Renal tissue oxygenation and development of AKI in preterm neonates born < 32 weeks' gestational age in the first week of age

OBJECTIVE

To evaluate the relationship between regional renal saturation of oxygen (RrSO2) changes and serum creatinine (SCr) during the first eight days of age for preterm neonates born < 32 weeks' gestational age.

DESIGN

Post-hoc analysis of multicenter prospectively measured neonatal RrSO2 values collected during the first 8 days of age in neonates born at < 32 weeks' gestation. Acute kidney injury (AKI) was defined by the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Variables were compared between groups of neonates with and with AKI.

RESULTS

One hundred nine neonates were included and 561 SCr values were obtained. Eight participants developed AKI by SCr criteria. A 10-percentage point increase in mean %RrSO2 was associated with a 40% decrease in risk of AKI (95%CI: 9.6-61%; p = 0.016).

CONCLUSIONS

Increases in mean %RrSO2 in neonates born at < 32 weeks' GA were associated with a decreased risk of AKI. These findings support the design of further prospective trials utilizing RrSO2 monitoring to evaluate new therapies or clinical protocols to prevent and treat neonatal AKI.

Caffeine and kidney function at two years in former extremely low gestational age neonates

BACKGROUND

Extremely low gestational age neonates (ELGANs) are at risk for chronic kidney disease. The long-term kidney effects of neonatal caffeine are unknown. We hypothesize that prolonged caffeine exposure will improve kidney function at 22-26 months.

METHODS

Secondary analysis of the Preterm Erythropoietin Neuroprotection Trial of neonates <28 weeks' gestation. Participants included if any kidney outcomes were collected at 22-26 months corrected age. Exposure was post-menstrual age of caffeine discontinuation.

PRIMARY OUTCOMES

'reduced eGFR' <90 ml/min/1.73 m2, 'albuminuria' (>30 mg albumin/g creatinine), or 'elevated blood pressure' (BP) >95th %tile. A general estimating equation logistic regression model stratified by bronchopulmonary dysplasia (BPD) status was used.

RESULTS

598 participants had at least one kidney metric at follow up. Within the whole cohort, postmenstrual age of caffeine discontinuation was not associated with any abnormal measures of kidney function at 2 years. In the stratified analysis, for each additional week of caffeine, the no BPD group had a 21% decreased adjusted odds of eGFR <90 ml/min/1.73m2 (aOR 0.78; CI 0.62-0.99) and the BPD group had a 15% increased adjusted odds of elevated BP (aOR 1.15; CI: 1.05-1.25).

CONCLUSIONS

Longer caffeine exposure during the neonatal period is associated with differential kidney outcomes at 22-26 months dependent on BPD status.

IMPACT

In participants born <28 weeks' gestation, discontinuation of caffeine at a later post menstrual age was not associated with abnormal kidney outcomes at 22-26 months corrected age. When assessed at 2 years of age, later discontinuation of caffeine in children born <28 weeks' gestation was associated with a greater risk of reduced eGFR in those without a history of BPD and an increased odds of hypertension in those with a history of BPD. More work is necessary to understand the long-term impact of caffeine on the developing kidney.

Acute Kidney Injury Defined by Fluid-Corrected Creatinine in Premature Neonates: A Secondary Analysis of the PENUT Randomized Clinical Trial

Importance

Acute kidney injury (AKI) and disordered fluid balance are common in premature neonates; a positive fluid balance dilutes serum creatinine, and a negative fluid balance concentrates serum creatinine, both of which complicate AKI diagnosis. Correcting serum creatinine for fluid balance may improve diagnosis and increase diagnostic accuracy for AKI.

Objective

To determine whether correcting serum creatinine for fluid balance would identify additional neonates with AKI and alter the association of AKI with short-term and long-term outcomes.

Design, Setting, and Participants

This study was a post hoc cohort analysis of the Preterm Erythropoietin Neuroprotection Trial (PENUT), a phase 3, randomized clinical trial of erythropoietin, conducted at 19 academic centers and 30 neonatal intensive care units in the US from December 2013 to September 2016. Participants included extremely premature neonates born at less than 28 weeks of gestation. Data analysis was conducted in December 2022.

Exposure

Diagnosis of fluid-corrected AKI during the first 14 postnatal days, calculated using fluid-corrected serum creatinine (defined as serum creatinine multiplied by fluid balance [calculated as percentage change from birth weight] divided by total body water [estimated 80% of birth weight]).

