLUSIONS Recurrent AKI in preterm neonates was associated with earlier episodes and higher KDIGO stage of the initial AKI episode. Neonates with rAKI had higher mortality and longer LOS compared to those with sAKI. IMPACT Definition and study of the incidence of rAKI and its associated outcomes among preterm neonates. Recurrent AKI is common among preterm neonates and may contribute to worse outcomes for premature neonates in the NICU. Early recognition of the risk factors for AKI, and effective management of initial AKI and early phase of recurrent AKI may improve outcomes of these preterm neonates.
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20
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Roy JP, Goldstein SL, Schuh MP. Under-Recognition of Neonatal Acute Kidney Injury and Lack of Follow-Up. Am J Perinatol 2022; 39:526-531. [PMID: 32971562 DOI: 10.1055/s-0040-1716841] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Acute kidney injury (AKI) incidence is 30% in neonatal intensive care units (NICU). AKI is associated with increased mortality and risk of chronic kidney disease (CKD) in children. To assess follow-up and early CKD, we retrospectively reviewed outcomes of Cincinnati Children's Hospital Medical Center (CCHMC) cohort of neonates from the AWAKEN trial (2014). STUDY DESIGN Data from 81 CCHMC patients were extracted from the AWAKEN dataset. KDIGO (Kidney Disease: Improving Global Outcomes) criteria for serum creatinine (SCr) and urine output (UOP) <1 mL/kg/h, reported per 24 hours on postnatal days 2 to 7, were used to define AKI. Charts were reviewed until May 2019 for death, nephrology consult, AKI diagnosis on discharge summary, follow-up, and early CKD at >6 months of age (defined as: estimated glomerular filtration rate < 90 mL/min/1.73 m2, hyperfiltration, proteinuria, hypertension, or abnormal ultrasound). Patients were considered to have renal follow-up if they had ≥1 follow-up visit containing: SCr, urinalysis, or blood pressure measurement. RESULTS Seventy-seven patients had sufficient data to ascertain AKI diagnosis. In total 47 of 77 (61%) were AKI+ by SCr or UOP criteria (20 stage 1, 14 stage 2, 13 stage 3). Four died during their admission and five were removed from CKD analyses due to urologic anomalies. AKI-UOP alone outnumbered AKI-SCr (45 AKI+ vs 5 AKI+ for all stages). 33% of patients had <2 SCr measured while inpatient. Only 3 of 47 AKI+ patients had a nephrology consult (all stage 3 by SCr) and 2 of 47 had AKI included in discharge summary. 67% of AKI+ patients had follow-up. In total 10 of 43 (23%) AKI+ versus 12 of 25 (48%) AKI- patients had ≥1 marker of early CKD assessed after 6 months. Based on SCr, 3 of 7 (43%) AKI+ had hyperfiltration versus 0 of 7 (0%) AKI- (p = 0.19). CONCLUSION AKI is vastly under-recognized in the NICU, especially if based on SCr alone. This leads to insufficient follow-up to ascertain renal sequelae in this high-risk population. KEY POINTS · AKI is under-recognized in high-risk neonates.. · There is a lack of adequate follow-up.. · Identification of AKI by SCr alone is insufficient..
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Affiliation(s)
- Jean-Philippe Roy
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Meredith P Schuh
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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21
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Improving the identification of acute kidney injury in the neonatal ICU: three centers' experiences. J Perinatol 2022; 42:243-246. [PMID: 34480111 DOI: 10.1038/s41372-021-01198-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/10/2021] [Accepted: 08/20/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To describe three different standardized approaches to improving neonatal acute kidney injury (AKI) identification and the impact on AKI identification, incidence, and nephrology consultation and referral. STUDY DESIGN A retrospective cohort study in three academic NICUs. We compared AKI identification, AKI incidence, nephrology consultation, and nephrology follow-up before and after implantation of local protocols to standardize neonatal AKI identification. RESULT Neonatal AKI identification improved in all three NICUs following protocol implementation (26-85%, P < 0.0001). Each center also saw increases in nephrology consultation (15-83%, P < 0.0001) and nephrology follow-up (7-73%, P < 0.0001). AKI incidence decreased significantly (21-12%, P < 0.0001). CONCLUSION Multiple strategies can be successfully operationalized to improve neonatal AKI identification. While different in approach, each strategy resulted in increased AKI identification and nephrology involvement. This study emphasizes the importance of local standardized approaches to AKI to improve AKI identification and nephrology involvement in the NICU.
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22
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Segar J, Jetton JG. Diuretic use, acute kidney injury, and premature infants: the call for evidence-based guidelines. Pediatr Nephrol 2021; 36:3807-3811. [PMID: 34258644 DOI: 10.1007/s00467-021-05201-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Jeffrey Segar
- Departments of Pediatrics and Physiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA.
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23
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Cwiek A, Suzuki M, deRonde K, Conaway M, Bennett KM, El Dahr S, Reidy KJ, Charlton JR. Premature differentiation of nephron progenitor cell and dysregulation of gene pathways critical to kidney development in a model of preterm birth. Sci Rep 2021; 11:21667. [PMID: 34737344 PMCID: PMC8569166 DOI: 10.1038/s41598-021-00489-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 10/05/2021] [Indexed: 12/31/2022] Open
Abstract
Preterm birth is a leading cause of neonatal morbidity. Survivors have a greater risk for kidney dysfunction and hypertension. Little is known about the molecular changes that occur in the kidney of individuals born preterm. Here, we demonstrate that mice delivered two days prior to full term gestation undergo premature cessation of nephrogenesis, resulting in a lower glomerular density. Kidneys from preterm and term groups exhibited differences in gene expression profiles at 20- and 27-days post-conception, including significant differences in the expression of fat-soluble vitamin-related genes. Kidneys of the preterm mice exhibited decreased proportions of endothelial cells and a lower expression of genes promoting angiogenesis compared to the term group. Kidneys from the preterm mice also had altered nephron progenitor subpopulations, early Six2 depletion, and altered Jag1 expression in the nephrogenic zone, consistent with premature differentiation of nephron progenitor cells. In conclusion, preterm birth alone was sufficient to shorten the duration of nephrogenesis and cause premature differentiation of nephron progenitor cells. These candidate genes and pathways may provide targets to improve kidney health in preterm infants.
