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Charlton JR, Boohaker L, Askenazi D, Brophy PD, D'Angio C, Fuloria M, Gien J, Griffin R, Hingorani S, Ingraham S, Mian A, Ohls RK, Rastogi S, Rhee CJ, Revenis M, Sarkar S, Smith A, Starr M, Kent AL. Incidence and Risk Factors of Early Onset Neonatal AKI. Clin J Am Soc Nephrol 2019; 14:184-195. [PMID: 31738181 PMCID: PMC6390916 DOI: 10.2215/cjn.03670318] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 10/05/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Neonatal AKI is associated with poor short- and long-term outcomes. The objective of this study was to describe the risk factors and outcomes of neonatal AKI in the first postnatal week. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The international retrospective observational cohort study, Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), included neonates admitted to a neonatal intensive care unit who received at least 48 hours of intravenous fluids. Early AKI was defined by an increase in serum creatinine >0.3 mg/dl or urine output <1 ml/kg per hour on postnatal days 2-7, the neonatal modification of Kidney Disease: Improving Global Outcomes criteria. We assessed risk factors for AKI and associations of AKI with death and duration of hospitalization. RESULTS Twenty-one percent (449 of 2110) experienced early AKI. Early AKI was associated with higher risk of death (adjusted odds ratio, 2.8; 95% confidence interval, 1.7 to 4.7) and longer duration of hospitalization (parameter estimate: 7.3 days 95% confidence interval, 4.7 to 10.0), adjusting for neonatal and maternal factors along with medication exposures. Factors associated with a higher risk of AKI included: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children's hospital. Those factors that were associated with a lower risk included multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors. Risk factors varied by gestational age strata. CONCLUSIONS AKI in the first postnatal week is common and associated with death and longer duration of hospitalization. The AWAKEN study demonstrates a number of specific risk factors that should serve as "red flags" for clinicians at the initiation of the neonatal intensive care unit course.
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Affiliation(s)
| | - Louis Boohaker
- University of Alabama at Birmingham, Birmingham, Alabama
| | - David Askenazi
- University of Alabama at Birmingham, Birmingham, Alabama
| | - Patrick D Brophy
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Carl D'Angio
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Mamta Fuloria
- Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Jason Gien
- Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | | | - Sangeeta Hingorani
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Susan Ingraham
- Kapi'olani Medical Center for Women and Children, Honolulu, Hawaii
| | - Ayesa Mian
- Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Robin K Ohls
- University of New Mexico, Albuquerque, New Mexico
| | | | | | - Mary Revenis
- Children's National Medical Center, The George Washington University School of Medicine and The Health Sciences, Washington, DC
| | - Subrata Sarkar
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan; and
| | | | - Michelle Starr
- Seattle Children's Hospital/University of Washington, Seattle, Washington
| | - Alison L Kent
- Golisano Children's Hospital, University of Rochester, Rochester, New York
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Blanco CL, McGill-Vargas LL, Gastaldelli A, Seidner SR, McCurnin DC, Leland MM, Anzueto DG, Johnson MC, Liang H, DeFronzo RA, Musi N. Peripheral insulin resistance and impaired insulin signaling contribute to abnormal glucose metabolism in preterm baboons. Endocrinology 2015; 156:813-23. [PMID: 25560831 PMCID: PMC4330304 DOI: 10.1210/en.2014-1757] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Premature infants develop hyperglycemia shortly after birth, increasing their morbidity and death. Surviving infants have increased incidence of diabetes as young adults. Our understanding of the biological basis for the insulin resistance of prematurity and developmental regulation of glucose production remains fragmentary. The objective of this study was to examine maturational differences in insulin sensitivity and the insulin-signaling pathway in skeletal muscle and adipose tissue of 30 neonatal baboons using the euglycemic hyperinsulinemic clamp. Preterm baboons (67% gestation) had reduced peripheral insulin sensitivity shortly after birth (M value 12.5 ± 1.5 vs 21.8 ± 4.4 mg/kg · min in term baboons) and at 2 weeks of age (M value 12.8 ± 2.6 vs 16.3 ± 4.2, respectively). Insulin increased Akt phosphorylation, but these responses were significantly lower in preterm baboons during the first week of life (3.2-fold vs 9.8-fold). Preterm baboons had lower glucose transporter-1 protein content throughout the first 2 weeks of life (8%-12% of term). In preterm baboons, serum free fatty acids (FFAs) did not decrease in response to insulin, whereas FFAs decreased by greater than 80% in term baboons; the impaired suppression of FFAs in the preterm animals was paired with a decreased glucose transporter-4 protein content in adipose tissue. In conclusion, peripheral insulin resistance and impaired non-insulin-dependent glucose uptake play an important role in hyperglycemia of prematurity. Impaired insulin signaling (reduced Akt) contributes to the defect in insulin-stimulated glucose disposal. Counterregulatory hormones are not major contributors.