Main Outcomes and Measures

The primary outcome was invasive mechanical ventilation on postnatal day 14. Secondary outcomes included death, hospital length of stay, and severe bronchopulmonary dysplasia (BPD). Categorical variables were analyzed by proportional differences with the χ2 test or Fisher exact test. The t test and Wilcoxon rank sums test were used to compare continuous and ordinal variables, respectively. Odds ratios (ORs) and 95% CIs for the association of exposure with outcomes of interest were estimated using unconditional logistic regression models.

Results

A total of 923 premature neonates (479 boys [51.9%]; median [IQR] birth weight, 801 [668-940] g) were included, of whom 215 (23.3%) received a diagnosis of AKI using uncorrected serum creatinine. After fluid balance correction, 13 neonates with AKI were reclassified as not having fluid-corrected AKI, and 111 neonates previously without AKI were reclassified as having fluid-corrected AKI (ie, unveiled AKI). Therefore, fluid-corrected AKI was diagnosed in 313 neonates (33.9%). Neonates with unveiled AKI were similar in clinical characteristics to those with AKI whose diagnoses were made with uncorrected serum creatinine. Compared with those without AKI, neonates with unveiled AKI were more likely to require ventilation (81 neonates [75.0%] vs 254 neonates [44.3%] and have longer hospital stays (median [IQR], 102 [84-124] days vs 90 [71-110] days). In multivariable analysis, a diagnosis of fluid-corrected AKI was associated with increased odds of adverse clinical outcomes, including ventilation (adjusted OR, 2.23; 95% CI, 1.56-3.18) and severe BPD (adjusted OR, 2.05; 95% CI, 1.15-3.64).

Conclusions and Relevance

In this post hoc cohort study of premature neonates, fluid correction increased the number of premature neonates with a diagnosis of AKI and was associated with increased odds of adverse clinical outcomes, including ventilation and BPD. Failing to correct serum creatinine for fluid balance underestimates the prevalence and impact of AKI in premature neonates. Future studies should consider correcting AKI for fluid balance.

Trial Registration

ClinicalTrials.gov Identifier: NCT01378273.

Survival of neonates born with kidney failure during the initial hospitalization

BACKGROUND

Survival to hospital discharge in neonates born with kidney failure has not been previously described.

METHODS

This was a retrospective, observational analysis of the Pediatric Health Information System (PHIS) database from 2005 to 2019. Primary outcome was survival at discharge; secondary outcomes were hospital and ICU length of stay (LOS). Univariate analysis was performed to describe the population by birth weight (BW) and characterize survival; multivariable generalized liner mixed modeling assuming a binomial distribution and logit link was performed to identify mortality risk factors.

RESULTS

Of 213 neonates born with kidney failure (median BW 2714 g; GA 35 weeks; 68% male), 4 (1.9%) did not receive dialysis or peritoneal dialysis (PD) catheter placement, 152 (72.9%) received PD only, 49 (23.4%) received PD plus extracorporeal dialysis (ECD), and 8 (3.4%) were treated with an undocumented dialysis modality. Median age at dialysis initiation was 7 days; median hospital LOS and ICU LOS were 84 and 69 days, respectively. One-hundred and sixty-two patients (76%) survived to discharge. Non-survivors (n = 51) were more likely to have received ECD and mechanical ventilation, and had a longer duration of mechanical ventilation. Every day of mechanical ventilation increased the mortality odds by 2% (n = 189; adjusted OR 1.02; 1.01, 1.03); in addition, the odds of mortality were 2 times higher in those who received ECD vs. only PD (adjusted OR 2.25; 1.04, 4.86).

CONCLUSIONS

Survival to initial hospital discharge occurs in the majority of neonates born with kidney failure. Predictors of increased mortality included longer duration of mechanical ventilation, as well as the requirement for ECD. A higher resolution version of the Graphical abstract is available as Supplementary information.

Correlation of Renal Tissue Oxygenation to Venous, Arterial, and Capillary Blood Gas Oxygen Saturation in Preterm Neonates

OBJECTIVE

 The aim of the study is to assess the correlation of renal regional tissue saturation of oxygen (RrSO2) measured by near-infrared spectroscopy (NIRS) in preterm neonates to venous oxygen saturation (SvO2) obtained from umbilical venous catheters (UVCs), arterial oxygen saturation (SaO2) obtained from umbilical artery catheters (UACs), and capillary oxygen saturation (ScO2) from capillary heel blood draws.