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Affiliation(s)
- Aleksandra Cwiek
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA
- Cell & Developmental Biology Graduate Program, University of Virginia School of Medicine, Charlottesville, VA, 22903, USA
| | - Masako Suzuki
- Department of Genetics, Albert Einstein College of Medicine, New York, NY, USA
| | - Kimberly deRonde
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA
| | - Mark Conaway
- University of Virginia Health System, Charlottesville, VA, USA
- Division of Translational Research and Applied Statistics, Department of Public Health Sciences, University of Virginia School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kevin M Bennett
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Samir El Dahr
- Department of Pediatrics, Tulane University School of Medicine and Children's Hospital of New Orleans, New Orleans, LA, USA
| | - Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore, New York, NY, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA.
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Slagle CL, Goldstein SL, Gavigan HW, Rowe JA, Krallman KA, Kaplan HC, Liu C, Ehrlich SR, Kotagal M, Bondoc AJ, Poindexter BB. Association between Elevated Urine Neutrophil Gelatinase-Associated Lipocalin and Postoperative Acute Kidney Injury in Neonates. J Pediatr 2021; 238:193-201.e2. [PMID: 34371091 PMCID: PMC8551040 DOI: 10.1016/j.jpeds.2021.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To examine the incidence of postoperative neonatal acute kidney injury (AKI) following general surgical procedures and to test the hypothesis that postoperative urine neutrophil gelatinase-associated lipocalin (uNGAL) concentrations predict AKI. The secondary objective was to evaluate for an association between AKI and hospital mortality. STUDY DESIGN Prospective observational study of infants undergoing abdominal and thoracic surgical procedures in the neonatal intensive care unit from October 2018 to March 2020. The primary outcome was incidence of neonatal AKI (defined by the neonatal modified Kidney Diseases Improving Global Outcomes criteria) following each procedure to postoperative day 5. Severe AKI was defined as stage 2 or 3 AKI. Urine samples were obtained pre- and postoperatively at 6 time points to evaluate for levels of uNGAL. Secondary outcomes were in-hospital mortality and length of stay. RESULTS Subjects (n = 141) underwent a total of 192 general surgical procedures during the study period. Neonatal AKI and severe AKI occurred following 36 (18%) and 15 (8%) procedures (n = 33 subjects). Percent change of uNGAL from 24 hours preoperatively to 24 hours postoperatively was greater in subjects with neonatal AKI (190.2% [IQR 0.0, 1666.7%] vs 0.7% [IQR -31.2%,140.2%], P = .0374). The strongest association of uNGAL and AKI occurred at 24 hours postoperatively (area under the receiver operator curves of 0.81, 95% CI 0.72, 0.89). Increased mortality risk was observed in subjects with any postoperative AKI (aOR 11.1 95% CI 2.0, 62.8, P = .0063) and severe AKI (aOR 13.8; 95% CI 3.0, 63.1, P = .0007). CONCLUSION Elevation in uNGAL 24 hours postoperative was associated with AKI. Neonates with postoperative AKI had increased mortality.
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Affiliation(s)
- Cara L Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Hailey W Gavigan
- Division of Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - James A Rowe
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kelli A Krallman
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Heather C Kaplan
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shelley R Ehrlich
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Alexander J Bondoc
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center and Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Brenda B Poindexter
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neonatology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA
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Starr MC, Charlton JR, Guillet R, Reidy K, Tipple TE, Jetton JG, Kent AL, Abitbol CL, Ambalavanan N, Mhanna MJ, Askenazi DJ, Selewski DT, Harer MW. Advances in Neonatal Acute Kidney Injury. Pediatrics 2021; 148:peds.2021-051220. [PMID: 34599008 DOI: 10.1542/peds.2021-051220] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 01/14/2023] Open
Abstract
In this state-of-the-art review, we highlight the major advances over the last 5 years in neonatal acute kidney injury (AKI). Large multicenter studies reveal that neonatal AKI is common and independently associated with increased morbidity and mortality. The natural course of neonatal AKI, along with the risk factors, mitigation strategies, and the role of AKI on short- and long-term outcomes, is becoming clearer. Specific progress has been made in identifying potential preventive strategies for AKI, such as the use of caffeine in premature neonates, theophylline in neonates with hypoxic-ischemic encephalopathy, and nephrotoxic medication monitoring programs. New evidence highlights the importance of the kidney in "crosstalk" between other organs and how AKI likely plays a critical role in other organ development and injury, such as intraventricular hemorrhage and lung disease. New technology has resulted in advancement in prevention and improvements in the current management in neonates with severe AKI. With specific continuous renal replacement therapy machines designed for neonates, this therapy is now available and is being used with increasing frequency in NICUs. Moving forward, biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, and other new technologies, such as monitoring of renal tissue oxygenation and nephron counting, will likely play an increased role in identification of AKI and those most vulnerable for chronic kidney disease. Future research needs to be focused on determining the optimal follow-up strategy for neonates with a history of AKI to detect chronic kidney disease.
