Incidence and Risk Factors of Early Onset Neonatal AKI

Abstract

Background and objectivesNeonatal 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, & measurementsThe 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.ResultsTwenty-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.ConclusionsAKI 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.Clinical Trial registry name and registration number:Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN), NCT02443389

Elevated Levels of Urinary Biomarkers TIMP-2 and IGFBP-7 Predict Acute Kidney Injury in Neonates after Congenital Heart Surgery

“…19 The current study confirms [TIMP-2 Ã IGFBP7] urinary level measured at 24 hours post-CPB as an early and accurate predictor of neonatal AKI in cardiac surgical population. Given that the incidence of AKI is high in this population, and that long-term complications have been reported, 20 early identification of patients at risk may enable selective implementation of kidney protective strategies and consultation with pediatric nephrologists, as have been described in adult populations. 21 In a study of 276 adult patients after cardiac surgery, patients enrolled in a KDIGO bundle group (consisting of optimization of volume status and hemodynamics, avoidance of nephrotoxic drugs, and preventing hyperglycemia in high-risk patients defined as urinary [TIMP-2] Ã [IGFBP-7] > 0.3) had reduced frequency and severity of AKI.…”

Maternal Hypertension Disorders and Neonatal Acute Kidney Injury: Results from the AWAKEN Study

“…Then we looked at the association between maternal HTN exposure and early AKI, defined as occurring within the first 2 to 7 days after birth, and late AKI, defined as >7 days after birth. 30 31 AKI severity stages were assigned and are included in Supplemental Table S1 (available in the online version). 29 The frequency and methodology for SCr monitoring and measurement were center dependent and variations by site have been previously published.…”

“…24 25 26 27 28 In the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) cohort, the largest multicenter and international study evaluating neonatal AKI to date, the incidence of neonatal AKI was nearly 30% and was associated with a higher adjusted odds of death. 29 30 31 Outborn delivery and gestational age (GA) <29 or >36 weeks are among the most highly associated risk factors for neonatal AKI in the AWAKEN cohort. 29 30 32 This secondary analysis of the AWAKEN dataset was designed to investigate whether exposure to maternal HTN disorders was associated with the presence, timing, or severity of neonatal AKI and to identify potential maternal or neonatal factors that modified this association such as the site of delivery and GA.…”

“…29 30 31 Outborn delivery and gestational age (GA) <29 or >36 weeks are among the most highly associated risk factors for neonatal AKI in the AWAKEN cohort. 29 30 32 This secondary analysis of the AWAKEN dataset was designed to investigate whether exposure to maternal HTN disorders was associated with the presence, timing, or severity of neonatal AKI and to identify potential maternal or neonatal factors that modified this association such as the site of delivery and GA.…”

Acute Kidney Injury and Intraoperative Hypotension in Children: More Questions than Answers

“…There is, however, other published evidence that neonates may be particularly susceptible to acute kidney injury after noncardiac surgery, though apart from recognizing the risk, we have only rudimentary data about which surgical neonates are at greatest risk, and few specific evidence-based strategies to prevent the injury. [5][6][7] Another limitation of this study is the definition of hypotension. There are various ways to define significant intraoperative hypotension.…”