STUDY DESIGN

 A secondary analysis of a prospective RrSO2 monitoring study in preterm neonates born <32 weeks gestational age. Neonates with any blood gas obtained during RrSO2 monitoring were included. RrSO2 was compared with simultaneous O2 saturation using non-parametric Mann Whitney U-test and Spearman correlation coefficient.

RESULTS

 In 35 neonates, 25 UVC, 151 UAC, and 68 heel capillary specimens were obtained. RrSO2 was lower than the median SvO2 (58.8 vs. 78.9, p <0.01), SaO2 (51.0 vs. 93.2, p <0.01), and ScO2 (62.2 vs. 94.25, p <0.01). RrSO2 values correlated to both SaO2 and ScO2 (r = 0.32; p <0.01, r = 0.26; p = 0.03), but not SvO2 (r = 0.07; p = 0.74).

CONCLUSION

 In this secondary analysis, RrSO2 was consistently lower than blood gas O2 saturations and correlated with SaO2 and ScO2 but not SvO2. Lack of a correlation to SvO2 could be due to the small UVC sample size limiting statistical power. Future studies should prospectively evaluate if RrSO2 truly primarily reflects venous oxygenation in preterm neonates.

KEY POINTS

· Renal oxygenation correlates with arterial and capillary oxygen saturation.. · Renal oxygenation did not correlate with venous oxygenation from umbilical venous catheters.. · Studies are needed to determine if renal oxygenation primarily reflects venous or arterial oxygen..

Documentation of acute kidney injury at discharge from the neonatal intensive care unit and role of nephrology consultation

OBJECTIVE

To investigate whether NICU discharge summaries documented neonatal AKI and estimate if nephrology consultation mediated this association.

STUDY DESIGN

Secondary analysis of AWAKEN multicenter retrospective cohort.

EXPOSURES

AKI severity and diagnostic criteria.

OUTCOME

AKI documentation on NICU discharge summaries using multivariable logistic regression to estimate associations and test for causal mediation.

RESULTS

Among 605 neonates with AKI, 13% had documented AKI. Those with documented AKI were more likely to have severe AKI (70.5% vs. 51%, p < 0.001) and SCr-only AKI (76.9% vs. 50.1%, p = 0.04). Nephrology consultation mediated 78.0% (95% CL 46.5-109.4%) of the total effect of AKI severity and 82.8% (95% CL 70.3-95.3%) of the total effect of AKI diagnostic criteria on documentation.

CONCLUSION

We report a low prevalence of AKI documentation at NICU discharge. AKI severity and SCr-only AKI increased odds of AKI documentation. Nephrology consultation mediated the associations of AKI severity and diagnostic criteria with documentation.

Advances in Neonatal Acute Kidney Injury

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.

Treatment of positive urine cultures in the neonatal intensive care unit: a guideline to reduce antibiotic utilization

BACKGROUND

The pediatric definition of bacterial urinary tract infection (UTI) is >50,000 colony forming units (CFU) of a single organism on catheterized culture or 10,000-50,000 CFU with pyuria on urinalysis.

LOCAL PROBLEM

The diagnosis of UTI in our NICU is clinician-dependent and not based on the accepted pediatric definition.

METHODS

A retrospective review of positive urine cultures between 2015 and 2017 was performed.

INTERVENTION

A treatment guideline for positive urine cultures was adopted and PDSA methodology utilized for incremental improvements.

RESULTS

For 909 pre-intervention neonates, 26 of 38 positive urine cultures were treated for UTI but only 23% (6/26) met the pediatric definition. For 644 post-guideline neonates, only 7 of 25 positive urine cultures were treated and 86% met guideline criteria with no increase in urosepsis.

CONCLUSIONS

A guideline to treat positive urine cultures resulted in a decreased rate of UTI diagnosis and thus prevented unnecessary antibiotic exposure.