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Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Reidy
- Division of Pediatric Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Medicine, The University of Oklahoma, Oklahoma City, Oklahoma
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Alison L Kent
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York.,College of Health and Medicine, The Australian National University, Canberra, Australia Capitol Territory, Australia
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami and Holtz Children's Hospital, Miami, Florida
| | | | - Maroun J Mhanna
- Department of Pediatrics, Louisiana State University Shreveport, Shreveport, Louisiana
| | - David J Askenazi
- Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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Starr MC, Menon S. Neonatal acute kidney injury: a case-based approach. Pediatr Nephrol 2021; 36:3607-3619. [PMID: 33594463 DOI: 10.1007/s00467-021-04977-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 01/19/2021] [Accepted: 02/01/2021] [Indexed: 12/19/2022]
Abstract
Neonatal acute kidney injury (AKI) is increasingly recognized as a common complication in critically ill neonates. Over the last 5-10 years, there have been significant advancements which have improved our understanding and ability to care for neonates with kidney disease. A variety of factors contribute to an increased risk of AKI in neonates, including decreased nephron mass and immature tubular function. Multiple factors complicate the diagnosis of AKI including low glomerular filtration rate at birth and challenges with serum creatinine as a marker of kidney function in newborns. AKI in neonates is often multifactorial, but the cause can be identified with careful diagnostic evaluation. The best approach to treatment in such patients may include diuretic therapies or kidney support therapy. Data for long-term outcomes are limited but suggest an increased risk of chronic kidney disease (CKD) and hypertension in these infants. We use a case-based approach throughout this review to illustrate these concepts and highlight important evidence gaps in the diagnosis and management of neonatal AKI.
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Affiliation(s)
- Michelle C Starr
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Shina Menon
- Department of Pediatrics, University of Washington, Seattle, WA, USA
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27
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Elgendy MM, Othman HF, Younis M, Puthuraya S, Matar RB, Aly H. Trends and racial disparities for acute kidney injury in premature infants: the US national database. Pediatr Nephrol 2021; 36:2789-2795. [PMID: 33619659 DOI: 10.1007/s00467-021-04998-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 01/30/2021] [Accepted: 02/10/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND To assess prevalence and outcomes of acute kidney injury (AKI) in very-low-birth-weight infants. METHODS This cross-sectional study utilized the National Inpatient Sample (NIS) dataset for years 2000-2017. All premature infants with birth weight (BW) <1500g and/or gestational age (GA) ≤32 weeks were included. Analyses were conducted for overall population and two BW categories: <1000g and 1000-1499g. Adjusted odds ratios were calculated after controlling for confounding variables in logistic regression analysis. Cochrane-Armitage test was used to assess for statistically significant trends in AKI frequency over the years. RESULTS In total, 1,311,681 hospitalized premature infants were included; 19,603 (1.5%) were diagnosed with AKI. The majority (74.3%) were BW <1000g and 63.9% ≤28 weeks gestation. Prevalence of AKI differed by ethnicity; White had significantly less AKI than Black (OR=0.79, p<0.001) and Hispanic (OR=0.83, p<0.001). AKI was significantly associated with higher mortality compared to controls (35.1 vs. 3.0%, p<0.001). AKI was associated with comorbidities such as necrotizing enterocolitis, patent ductus arteriosus, bronchopulmonary dysplasia, intraventricular hemorrhage, and septicemia. In a regression model, AKI was associated with higher mortality after controlling confounding factors (aOR=7.79, p<0.001). AKI was associated with significant increase in length of stay (p<0.001) and cost of hospitalization in survivors (p<0.001). There is a significant trend for increased AKI frequency over the years (Z score=4.33, p<0.001). CONCLUSION AKI is associated with increased mortality and comorbidities in preterm infants, especially in infants with BW <1000g. Further studies are needed to understand precipitating factors and assess preventative measures for this serious complication.
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Affiliation(s)
- Marwa M Elgendy
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA.
| | - Hasan F Othman
- Department of Pediatrics, Michigan State University/Sparrow Health System, Lansing, MI, USA
| | - Mira Younis
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA
| | - Subhash Puthuraya
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA
| | - Raed Bou Matar
- Department of Pediatric Nephrology, Cleveland Clinic Children's, Cleveland, OH, USA
| | - Hany Aly
- Department of Neonatology, Cleveland Clinic Children's, 900 Euclid Avenue, M31-37, Cleveland, OH, 44195, USA
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Chen CC, Lin YC, Wang ST, Huang CC. Temporal Trends of Acute Kidney Injury and Associated Risk Exposures in Extremely Preterm Infants. Clin J Am Soc Nephrol 2021; 16:1169-1177. [PMID: 34348930 PMCID: PMC8455040 DOI: 10.2215/cjn.19301220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES Neonatal AKI in the preterm population is an under-recognized morbidity. Detecting AKI in preterm infants is important for their long-term kidney health. We aimed to examine the yearly trends of incidence and the related morbidities and care practices affecting the occurrence of neonatal AKI in extremely preterm (gestational age <29 weeks) and very preterm (gestational age 29-32 weeks) infants. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The trends and the related risk factors and care practices of AKI were examined in the extremely preterm (n=434) and very preterm (n=257) infants who were admitted within 14 days after birth from 2005 to 2018 to the University Hospital and had at least two serum creatinine measurements during hospitalization. We defined AKI as a serum creatinine rise of 0.3 mg/dl or more within 48 hours or a 1.5-fold increase within 7 days. RESULTS The extremely preterm group had a three-fold higher incidence of AKI (30% versus 10%) than the very preterm group. Among preterm infants with AKI, 92% had one episode of AKI, and 45% experienced stage 2 or 3 AKI; the mean duration of AKI was 12±9 days. Across the 14-year period, the crude incidence of AKI declined markedly from 56% to 17% in the extremely preterm group and from 23% to 6% in the very preterm group. After adjustment, a significant decline of AKI incidence was still observed in the extremely preterm group. The declining AKI in the extremely preterm infants was related to the trends of decreasing incidences of neonatal transfer, prolonged aminoglycoside exposure, prophylactic use of nonsteroidal anti-inflammatory drugs, and sepsis. CONCLUSIONS We observed a declining trend in the incidence of neonatal AKI among extremely preterm infants from 2005 to 2018, which may be related to improvement of care practices.