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Affiliation(s)
- Cynthia L Blanco
- Department of Pediatrics (C.L.B., L.L.M.-V., S.R.S., D.C.M., M.M.L., D.G.A., M.C.J.), Division of Neonatology, University of Texas Health Science Center at San Antonio, Department of Medicine (A.G., H.L., R.A.D., N.M.), Division of Diabetes, University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229; Texas Diabetes Institute (H.L., R.A.D., N.M.), San Antonio, Texas 78207; San Antonio Geriatric, Research and Education Center and Barshop Institute for Longevity and Aging Studies (N.M.), San Antonio, Texas 78245, and Institute of Clinical Physiology, CNR, Pisa, Italy (A.G.)
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Gubhaju L, Sutherland MR, Yoder BA, Zulli A, Bertram JF, Black MJ. Is nephrogenesis affected by preterm birth? Studies in a non-human primate model. Am J Physiol Renal Physiol 2009; 297:F1668-77. [PMID: 19759270 DOI: 10.1152/ajprenal.00163.2009] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nephrogenesis occurs predominantly in late gestation at a time when preterm infants are already delivered. The aims of this study were to assess the effect of preterm birth and the effect of antenatal glucocorticoid treatment on nephrogenesis. Preterm baboons, which were delivered at 125 days gestation and ventilated for up to 21 days postnatally, were compared with gestational controls. A cohort of preterm baboons that had been exposed to antenatal glucocorticoids were compared with unexposed preterm baboons. The number of glomerular generations was estimated using a medullary ray glomerular-counting method, and glomerular number was estimated using unbiased stereology. CD31 and WT-1 localization was examined using immunohistochemistry and VEGF was localized using in situ hybridization. The number of glomerular generations was not affected by preterm birth, and total glomerular numbers were within the normal range. Kidneys were significantly enlarged in preterm baboons with a significant decrease in glomerular density (number of glomeruli per gram of kidney) in the preterm kidney compared with gestational controls. Neonates exposed to antenatal steroids had an increased kidney-to-body weight ratio and also more developed glomeruli compared with unexposed controls. Abnormal glomeruli, with a cystic Bowman's space and shrunken glomerular tuft, were often present in the superficial renal cortex of both the steroid-exposed and unexposed preterm kidneys; steroid exposure had no significant effect on the proportion of abnormal glomeruli. The proportion of abnormal glomeruli in the preterm kidneys ranged from 0.2 to 18%. In conclusion, although nephrogenesis is ongoing in the extrauterine environment, our findings demonstrate that preterm birth, independent of steroid exposure, is associated with a high proportion of abnormal glomeruli in some, but not all neonatal kidneys. Whether final nephron endowment is affected in those kidneys exhibiting a high proportion of abnormal glomeruli is yet to be confirmed.