The effect of antenatal indomethacin on extremely preterm neonatal kidney function

Introduction/Objective: Indomethacin is an effective tocolytic to prevent extremely preterm birth. Prior studies have associated antenatal indomethacin exposure with adverse preterm neonatal intestinal and neurological outcomes. Indomethacin is a nephrotoxic medication that may also affect preterm neonatal kidneys. We sought to evaluate the effect of antenatal indomethacin on extremely preterm neonatal kidney function and acute kidney injury (AKI) in the first week of age.Methods: A retrospective cohort study was conducted on neonates born < 29 weeks at a level III neonatal intensive care unit (NICU) from January 2018-April 2019. Serum creatinine (sCr) values and urine output (UOP) in the first seven days of age and the neonate's peak serum creatinine within the first 30 days were evaluated. Neonatal AKI was defined by the modified neonatal Kidney Disease Improving Global Outcomes (KDIGO) definition including urine output.Results: 17 of the 55 neonates meeting criteria for this study were exposed to indomethacin. The average gestational age at birth was similar between study groups. Maternal preeclampsia was more common among women who did not receive indomethacin (p = 0.021). Indomethacin exposed neonates received more gentamicin (p = 0.024). Overall, staging of the neonatal AKI did not differ significantly between the study groups, regardless of how it was quantified (sCr or UOP) or the duration of time in which the injury developed (7 days or 30 days). Separate analysis of sCr and UOP in the first seven days also failed to show any statistically significant differences between the two groups.Conclusion: In this small cohort study of extremely preterm neonates, those born to mothers treated with indomethacin did not have an increased incidence of AKI compared to neonates born to unexposed mothers. Although no statistically significant differences in UOP or sCr were found, they deserve further evaluation in adequately powered prospective clinical trials. Future prospective studies with long-term follow-up utilizing advanced biomarkers are needed to determine how antenatal indomethacin affects extremely preterm neonatal kidney function in the NICU, during childhood, and as adults.

Fluid Balance in the Critically Ill Child Section: "How Bad Is Fluid in Neonates?"

Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.

Preterm birth and neonatal acute kidney injury: implications on adolescent and adult outcomes

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.

Delayed Umbilical Cord Clamping is Not Associated with Acute Kidney Injury in Very Low Birth Weight Neonates

OBJECTIVE

This study aimed to determine if delayed cord clamping (DCC) is associated with a reduction in neonatal acute kidney injury (AKI).

STUDY DESIGN

A retrospective single-center cohort study of 278 very low birth weight (VLBW) neonates was performed to compare the incidence of AKI in the following groups: immediate cord clamping (ICC), DCC, and umbilical cord milking. AKI was diagnosed by the modified neonatal Kidney Diseases and Improving Global Outcomes (KDIGO) definition.

RESULTS

The incidence of AKI in the first week was 20.1% with no difference between groups (p = 0.78). After adjustment for potential confounders, the odds of developing AKI, following DCC, compared with ICC was 0.93 (confidence interval [CI]: 0.46-1.86) with no reduction in the stage of AKI between groups.

CONCLUSION

In this study, DCC was not associated with a reduced rate of AKI in VLBW neonates. However, the data suggest that DCC is also not harmful to the kidneys, further supporting the safety of DCC in VLBW neonates.

Renal Tissue Oxygenation Monitoring-An Opportunity to Improve Kidney Outcomes in the Vulnerable Neonatal Population

Adequate oxygenation of the kidney is of critical importance in the neonate. Non-invasive monitoring of renal tissue oxygenation using near-infrared spectroscopy (NIRS) is a promising bedside strategy for early detection of circulatory impairment as well as recognition of specific renal injury. As a diagnostic tool, renal NIRS monitoring may allow for earlier interventions to prevent or reduce injury in various clinical scenarios in the neonatal intensive care unit. Multiple studies utilizing NIRS monitoring in preterm and term infants have provided renal tissue oxygenation values at different time points during neonatal hospitalization, and have correlated measures with ultrasound and Doppler flow data. With the establishment of normal values, studies have utilized renal tissue oxygenation monitoring in preterm neonates to predict a hemodynamically significant patent ductus arteriosus, to assess response to potentially nephrotoxic medications, to identify infants with sepsis, and to describe changes after red blood cell transfusions. Other neonatal populations being investigated with renal NIRS monitoring include growth restricted infants, those requiring delivery room resuscitation, infants with congenital heart disease, and neonates undergoing extracorporeal membrane oxygenation. Furthermore, as the recognition of acute kidney injury (AKI) and its associated morbidity and mortality in neonates has increased over the last decade, alternative methods are being investigated to diagnose AKI before changes in serum creatinine or urine output occur. Studies have utilized renal NIRS monitoring to diagnose AKI in specific populations, including neonates with hypoxic ischemic encephalopathy after birth asphyxia and in infants after cardiac bypass surgery. The use of renal tissue oxygenation monitoring to improve renal outcomes has yet to be established, but results of studies published to date suggest that it holds significant promise to function as a real time, early indicator of poor renal perfusion that may help with development of specific treatment protocols to prevent or decrease the severity of AKI.