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Affiliation(s)
- Chih-Chia Chen
- Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan,Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yung-Chieh Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Cheng-Kung University, Tainan, Taiwan,Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Shan-Tair Wang
- Gerontology, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Division of Research, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Chao-Ching Huang
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan,Department of Pediatrics, College of Medicine, Taipei Medical University, Taipei, Taiwan,Correspondence: Prof. Chao-Ching Huang, Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, North District, Tainan 70403, Taiwan.
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29
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Hingorani S, Schmicker RH, Brophy PD, Heagerty PJ, Juul SE, Goldstein SL, Askenazi D. Severe Acute Kidney Injury and Mortality in Extremely Low Gestational Age Neonates. Clin J Am Soc Nephrol 2021; 16:862-869. [PMID: 34117080 PMCID: PMC8216626 DOI: 10.2215/cjn.18841220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 03/30/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVES AKI is associated with poor short- and long-term outcomes. Questions remain about the frequency and timing of AKI, and whether AKI is a cause of death in extremely low gestational age neonates. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The Recombinant Erythropoietin for Protection of Infant Kidney Disease Study examines the kidney outcomes of extremely low gestational age neonates enrolled in the Preterm Epo Neuroprotection study, a randomized, placebo-controlled trial of recombinant human erythropoietin. We included 900 of 941 patients enrolled in Preterm Epo Neuroprotection. Baseline characteristics were compared by primary exposure (severe AKI versus none/stage 1 AKI) using unadjusted logistic regression models. Cox regression models estimated the relationship between severe AKI and death after adjustment for potential confounders. Time-dependent AKI was modeled as a binary outcome and a categorical variable by stage of AKI. We fit Cox models using time-dependent AKI status lagged by <7 days before death. Landmark analyses examined the relationship of death with development of severe AKI. RESULTS Severe AKI occurred in 168 of 900 (19%, 95% confidence interval, 17% to 20%) neonates, and stage 3 AKI occurred in 60 (7%, 95% confidence interval, 5% to 8%). Stage 3 AKI occurring 7 days before death (hazard ratio, 3.88; 95% confidence interval, 1.26 to 11.96), intraventricular hemorrhage (hazard ratio, 2.01; 95% confidence interval, 1.01 to 3.99) and sepsis (hazard ratio, 2.85; 95% confidence interval, 1.12 to 7.22) were all independently associated with death. Severe AKI occurring 7 days before death (hazard ratio, 2.21; 95% confidence interval, 0.92 to 5.26) was associated with death but not statistically significant. In a landmark analysis, after adjusting for potential confounders, late (after day 14 and before day 28) severe AKI was strongly associated with higher hazard of death (hazard ratio, 4.57; 95% confidence interval, 1.82 to 11.5). CONCLUSIONS Severe AKI occurs frequently in extremely low gestational age neonates. Stage 3 AKI is associated with mortality, and this association is present 7 days before death.
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Affiliation(s)
- Sangeeta Hingorani
- Division of Nephrology, Seattle Children’s Hospital and University of Washington, Seattle, Washington,Department of Biostatistics, University of Washington, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle, Washington
| | | | - Patrick D. Brophy
- Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York
| | | | - Sandra E. Juul
- Department of Pediatrics, University of Washington, Seattle, Washington,Division of Neonatology, Seattle Children’s Hospital and University of Washington, Seattle, Washington
| | - Stuart L. Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center and The University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David Askenazi
- Division of Nephrology, University of Alabama at Birmingham, Children’s of Alabama, Birmingham, Alabama
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Coggins SA, Laskin B, Harris MC, Grundmeier RW, Passarella M, McKenna KJ, Srinivasan L. Acute Kidney Injury Associated with Late-Onset Neonatal Sepsis: A Matched Cohort Study. J Pediatr 2021; 231:185-192.e4. [PMID: 33340552 DOI: 10.1016/j.jpeds.2020.12.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine incidence and severity of acute kidney injury (AKI) within 7 days of sepsis evaluation and to assess AKI duration and the association between AKI and 30-day mortality. STUDY DESIGN Retrospective, matched cohort study in a single-center level IV neonatal intensive care unit. Eligible infants underwent sepsis evaluations at ≥72 hours of age during calendar years 2013-2018. Exposed infants (cases) were those with culture-proven sepsis and antimicrobial duration ≥5 days. Nonexposed infants (controls) were matched 1:1 to exposed infants based on gestational and corrected gestational age, and had negative sepsis evaluations with antibiotic durations <48 hours. AKI was defined by modified neonatal Kidney Disease Improving Global Outcomes criteria. Statistical analysis included Mann-Whitney and χ2 tests, multivariable logistic regression, and Kaplan-Meier time-to-event analysis. RESULTS Among 203 episodes of late-onset sepsis, 40 (20%) developed AKI within 7 days after evaluation, and among 193 episodes with negative cultures, 16 (8%) resulted in AKI (P = .001). Episodes of sepsis also led to greater AKI severity, compared with nonseptic episodes (P = .007). The timing of AKI onset and AKI duration did not differ between groups. Sepsis was associated with increased odds of developing AKI (aOR, 3.0; 95% CI, 1.5-6.2; P = .002). AKI was associated with increased 30-day mortality (aOR, 4.5; 95% CI, 1.3-15.6; P = .017). CONCLUSIONS Infants with late-onset sepsis had increased odds of AKI and greater AKI severity within 7 days of sepsis evaluation, compared with age-matched infants without sepsis. AKI was independently associated with increased 30-day mortality. Strategies to mitigate AKI in critically ill neonates with sepsis may improve outcomes.
