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Jackson W, Gonzalez D, Greenberg RG, Lee YZ, Laughon MM. A phase I trial of caffeine to evaluate safety in infants with hypoxic-ischemic encephalopathy. J Perinatol 2024; 44:508-512. [PMID: 37587184 PMCID: PMC10869636 DOI: 10.1038/s41372-023-01752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/28/2023] [Accepted: 08/09/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVE Caffeine provides neuroprotection following hypoxic-ischemic injury in animals. We characterized the safety of escalating doses of caffeine in infants with hypoxic-ischemic encephalopathy (HIE) receiving therapeutic hypothermia. STUDY DESIGN Phase I trial of infants undergoing therapeutic hypothermia for HIE receiving IV caffeine 20 mg/kg followed by up to two daily doses of 5 mg/kg (n = 9) or 10 mg/kg (n = 8). Safety was evaluated based on adverse events and frequency of pre-specified outcomes compared to data from the Whole-Body Hypothermia for HIE trial (Shankaran, 2005). RESULTS Twelve of 17 (71%) infants had ≥1 adverse event during the study period. The frequency of clinical outcomes related to HIE were not statistically different from outcomes in infants receiving hypothermia in the Whole-Body Hypothermia for HIE trial. CONCLUSION Caffeine administration was well tolerated. A larger study is required to determine the optimal dose and evaluate drug safety and efficacy. CLINICAL TRIAL ClinicalTrials.gov Identifier: NCT03913221.
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Affiliation(s)
- Wesley Jackson
- Department of Pediatrics, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, 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, USA
| | - Rachel G Greenberg
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Yueh Z Lee
- Department of Radiology, The University of North Carolina at Chapel Hill, 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
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2
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Aithal N, Kandasamy Y. The Babyccino: The Role of Caffeine in the Prevention of Acute Kidney Injury in Neonates-A Literature Review. Healthcare (Basel) 2024; 12:529. [PMID: 38470639 PMCID: PMC10931184 DOI: 10.3390/healthcare12050529] [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: 01/15/2024] [Revised: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/14/2024] Open
Abstract
Acute kidney injury (AKI) in neonates is associated with increased morbidity and mortality. Theophylline (a methylxanthine) has been shown to prevent neonatal AKI but is seldom used due to its unfavorable profile. Caffeine, another methylxanthine, is utilized ubiquitously to treat apnea of prematurity, but there are no randomized trials evaluating its efficacy in preventing neonatal AKI. This literature review aims to summarize the existing research pertaining to the relationship between caffeine and neonatal AKI. The review was conducted using Pubmed, Embase, Google Scholar, and Cochrane. Inclusion criteria incorporated empirical studies, being published in English, and being available electronically. All eight studies identified were included. Seven studies found caffeine-exposed premature neonates had lower rates of AKI than caffeine-unexposed neonates. Four found reduced AKI severity with caffeine exposure. One study included term neonates and did not find a difference in the AKI rate between caffeine-exposed and non-exposed babies. Limitations include exclusively observational studies, short study periods, heterogenous definitions of prematurity, and a lack of assessment of dose-effect relationships. In conclusion, premature neonates exposed to caffeine appear to have lower rates and potentially less severe AKI. Further research is needed before caffeine can be considered for use in the primary prevention of neonatal AKI.
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Affiliation(s)
- Nimisha Aithal
- Department of Pediatrics, Townsville University Hospital, Townsville, QLD 4811, Australia
| | - Yogavijayan Kandasamy
- Department of Neonatology, Townsville University Hospital, Townsville, QLD 4811, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, QLD 4814, Australia
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3
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Nyann BI, Nourse P, Masu A, Agyabeng K, McCulloch MI. Effects of aminophylline therapy on urine output and kidney function in children with acute kidney injury. Pediatr Nephrol 2024; 39:559-567. [PMID: 37532898 PMCID: PMC10728232 DOI: 10.1007/s00467-023-06065-y] [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: 01/16/2023] [Revised: 06/13/2023] [Accepted: 06/13/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent complication of children admitted to the paediatric intensive care unit. One key management modality of AKI is the use of diuretics to reduce fluid overload. Aminophylline, a drug that is well known for its use in the treatment of bronchial asthma, is also purported to have diuretic effects on the kidneys. This retrospective cohort study assesses the effect of aminophylline in critically ill children with AKI. METHODS A retrospective chart review of children admitted to the paediatric intensive care unit of the Red Cross War Memorial Children's Hospital (RCWMCH) with AKI who received aminophylline (from 2012 to June 2018) was carried out. Data captured and analyzed included demographics, underlying disease conditions, medications, urine output, fluid balance, and kidney function. RESULTS Data from thirty-four children were analyzed. Urine output increased from a median of 0.4 mls/kg/hr [IQR: 0.1, 1.1] at six hours prior to aminophylline administration to 0.6 mls/kg/hr [IQR: 0.2, 1.9] at six hours and 1.6 mls/kg/hr [IQR:0.2, 4.2] at twenty-four hours post aminophylline therapy. The median urine output significantly varied across the age groups over the 24-h time period post-aminophylline, with the most response in the neonates. There was no significant change in serum creatinine levels six hours post-aminophylline administration [109(IQR: 77, 227)-125.5(IQR: 82, 200) micromole/l] P-value = 0.135. However, there were significant age-related changes in creatinine levels at six hours post-aminophylline therapy. CONCLUSIONS Aminophylline increases urine output in critically ill children with AKI. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Beatrice I Nyann
- Department of Paediatrics, University of Ghana Medical Centre, Legon, Accra, Ghana.