Neonatal hypertension: an educational review

Hypertension is encountered in up to 3% of neonates and occurs more frequently in neonates requiring hospitalization in the neonatal intensive care unit (NICU) than in neonates in newborn nurseries or outpatient clinics. Former NICU neonates are at higher risk of hypertension secondary to invasive procedures and disease-related comorbidities. Accurate measurement of blood pressure (BP) remains challenging, but new standardized methods result in less measurement error. Multiple factors contribute to the rapidly changing BP of a neonate: gestational age, postmenstrual age (PMA), birth weight, and maternal factors are the most significant contributors. Given the natural evolution of BP as neonates mature, a percentile cutoff of 95% for PMA has been the most common definition used; however, this is not based on outcome data. Common causes of neonatal hypertension are congenital and acquired renal disease, history of umbilical arterial catheter placement, and bronchopulmonary dysplasia. The treatment of neonatal hypertension has mostly been off-label, but as evidence accumulates, the safety of medical management has increased. The prognosis of neonatal hypertension remains largely unknown and thankfully most often resolves unless secondary to renovascular disease, but further research is needed. This review discusses important factors related to neonatal hypertension including BP measurement, determinants of BP, and management of neonatal hypertension.

Association Between Early Caffeine Citrate Administration and Risk of Acute Kidney Injury in Preterm Neonates: Results From the AWAKEN Study

IMPORTANCE

Acute kidney injury (AKI) occurs commonly in preterm neonates and is associated with increased morbidity and mortality.

OBJECTIVES

To examine the association between caffeine citrate administration and AKI in preterm neonates in the first 7 days after birth and to test the hypothesis that caffeine administration would be associated with reduced incidence and severity of AKI.

DESIGN, SETTING, AND PARTICIPANTS

This study was a secondary analysis of the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study, a retrospective observational cohort that enrolled neonates born from January 1 to March 31, 2014. The dates of analysis were October 2016 to December 2017. The setting was an international, multicenter cohort study of neonates admitted to 24 participating level III or IV neonatal intensive care units. Participants met the original inclusion and exclusion criteria of the AWAKEN study. Additional exclusion criteria for this study included participants greater than or equal to 33 weeks' gestation at birth, admission after age 7 days, use of theophylline in the neonatal intensive care unit, or lack of data to define AKI. There were 675 preterm neonates available for analysis.

EXPOSURE

Administration of caffeine in the first 7 days after birth.

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of AKI (based on the modified neonatal Kidney Disease: Improving Global Outcomes [KDIGO] definition) in the first 7 days after birth. The hypothesis that caffeine administration would be associated with reduced AKI incidence was formulated before data analysis.

RESULTS

The study cohort (n = 675) was 55.4% (n = 374) male, with a mean (SD) gestational age of 28.9 (2.8) weeks and a mean (SD) birth weight of 1285 (477) g. Acute kidney injury occurred in 122 neonates (18.1%) in the first 7 days after birth. Acute kidney injury occurred less frequently among neonates who received caffeine than among those who did not (50 of 447 [11.2%] vs 72 of 228 [31.6%], P < .01). After multivariable adjustment, administration of caffeine remained associated with reduced odds of developing AKI (adjusted odds ratio, 0.20; 95% CI, 0.11-0.34), indicating that for every 4.3 neonates exposed to caffeine one case of AKI was prevented. Among neonates with early AKI, those receiving caffeine were less likely to develop stage 2 or 3 AKI (adjusted odds ratio, 0.20; 95% CI, 0.12-0.34).

CONCLUSIONS AND RELEVANCE

Caffeine administration in preterm neonates is associated with reduced incidence and severity of AKI. Further studies should focus on the timing and dosage of caffeine to optimize the prevention of AKI.