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Affiliation(s)
- Sarah A Coggins
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA.
| | - Benjamin Laskin
- Division of Nephrology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mary Catherine Harris
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Robert W Grundmeier
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Molly Passarella
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Center for Perinatal and Pediatric Health Disparities Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristin J McKenna
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Lakshmi Srinivasan
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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Low hemoglobin levels are independently associated with neonatal acute kidney injury: a report from the AWAKEN Study Group. Pediatr Res 2021; 89:922-931. [PMID: 32526767 PMCID: PMC8730540 DOI: 10.1038/s41390-020-0963-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Studies in adults showed a relationship between low hemoglobin (Hb) and acute kidney injury (AKI). We performed this study to evaluate this association in newborns. METHODS We evaluated 1891 newborns from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database. We evaluated the associations for the entire cohort and 3 gestational age (GA) groups: <29, 29-<36, and ≥36 weeks' GA. RESULTS Minimum Hb in the first postnatal week was significantly lower in neonates with AKI after the first postnatal week (late AKI). After controlling for multiple potential confounders, compared to neonates with a minimum Hb ≥17.0 g/dL, both those with minimum Hb ≤12.6 and 12.7-14.8 g/dL had an adjusted increased odds of late AKI (aOR 3.16, 95% CI 1.44-6.96, p = 0.04) and (aOR 2.03, 95% CI 1.05-3.93; p = 0.04), respectively. This association was no longer evident after controlling for fluid balance. The ability of minimum Hb to predict late AKI was moderate (c-statistic 0.68, 95% CI 0.64-0.72) with a sensitivity of 65.9%, a specificity of 69.7%, and a PPV of 20.8%. CONCLUSIONS Lower Hb in the first postnatal week was associated with late AKI, though the association no longer remained after fluid balance was included. IMPACT The current study suggests a possible novel association between low serum hemoglobin (Hb) and neonatal acute kidney injury (AKI). The study shows that low serum Hb levels in the first postnatal week are associated with increased risk of AKI after the first postnatal week. This study is the first to show this relationship in neonates. Because this study is retrospective, our observations cannot be considered proof of a causative role but do raise important questions and deserve further investigation. Whether the correction of low Hb levels might confer short- and/or long-term renal benefits in neonates was beyond the scope of this study.
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Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 2021; 41:185-195. [PMID: 32892210 DOI: 10.1038/s41372-020-00810-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
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Liberio BM, Brinton JT, Gist KM, Soranno DE, Kirkley MJ, Gien J. Risk factors for acute kidney injury in neonates with congenital diaphragmatic hernia. J Perinatol 2021; 41:1901-1909. [PMID: 34120147 PMCID: PMC8196921 DOI: 10.1038/s41372-021-01119-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 05/13/2021] [Accepted: 05/25/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To examine incidence of acute kidney injury (AKI), antenatal and postnatal predictors, and impact of AKI on outcomes in infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN Single center retrospective study of 90 CDH infants from 2009-2017. Baseline characteristics, CDH severity, possible AKI predictors, and clinical outcomes were compared between infants with and without AKI. RESULT In total, 38% of infants developed AKI, 44% stage 1, 29% stage 2, 27% stage 3. Lower antenatal lung volumes and liver herniation were associated with AKI. Extracorporeal life support (ECLS), diuretics, abdominal closure surgery, hypotension, and elevated plasma free hemoglobin were associated with AKI. Overall survival was 79%, 47% with AKI, and 35% with AKI on ECLS. AKI is associated with increased mechanical ventilation duration and length of stay. CONCLUSION AKI is common among CDH infants and associated with adverse outcomes. Standardized care bundles addressing AKI risk factors may reduce AKI incidence and severity.
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Affiliation(s)
- Brianna M. Liberio
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - John T. Brinton
- grid.414594.90000 0004 0401 9614Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA
| | - Katja M. Gist
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Cardiology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Danielle E. Soranno
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Nephrology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Megan J. Kirkley
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.239638.50000 0001 0369 638XDepartment of Pediatrics, Denver Health Medical Center, Denver, CO USA
| | - Jason Gien
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, Section of Neonatology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO USA
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Salerno SN, Liao Y, Jackson W, Greenberg RG, McKinzie CJ, McCallister A, Benjamin DK, Laughon MM, Sanderson K, Clark RH, Gonzalez D. Association between Nephrotoxic Drug Combinations and Acute Kidney Injury in the Neonatal Intensive Care Unit. J Pediatr 2021; 228:213-219. [PMID: 32818481 PMCID: PMC7752849 DOI: 10.1016/j.jpeds.2020.08.035] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/06/2020] [Accepted: 08/13/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine the incidence of acute kidney injury (AKI) in infants exposed to nephrotoxic drug combinations admitted to 268 neonatal intensive care units managed by the Pediatrix Medical Group. STUDY DESIGN We included infants born at 22-36 weeks gestational age, ≤120 days postnatal age, exposed to nephrotoxic drug combinations, with serum creatinine measurements available, and discharged between 2007 and 2016. To identify risk factors associated with a serum creatinine definition of AKI based on the Kidney Disease: Improving Global Outcomes criteria, we performed multivariable logistic and Cox regression adjusting for gestational age, sex, birth weight, postnatal age, race/ethnicity, sepsis, respiratory distress syndrome, baseline serum creatinine, and duration of combination drug exposure. The adjusted odds of AKI were determined relative to gentamicin + indomethacin for the following nephrotoxic drug combinations: chlorothiazide + ibuprofen; chlorothiazide + indomethacin; furosemide + gentamicin; furosemide + ibuprofen; furosemide + tobramycin; ibuprofen + spironolactone; and vancomycin + piperacillin-tazobactam. RESULTS Among 8286 included infants, 1384 (17%) experienced AKI. On multivariable analysis, sepsis, lower baseline creatinine, and duration of combination therapy were associated with increased odds of AKI. Furosemide + tobramycin and vancomycin + piperacillin-tazobactam were associated with a decreased risk of AKI relative to gentamicin + indomethacin in both the multivariable and Cox regression models. CONCLUSIONS In this cohort, infants receiving longer durations of nephrotoxic combination therapy had an increased odds of developing AKI.