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Affiliation(s)
- Lina Gubhaju
- Dept. of Anatomy and Developmental Biology, Monash Univ., Victoria 3800, Australia
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5
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de Vries A, Holmes MC, Heijnis A, Seier JV, Heerden J, Louw J, Wolfe-Coote S, Meaney MJ, Levitt NS, Seckl JR. Prenatal dexamethasone exposure induces changes in nonhuman primate offspring cardiometabolic and hypothalamic-pituitary-adrenal axis function. J Clin Invest 2007; 117:1058-67. [PMID: 17380204 PMCID: PMC1821070 DOI: 10.1172/jci30982] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 01/30/2007] [Indexed: 01/08/2023] Open
Abstract
Prenatal stress or glucocorticoid administration has persisting "programming" effects on offspring in rodents and other model species. Multiple doses of glucocorticoids are in widespread use in obstetric practice. To examine the clinical relevance of glucocorticoid programming, we gave 50, 120, or 200 microg/kg/d of dexamethasone (dex50, dex120, or dex200) orally from mid-term to a singleton-bearing nonhuman primate, Chlorocebus aethiops (African vervet). Dexamethasone dose-dependently reduced maternal cortisol levels without effecting maternal blood pressure, glucose, electrolytes, or weight gain. Birth weight was unaffected by any dexamethasone dose, although postnatal growth was attenuated after dex120 and dex200. At 8 months of age, dex120 and dex200 offspring showed impaired glucose tolerance and hyperinsulinemia, with reduced (approximately 25%) pancreatic beta cell number at 12 months. Dex120 and dex200 offspring had increased systolic and diastolic blood pressures at 12 months. Mild stress produced an exaggerated cortisol response in dex200 offspring, implying hypothalamic-pituitary-adrenal axis programming. The data are compatible with the extrapolation of the glucocorticoid programming hypothesis to primates and indicate that repeated glucocorticoid therapy and perhaps chronic stress in humans may have long-term effects.
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Affiliation(s)
- Annick de Vries
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Megan C. Holmes
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Areke Heijnis
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jürgen V. Seier
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Joritha Heerden
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Johan Louw
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sonia Wolfe-Coote
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Michael J. Meaney
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Naomi S. Levitt
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Jonathan R. Seckl
- Endocrinology Unit, University of Edinburgh, The Queen’s Medical Research Institute, Edinburgh, United Kingdom.
Primate Unit, Diabetes Research Group, South African Medical Research Council, Cape Town, South Africa.
Douglas Hospital Research Center, McGill University, Montreal, Quebec, Canada.
Endocrine and Diabetes Unit, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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Ervin MG, Padbury JF, Polk DH, Ikegami M, Berry LM, Jobe AH. Antenatal glucocorticoids alter premature newborn lamb neuroendocrine and endocrine responses to hypoxia. Am J Physiol Regul Integr Comp Physiol 2000; 279:R830-8. [PMID: 10956240 DOI: 10.1152/ajpregu.2000.279.3.r830] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Glucocorticoids are administered for preterm labor to improve postnatal adaptation. We assessed the effect of antenatal betamethasone (Beta) treatment on preterm newborn lamb neuroendocrine [catecholamine, arginine vasopressin (AVP)] and endocrine [triiodothyronine (T(3)), ANG II, and atrial natriuretic factor (ANF)] adaptive responses following delivery and a hypoxic challenge. Beta treatment included direct fetal injection at 0.2 (F(0.2); n = 8) or 0.5 (F(0.5); n = 7) mg/kg estimated fetal body weight or maternal injection with 0.2 (n = 8) or 0.5 mg/kg (M(0.5); n = 8). Control animals received fetal and maternal intramuscular injections of saline (n = 8). After 24 h, lambs were delivered by cesarean section, surfactant treated, and ventilated for 4 h. Relative to the control lambs, 3 h after delivery, there was a marked suppression of plasma cortisol, epinephrine, norepinephrine, and ANG II levels and elevated plasma T(3) and ANF levels, systolic blood pressure, and left ventricular contractility (dP/dt; F(0.5) and M(0.5)) values in F(0.5) and both maternal Beta-treated groups. However, Beta treatment augmented the cardiac output, cortisol, norepinephrine, AVP, and ANF responses to 20 min of hypoxia (PO(2) = 25-30 mmHg). We concluded that short-term (24 h) antenatal glucocorticoid exposure 1) alters preterm newborn postnatal blood pressure regulation in the face of marked depression of plasma cortisol, catecholamine, and ANG II levels and 2) augments the postnatal neuroendocrine and endocrine responses to a hypoxic challenge.
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Affiliation(s)
- M G Ervin
- Department of Biology, Middle Tennessee State University, Murfreesboro, Tennessee 37132, USA.
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