Follow-up of Acute kidney injury in Neonates during Childhood Years (FANCY): a prospective cohort study

BACKGROUND

Very low birth weight (VLBW) neonates commonly experience acute kidney injury (AKI) in the neonatal intensive care unit (NICU). We hypothesize that VLBW neonates exposed to AKI in the NICU might be at a higher risk of renal dysfunction during childhood.

METHODS

In this cohort study, VLBW children (aged 3-7 years) completed a kidney health evaluation and were stratified according to AKI status in the NICU. The primary outcome was renal dysfunction defined as any of the following: estimated glomerular filtration rate (eGFR) <90 mL/min/1.73 m², urine protein/creatinine >0.2 or blood pressure ≥95th percentile.

RESULTS

Thirty-four subjects completed the study. Twenty subjects had a history of neonatal AKI (stage 1, n = 8; stage 2, n = 9; and stage 3, n = 3). At a median age of 5 years, the AKI group had a higher risk of renal dysfunction compared with the group without AKI (65% vs 14%, relative risk 4.5 (1.2-17.1), p = 0.01). Overall, 26% of the total cohort had an eGFR <90 mL/min/1.73 m² using serum cystatin C (35% of AKI subjects, 14% of no AKI subjects, p = 0.25).

CONCLUSIONS

Evidence of renal dysfunction in neonates born VLBW can be found early in childhood. Further work is necessary to determine how to reduce renal disease in this vulnerable population.

Caffeine Exposure and Risk of Acute Kidney Injury in a Retrospective Cohort of Very Low Birth Weight Neonates

OBJECTIVE

To evaluate the association between caffeine exposure and acute kidney injury (AKI) in very low birth weight (VLBW; ≤1500 g) neonates.

STUDY DESIGN

We retrospectively reviewed a cohort of 140 VLBW neonates consecutively admitted to the University of Virginia's neonatal intensive care unit from March 2011 to June 2012, excluding only those admitted >2 days of age or who died at <2 days after birth. We separately analyzed a subgroup of 44 neonates who received prolonged invasive respiratory support (mechanical ventilation for first 7 days after birth). The exposure of interest was caffeine exposure in the first week after birth. The primary outcome was AKI within the first 10 days after birth according to the Kidney Disease: Improving Global Outcomes system, modified to include only serum creatinine.

RESULTS

Caffeine exposure occurred in 72.1% of all patients and 54.5% of those who received prolonged invasive respiratory support. AKI occurred less frequently in neonates who received caffeine (all patients: 17.8% vs 43.6%; P = .002; prolonged invasive respiratory support: 29.2% vs 75.0%; P = .002). Caffeine exposure was associated with decreased odds for AKI in logistic regression models adjusted for sex, birth weight, gestational age, small for gestational age status, illness severity on admission, and receipt of indomethacin, invasive ventilation, dopamine, aminoglycosides, and vancomycin (all patients: OR 0.22; 95% CI 0.07-0.75, P = .02; prolonged invasive respiratory support subgroup: OR 0.06; 95% CI 0.01-0.57, P = .02).

CONCLUSIONS

In a cohort of VLBW neonates, those exposed to caffeine were less likely to experience AKI.

A survey of certification for cardiopulmonary resuscitation in high school athletic coaches

BACKGROUND

Cardiopulmonary resuscitation (CPR) can increase survival in instances of sudden cardiac arrest. Nationally, high school coaches are the first responders to sudden cardiac arrest in up to one-third of high school athlete collapses, but little is known about the status of their CPR certification. The primary goal of this study was to assess the proportion of Wisconsin high school coaches that are certified in CPR.

METHODS

A prospective web-based survey was developed and distributed to high school athletic directors in Wisconsin.

RESULTS

Seventy-eight percent of respondents reported that coaches are the primary responders to a collapse. The majority of high schools do not require CPR certification and only 50% of coaches are currently CPR certified. Athletic directors with greater than 12 years of experience were the most likely to have an emergency action plan in place (P= 0.004).

CONCLUSION

In Wisconsin, the proportion of coaches who act as the primary responder to a collapse is greater than previously reported. Although the majority of coaches in Wisconsin serve as the primary responder to an episode of sudden cardiac arrest, only about 50% are CPR certified. Due to the severe consequences of sudden cardiac arrest, CPR certification among coaches should be required.