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Affiliation(s)
- Sara N. Salerno
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yuting Liao
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rachel G. Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA,Duke Clinical Research Institute, Durham, NC, USA
| | - Cameron J. McKinzie
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Ashley McCallister
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | | | - Matthew M. Laughon
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keia Sanderson
- Department of Medicine-Nephrology, UNC School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Reese H. Clark
- MEDNAX Center for Research, Education, Quality and Safety, Sunrise, FL, USA
| | - Daniel Gonzalez
- Division of Pharmacotherapy and Experimental Therapeutics, UNC Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC.
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35
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Pokorná P, Šíma M, Tibboel D, Slanař O. Impact of haemolysis on vancomycin disposition in a full-term neonate treated with extracorporeal membrane oxygenation. Perfusion 2020; 36:864-867. [PMID: 33200670 DOI: 10.1177/0267659120973595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Extracorporeal membrane oxygenation (ECMO) is a lifesaving support technology for potentially reversible neonatal cardiac and/or respiratory failure. Pharmacological consequences of ECMO-induced haemolysis in neonates are not well understood. CASE REPORT We report a case report of a full-term neonate treated for congenital diaphragmatic hernia and sepsis with ECMO and with vancomycin. While the population elimination half-life of 7 h was estimated, fitting of the simulated population pharmacokinetic profile to truly observed drug concentration points resulted in the personalized value of 41 h. DISCUSSION The neonate developed ECMO-induced haemolysis with subsequent acute kidney injury resulting in prolonged drug elimination. Whole blood/serum ratio of 0.79 excluded possibility of direct increase of vancomycin serum concentration during haemolysis. CONCLUSION Vancomycin elimination may be severely prolonged due to ECMO-induced haemolysis and acute kidney injury, while hypothesis of direct increase of vancomycin levels by releasing the drug from blood cells during haemolysis has been disproved.
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Affiliation(s)
- Pavla Pokorná
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Martin Šíma
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Dick Tibboel
- Department of Paediatrics and Inherited Metabolic Disorders, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic.,Intensive Care and Department of Paediatric Surgery, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Ondřej Slanař
- Department of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
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36
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Aviles-Otero N, Ransom M, Weitkamp J, Charlton JR, Sullivan BA, Kaufman DA, Fairchild KD. Urinary tract infections in very low birthweight infants: A two-center analysis of microbiology, imaging and heart rate characteristics. J Neonatal Perinatal Med 2020; 14:269-276. [PMID: 33136069 DOI: 10.3233/npm-200513] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Increased understanding of characteristics of urinary tract infection (UTI) among very low birthweight infants (VLBW) might lead to improvement in detection and treatment. Continuous monitoring for abnormal heart rate characteristics (HRC) could provide early warning of UTIs. OBJECTIVE Describe the characteristics of UTI, including HRC, in VLBW infants. METHODS We reviewed records of VLBW infants admitted from 2005-2010 at two academic centers participating in a randomized clinical trial of HRC monitoring. Results of all urine cultures, renal ultrasounds (RUS), and voiding cystourethrograms (VCUG) were assessed. Change in the HRC index was analyzed before and after UTI. RESULTS Of 823 VLBW infants (27.7±2.9 weeks GA, 53% male), 378 had > / = 1 urine culture obtained. A UTI (≥10,000 CFU and >five days of antibiotics) was diagnosed in 80 infants, (10% prevalence, mean GA 25.8±2.0 weeks, 76% male). Prophylactic antibiotics were administered to 29 (36%) infants after UTI, of whom four (14%) had another UTI. Recurrent UTI also occurred in 7/51 (14%) of infants not on uroprophylaxis after their first UTI. RUS was performed after UTI in 78%, and hydronephrosis and other major anomalies were found in 19%. A VCUG was performed in 48% of infants and 18% demonstrated vesicoureteral reflux (VUR). The mean HRC rose and fell significantly in the two days before and after diagnosis of UTI. CONCLUSIONS UTI was diagnosed in 10% of VLBW infants, and the HRC index increased prior to diagnosis, suggesting that continuous HRC monitoring in the NICU might allow earlier diagnosis and treatment of UTI.
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Affiliation(s)
- N Aviles-Otero
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
| | - M Ransom
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J Weitkamp
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J R Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia, Charlottesville, VA, USA
| | - B A Sullivan
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
| | - D A Kaufman
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
| | - K D Fairchild
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
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McCulloch M, Luyckx VA, Cullis B, Davies SJ, Finkelstein FO, Yap HK, Feehally J, Smoyer WE. Challenges of access to kidney care for children in low-resource settings. Nat Rev Nephrol 2020; 17:33-45. [PMID: 33005036 DOI: 10.1038/s41581-020-00338-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Abstract
Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.
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Affiliation(s)
- Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric and Adult Renal Units, University of Cape Town, Cape Town, South Africa
| | - Brett Cullis
- Pediatric and Adult Renal Units, University of Cape Town, Cape Town, South Africa.,Nelson Mandela School of Medicine, University of Kwazulu Natal, Durban, South Africa
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Hui Kim Yap
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore
| | - John Feehally
- International Society of Nephrology, Brussels, Belgium
| | - William E Smoyer
- Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University, Columbus, OH, USA
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The impact of increased awareness of acute kidney injury in the Neonatal Intensive Care Unit on acute kidney injury incidence and reporting: results of a retrospective cohort study. J Perinatol 2020; 40:1301-1307. [PMID: 32681064 PMCID: PMC7442645 DOI: 10.1038/s41372-020-0725-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/29/2020] [Accepted: 07/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the impact of nephrology integration in the NICU on acute kidney injury (AKI) incidence, provider reporting, and nephrology referral. STUDY DESIGN Cohort study in a single-center NICU from January 2012 to December 2017 (n = 1464). We assessed the impact of clinical practice changes including neonatal-nephrology rounds on the incidence of AKI. RESULTS AKI occurred in 318 neonates (22%). AKI occurred less frequently in those admitted after clinical practice changes (P < 0.001). After multivariable adjustment, clinical practice changes were associated with reduced odds of AKI (adjusted odds ratio, 0.31; 95% CI 0.22-0.44, P < 0.001). Provider reporting of AKI improved (P < 0.001) and more neonates were referred for nephrology follow-up (P < 0.001). CONCLUSIONS Increased nephrology integration in the NICU was associated with decreased AKI incidence. While recognition of AKI improved, AKI remained poorly reported and nephrology AKI follow-up did not routinely occur. This study supports the importance of increased nephrology involvement in the NICU.