| | - Peter Nourse
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Adelaide Masu
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
| | - Kofi Agyabeng
- Department of Biostatistics, School of Public Health, University of Ghana, Legon, Accra, Ghana
| | - Mignon I McCulloch
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics and Child Health, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
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4
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Turner MJ, Dietz RM. Potential Adjuncts to Therapeutic Hypothermia to Mitigate Multiorgan Injury in Perinatal Hypoxia-Ischemia. Neoreviews 2023; 24:e771-e782. [PMID: 38036441 DOI: 10.1542/neo.24-12-e771] [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: 12/02/2023]
Abstract
Over the last 2 decades, therapeutic hypothermia has become the standard of care to reduce morbidity and mortality in neonates affected by moderate-to-severe hypoxic-ischemic encephalopathy (HIE). There is a significant interest in improving the neurologic outcomes of neonatal HIE, ranging from adjunctive therapy to therapeutic hypothermia. Importantly, the pathophysiologic mechanisms underlying HIE also affect multiple other organs, contributing to high morbidity and mortality in this patient population. This review focuses on the adjunct therapies currently under investigation to mitigate the impact of hypoxic-ischemic injury on the brain, kidneys, liver, heart, and gastrointestinal system.
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Affiliation(s)
- Megan J Turner
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Pediatrics, Denver Health Medical Center, Denver, CO
| | - Robert M Dietz
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
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5
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Rumpel JA, Spray BJ, Frymoyer A, Rogers S, Cho SH, Ranabothu S, Blaszak R, Courtney SE, Chock VY. Renal oximetry for early acute kidney injury detection in neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia. Pediatr Nephrol 2023; 38:2839-2849. [PMID: 36786860 DOI: 10.1007/s00467-023-05892-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Neonates with hypoxic ischemic encephalopathy (HIE) receiving therapeutic hypothermia are at high risk of acute kidney injury (AKI). METHODS We performed a two-site prospective observational study from 2018 to 2019 to evaluate the utility of renal near-infrared spectroscopy (NIRS) in detecting AKI in 38 neonates with HIE receiving therapeutic hypothermia. AKI was defined by a delayed rate of serum creatinine decline (< 33% on day 3 of life, < 40% on day 5, and < 46% on day 7). Renal saturation (Rsat) and systemic oxygen saturation (SpO2) were continuously measured for the first 96 h of life (HOL). Renal fractional tissue oxygen extraction (RFTOE) was calculated as (SpO2 - Rsat)/(SpO2). Using renal NIRS, urine biomarkers, and perinatal factors, logistic regression was performed to develop a model that predicted AKI. RESULTS AKI occurred in 20 of 38 neonates (53%). During the first 96 HOL, Rsat was higher, and RFTOE was lower in the AKI group vs. the no AKI group (P < 0.001). Rsat > 70% had a fair predictive performance for AKI at 48-84 HOL (AUC 0.71-0.79). RFTOE ≤ 25 had a good predictive performance for AKI at 42-66 HOL (AUC 0.8-0.83). The final statistical model with the best fit to predict AKI (AUC = 0.88) included RFTOE at 48 HOL (P = 0.012) and pH of the infants' first postnatal blood gas (P = 0.025). CONCLUSIONS Lower RFTOE on renal NIRS and pH on infant first blood gas may be early predictors for AKI in neonates with HIE receiving therapeutic hypothermia. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jennifer A Rumpel
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
- Arkansas Children's Hospital, One Children's Way Slot 512-5, Little Rock, AR, 72205, USA.
