Neonatal Acute Kidney Injury
Neonatal Acute Kidney Injury
David T. Selewski, MD, MSa, Jennifer R. Charlton, MD, MSb, Jennifer G. Jetton, MDc, Ronnie Guillet, MD, PhDd,
Maroun J. Mhanna, MD, MPHe, David J. Askenazi, MD, MPHf, Alison L. Kent, BMBS, FRACP, MDg
EPIDEMIOLOGY AND OUTCOMES OF poor outcomes (Table 4).8–12,45,62–64 until 36 weeks postmenstrual age.
NEONATAL AKI Here we review AKI studies in some The incidence of AKI, by using the
There have been a number of single- exemplar patient populations. neonatal modified KDIGO criteria,
center studies that have evaluated the was 18%. The mortality in infants
impact of AKI in VLBW neonates, VLBW and ELBW Neonates with AKI was significantly higher than
extremely low birth weight (ELBW) There have been 3 large single- those without AKI (42% vs 5%,
neonates, sick near-term/term center studies to date that have P , .001). After adjusting for potential
neonates, neonates on extracorporeal evaluated AKI in VLBW neonates confounders, those with AKI had
membrane oxygenation (ECMO), and (500–1500 g).10,65,66 In 2011, Koralkar a significantly higher chance of death
asphyxiated newborns showing that et al10 reported on 229 VLBW infants (hazard ratio 2.4, 95% confidence
AKI is common and associated with followed prospectively from birth interval [CI] 0.95–6.0; P , .06).
Viswanathan et al65 reported similar
findings in a retrospective single-
TABLE 3 Common Nephrotoxic Medications in NICU center study, where 12.5% (59/472)
Drug Mechanism of all ELBW infants developed AKI
Acyclovir Urinary precipitation, especially with low flow and and mortality among those with AKI
hypovolemia, with renal tubular obstruction and damage was significantly higher than controls
and decreased GFR. May cause direct tubular toxicity (70% vs 22%, respectively). In a large
(metabolites).
Angiotensin-converting enzyme Decreased angiotensin II production inhibiting compensatory
retrospective study of VLBW infants,
inhibitors constriction of the efferent arteriole to maintain GFR. Carmody et al66 examined 455 VLBW
Aminoglycosides Toxic to the proximal tubules (transport in the tubule, infants and found an AKI incidence of
accumulate in lysosome, intracellular rise in reactive 39.8%. In this study, AKI was
oxygen species and phospholipidosis, cell death); intrarenal independently associated with
vasoconstriction and local glomerular/mesangial cell
contraction.
increased mortality (odds ratio 4.0,
Amphotericin B Distal tubular toxicity, vasoconstriction, and decreased GFR. 95% CI 1.4–11.5) and length of stay
Nonsteroidal antiinflammatory drugs Decreased afferent arteriole dilatation as a result of inhibiting (11.7 hospital days, 95% CI 5.1–18.4).
prostaglandin production resulting in reduced GFR.
Radiocontrast agents Renal tubular toxicity secondary to increase in reactive oxygen Perinatal Asphyxia
species; intrarenal vasoconstriction may play a role.
Vancomycin Mechanism of AKI unclear, possible mechanism includes Infants with perinatal asphyxia have
proximal tubular injury with generation of reactive oxygen been recognized as a group that is at
species. high risk of AKI. Recently there have
been 2 single-center studies that have a mortality of 65% when AKI evaluating prerenal, intrinsic, and
looked at the incidence of AKI by progressed to the highest stage. These postrenal causes. We highlight
using modern AKI definitions. Kaur mirror the findings of Gadepalli et al8 important aspects of the evaluation. A
et al9 reported an incidence of AKI of in neonates with congenital detailed clinical history should
41.7%. Selewski et al12 evaluated diaphragmatic hernia on ECMO where include assessment of gestational age,
newborns undergoing therapeutic AKI occurred in 71% of neonates, and antenatal (ultrasounds), maternal
hypothermia for perinatal asphyxia those with the highest stage of AKI (nephrotoxic medication), birth (fetal
and found that 36 (38%) of 96 had had a mortality of 73%. heart rate monitoring and
AKI. Even after controlling for resuscitation), and postnatal
important potential confounders, Neonatal Cardiac Surgery (nephrotoxic medications,
children with AKI on average were The association of AKI with cardiac hypotension) events. The physical
ventilated 4 days longer (P , .001) surgery in older children has been examination should focus on volume
and hospitalized 3.4 days longer well studied and the association of status and vital signs. A thorough
(P = .023). In addition, these AKI with increased mortality is clear. evaluation of volume status also
investigators also showed that AKI Alabbas et al64 published requires assessment of serum
during therapeutic hypothermia was a retrospective study of 122 neonates electrolytes, fluid balance, and,
associated with abnormal brain MRI (,28 days) showing that AKI importantly, body weight. Utilization
findings at 7 to 10 days of life, occurred in 62% of the neonates. The of these 3 measurements can assist in
implicating AKI as a potential marker highest stage of AKI was associated determining both hypovolemia from
for neurologic outcomes.11 with increased mortality and insensible losses, as well as
increased ICU length of stay. These hypervolemia from fluid overload.
ECMO findings are similar to the findings Assessment of fractional excretion of
Neonates supported with ECMO reported by Blinder et al7 in 430 sodium can help to differentiate the
represent a unique patient population infants (,90 days) undergoing prerenal (hypovolemia) from intrinsic
that is particularly prone to AKI cardiac surgery. (acute tubular necrosis) causes of
based on the severity of their illness AKI, although in premature infants
and the inflammatory response that this metric may not be as helpful.
accompanies exposure to the EVALUATION AND MANAGEMENT OF Finally, to evaluate potential
extracorporeal circuit.67,68 Zwiers NEONATAL AKI postrenal (obstruction) causes of AKI,
et al69 evaluated AKI in 242 neonates The evaluation of a neonate who an ultrasound should be obtained.
on ECMO over a 14-year period develops AKI requires a systematic After the diagnosis of AKI, it becomes
showing an AKI incidence of 64% and approach, which frequently involves important to prevent the
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