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Askenazi DJ, Heagerty PJ, Schmicker RH, Griffin R, Brophy P, Juul SE, Mayock DE, Goldstein SL, Hingorani S. Prevalence of acute kidney injury (AKI) in extremely low gestational age neonates (ELGAN). Pediatr Nephrol 2020; 35:1737-1748. [PMID: 32488672 PMCID: PMC8093091 DOI: 10.1007/s00467-020-04563-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 03/05/2020] [Accepted: 03/30/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND To determine the prevalence and severity of acute kidney injury (AKI) at different time frames in relation to gestational age (GA) and birthweight (BW) in extremely low gestational age neonates (ELGAN). Our hypothesis is that ELGAN with lower GA and lower BW have higher AKI rates. METHODS A total of 923 ELGAN enrolled in the Preterm Erythropoietin Neuroprotection Trial were evaluated from birth until death or hospital discharge. AKI was defined according to kidney disease: improving global outcomes (KDIGO) definition from clinically-derived serum creatinine (SCr) measurements. Severe AKI was defined as stage 2 or higher. RESULTS For the entire cohort, 351/923 (38.0%, CI = 34.8-41.3%) had at least one episode of stage 1 or higher AKI and 168/923 (18.2%, CI = 15.7-20.7%) had at least one episode of severe (stage 2 or higher) AKI. The prevalence of AKI stage 1 or higher for the entire cohort during the early (days 3-7), middle (days 8-14), and late follow-up period (after day 14) was 112/923 (12.1%, CI = 10.0-14.3%), 142/891 (15.9%, CI = 13.5-18.4%), and 249/875 (28.5%, CI = 25.4-31.5%), respectively. The rates of severe AKI during the hospital course were 27.8%, 21.9%, 13.6%, and 9.4% for the 24-, 25-, 26-, and 27-week GA groups, respectively. AKI rates were significantly higher with decreasing GA and decreasing BW for stated time trends (all p < 0.01 using tests for trend). CONCLUSIONS AKI is relatively common in ELGAN during their initial hospital course and is associated with lower GA and BW.
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Affiliation(s)
- David J. Askenazi
- University of Alabama at Birmingham, Department of Pediatrics, Birmingham, AL
| | | | | | - Russell Griffin
- University of Alabama at Birmingham, Department of Epidemiology, Birmingham, AL
| | - Patrick Brophy
- University of Rochester / Golisano Children’s Hospital, Rochester NY
| | - Sandra E. Juul
- University of Washington / Seattle Children’s Hospital, Department of Pediatrics
| | - Dennis E. Mayock
- University of Washington / Seattle Children’s Hospital, Department of Pediatrics
| | - Stuart L. Goldstein
- Cincinnati Children’s Hospital Medical Center / University of Cincinnati College of Medicine, Department of Pediatrics
| | - Sangeeta Hingorani
- University of Washington / Seattle Children’s Hospital, Department of Pediatrics
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40
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Harer MW, Charlton JR, Tipple TE, Reidy KJ. Preterm birth and neonatal acute kidney injury: implications on adolescent and adult outcomes. J Perinatol 2020; 40:1286-1295. [PMID: 32277164 DOI: 10.1038/s41372-020-0656-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 03/02/2020] [Accepted: 03/11/2020] [Indexed: 02/06/2023]
Abstract
As a result of preterm birth, immature kidneys are exposed to interventions in the NICU that promote survival, but are nephrotoxic. Furthermore, the duration of renal development may be truncated in these vulnerable neonates. Immaturity and nephrotoxic exposures predispose preterm newborns to acute kidney injury (AKI), particularly in the low birth weight and extremely preterm gestational age groups. Several studies have associated preterm birth as a risk factor for future chronic kidney disease (CKD). However, only a few publications have investigated the impact of neonatal AKI on CKD development. Here, we will review the evidence linking preterm birth and AKI in the NICU to CKD and highlight the knowledge gaps and opportunities for future research. For neonatal intensive care studies, we propose the inclusion of AKI as an important short-term morbidity outcome and CKD findings such as a reduced glomerular filtration rate in the assessment of long-term outcomes.
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Affiliation(s)
- Matthew W Harer
- Department of Pediatrics, Division of Neonatology, University of Wisconsin-Madison, Madison, WI, USA
| | - Jennifer R Charlton
- Department of Pediatrics, Division of Nephrology, University of Virginia Children's Hospital, Box 800386, Charlottesville, VA, USA.
| | - Trent E Tipple
- Department of Pediatrics, Section of Neonatal-Perinatal Medicine, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Kimberly J Reidy
- Department of Pediatrics, Division of Pediatric Nephrology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
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Allegaert K, Smits A, van Donge T, van den Anker J, Sarafidis K, Levtchenko E, Mekahli D. Renal Precision Medicine in Neonates and Acute Kidney Injury: How to Convert a Cloud of Creatinine Observations to Support Clinical Decisions. Front Pediatr 2020; 8:366. [PMID: 32850523 PMCID: PMC7399072 DOI: 10.3389/fped.2020.00366] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/02/2020] [Indexed: 12/29/2022] Open
Abstract
Renal precision medicine in neonates is useful to support decision making on pharmacotherapy, signal detection of adverse (drug) events, and individual prediction of short- and long-term prognosis. To estimate kidney function or glomerular filtration rate (GFR), the most commonly measured and readily accessible biomarker is serum creatinine (Scr). However, there is extensive variability in Scr observations and GFR estimates within the neonatal population, because of developmental physiology and superimposed pathology. Furthermore, assay related differences still matter for Scr, but also exist for Cystatin C. Observations in extreme low birth weight (ELBW) and term asphyxiated neonates will illustrate how renal precision medicine contributes to neonatal precision medicine. When the Kidney Disease Improving Global Outcome (KDIGO) definition of acute kidney injury (AKI) is used, this results in an incidence up to 50% in ELBW neonates, associated with increased mortality and morbidity. However, urine output criteria needed adaptations to broader time intervals or weight trends, while Scr and its trends do not provide sufficient detail on kidney function between ELBW neonates. Instead, we suggest to use assay-specific centile Scr values to better describe postnatal trends and have illustrated its relevance by quantifying an adverse drug event (ibuprofen) and by explaining individual amikacin clearance. Term asphyxiated neonates also commonly display AKI. While oliguria is a specific AKI indicator, the majority of term asphyxiated cases are non-oliguric. Asphyxia results in a clinical significant-commonly transient-mean GFR decrease (-50%) with a lower renal drug elimination. But there is still major (unexplained) inter-individual variability in GFR and subsequent renal drug elimination between these asphyxiated neonates. Recently, the Baby-NINJA (nephrotoxic injury negated by just-in-time action) study provided evidence on the concept that a focus on nephrotoxic injury negation has a significant impact on AKI incidence and severity. It is hereby important to realize that follow-up should not be discontinued at discharge, as there are concerns about long-term renal outcome. These illustrations suggest that integration of renal (patho)physiology into neonatal precision medicine are an important tool to improve contemporary neonatal care, not only for the short-term but also with a positive health impact throughout life.
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Affiliation(s)
- Karel Allegaert
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pharmacy and Pharmaceutical Sciences, KU Leuven, Leuven, Belgium.,Department of Clinical Pharmacy, Erasmus MC, Rotterdam, Netherlands
| | - Anne Smits
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Neonatal Intensive Care Unit, University Hospitals Leuven, Leuven, Belgium
| | - Tamara van Donge
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital (UKBB), University of Basel, Basel, Switzerland
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics, University of Basel Children's Hospital (UKBB), University of Basel, Basel, Switzerland.,Division of Clinical Pharmacology, Children's National Hospital, Washington, DC, United States.,Intensive Care and Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, Netherlands
| | - Kosmas Sarafidis
- First Department of Neonatology, School of Medicine, Aristotle University of Thessaloniki, Hippokrateion General Hospital, Thessaloniki, Greece
| | - Elena Levtchenko
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatric Nephrology and Organ Transplantation, Hospitals Leuven, Leuven, Belgium
| | - Djalila Mekahli
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.,Department of Pediatric Nephrology and Organ Transplantation, Hospitals Leuven, Leuven, Belgium
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Abstract
In 2013, literature about the epidemiology of neonatal acute kidney injury (AKI) was limited to primarily retrospective, single center studies that suggested that AKI was common and that those with AKI had higher rates of mortality. We developed a 24-center retrospective cohort of neonates admitted to the NICU between January 1 and March 31, 2014. Analysis of the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) cohort, has allowed us to describe the prevalence, risk factors and impact of neonatal AKI for different gestational age cohorts. The ample sample size allows us to provide convincing data to show that those with AKI have an increase independent higher odds of death and prolonged hospitalization time (1). This data mirrors similar studies in pediatric (2) and adult (3) critically ill populations which collectively suggest that patients do not just die with AKI, but instead, AKI is directly linked to hard clinical outcomes. This study has allowed us to answer multiple other questions in the field which has expanded our understanding of the risk factors, complications, impact of fluid overload, the definition of neonatal AKI and suggests interventions for improving outcomes. Furthermore, this project brought together neonatologist and nephrologist within and across centers. Finally, the AWAKEN project has enabled us to build relationships and infrastructure that has launched the Neonatal Kidney Collaborative http://babykidney.org/ on its way to accomplish its stated mission to improve the health of newborns with or at risk for kidney disease through multidisciplinary collaborative research, advocacy, and education.
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Affiliation(s)
- David Joseph Askenazi
- Section of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States.,Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, Birmingham, AL, United States
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Desanti De Oliveira B, Xu K, Shen TH, Callahan M, Kiryluk K, D'Agati VD, Tatonetti NP, Barasch J, Devarajan P. Molecular nephrology: types of acute tubular injury. Nat Rev Nephrol 2019; 15:599-612. [PMID: 31439924 PMCID: PMC7303545 DOI: 10.1038/s41581-019-0184-x] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2019] [Indexed: 12/29/2022]
Abstract
The acute loss of kidney function has been diagnosed for many decades using the serum concentration of creatinine - a muscle metabolite that is an insensitive and non-specific marker of kidney function, but is now used for the very definition of acute kidney injury (AKI). Fortunately, myriad new tools have now been developed to better understand the relationship between acute tubular injury and elevation in serum creatinine (SCr). These tools include unbiased gene and protein expression analyses in kidney, urine and blood, the localization of specific gene transcripts in pathological biopsy samples by rapid in-situ RNA technology and single-cell RNA-sequencing analyses. However, this molecular approach to AKI has produced a series of unexpected problems, because the expression of specific kidney-derived molecules that are indicative of injury often do not correlate with SCr levels. This discrepancy between kidney injury markers and SCr level can be reconciled by the recognition that many separate subtypes of AKI exist, each with distinct patterning of molecular markers of tubular injury and SCr data. In this Review, we describe the weaknesses of isolated SCr-based diagnoses, the clinical and molecular subtyping of acute tubular injury, and the role of non-invasive biomarkers in clinical phenotyping. We propose a conceptual model that synthesizes molecular and physiological data along a time course spanning from acute cellular injury to organ failure.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Prasad Devarajan
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
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