| | - Beverly J Spray
- Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sydney Rogers
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Seo-Ho Cho
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Saritha Ranabothu
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Richard Blaszak
- Division of Nephrology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sherry E Courtney
- Division of Neonatology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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6
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Van Siang Lian Mang P, Hui JC, Tan RSJ, Hasan MS, Choo YM, Abosamak MF, Ng KT. The diuretic effect of adding aminophylline or theophylline to furosemide in pediatric populations: a systematic review. Eur J Pediatr 2023; 182:1-8. [PMID: 36251063 DOI: 10.1007/s00431-022-04655-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/28/2022] [Accepted: 10/08/2022] [Indexed: 01/12/2023]
Abstract
UNLABELLED The diuretic effect of the combined furosemide and aminophylline/theophylline among pediatric patients remains unclear. The primary aim of this systematic review was to examine the clinical diuretic effects (urine output and fluid balance) of co-administration of furosemide and aminophylline/theophylline as compared to furosemide alone in pediatric population. Ovid MEDLINE, CENTRAL, and EMBASE were searched from its inception until March 2022 for observational studies and randomized controlled trials (RCTs) comparing the administration of furosemide versus furosemide and aminophylline/theophylline in pediatric population. Case reports, case series, commentaries, letters to editors, systematic reviews, and meta-analyses were excluded. Five articles with a total sample population of 187 patients were included in this systematic review. As compared to the furosemide alone, our pooled data demonstrated that co-administration of furosemide and aminophylline/theophylline was associated with higher urine output (mean difference: 2.91 [90% CI 1.54 to 4.27], p < 0.0001, I2 = 90%) and a more negative fluid balance (mean difference - 28.27 [95% CI: - 46.21 to - 10.33], p = 0.002, I2 = 56%) than those who received furosemide alone. CONCLUSION This is the first paper summarizing the evidence of combined use of furosemide with aminophylline/theophylline in pediatric population. Our systematic review demonstrated that the co-administration of furosemide and aminophylline/theophylline could potentially yield better diuretic effects of urine output and negative fluid balance than furosemide alone in pediatric patients with fluid overload. Given the substantial degree of heterogeneity and low level of evidence, future adequately powered trials are warranted to provide evidence regarding the combined use of aminophylline/theophylline and furosemide as diuretic in the pediatric population. WHAT IS KNOWN • Fluid overload is associated with poor prognosis for children in the intensive care unit. • The ineffective result of furosemide alone, even at high dose, as diuretic agent for children with diuretic resistant fluid overload in the intensive care unit. WHAT IS NEW • This is the first systematic review that compares furosemide alone and co-administration of furosemide and aminophylline/theophylline. • This paper showed potential benefit of co-administration of furosemide and aminophylline/theophylline promoting urine output and negative fluid balance compared to furosemide alone.
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Affiliation(s)
| | | | | | - M Shahnaz Hasan
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Yao Mun Choo
- Department of Paediatrics, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia
| | - Mohammed F Abosamak
- Department of Anaesthesia and Intensive Care Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, Universiti Malaya, 50603, Kuala Lumpur, Malaysia.
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7
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Interventions for preventing and treating acute kidney injury in children. Cochrane Database Syst Rev 2022; 2022:CD015296. [PMCID: PMC9680039 DOI: 10.1002/14651858.cd015296] [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] [Indexed: 09/18/2023]
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: This review aims to look at the benefits and harms of all pharmacological interventions except dialysis for the prevention and treatment of AKI.
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8
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Coleman C, Tambay Perez A, Selewski DT, Steflik HJ. Neonatal Acute Kidney Injury. Front Pediatr 2022; 10:842544. [PMID: 35463895 PMCID: PMC9021424 DOI: 10.3389/fped.2022.842544] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common occurrence in the neonatal intensive care unit (NICU). In recent years, our knowledge of the incidence and impact of neonatal AKI on outcomes has expanded exponentially. Neonatal AKI has been shown to be associated with adverse outcomes including increased length of mechanical ventilation, prolonged length of stay, and rise in mortality. There has also been increasing work suggesting that neonates with AKI are at higher risk of chronic kidney disease (CKD). In the past, AKI had been defined multiple ways. The utilization of the neonatal modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria as the standard definition for neonatal AKI in research and clinical care has driven the advances in our understanding of neonatal AKI over the last 10 years. This definition has allowed researchers and clinicians to better understand the incidence, risk factors, and outcomes associated with neonatal AKI across populations through a multitude of single-center studies and the seminal, multicenter Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. As the impacts of neonatal AKI have become clear, a shift in efforts toward identifying those at highest risk, protocolizing AKI surveillance, improving prevention and diagnosis, and expanding kidney support therapy (KST) for neonates has occurred. These efforts also include improving risk stratification (identifying high risk populations, including those with nephrotoxic medication exposure) and diagnostics (novel biomarkers and diagnostic tools). Recent work has also shown that the targeted use of methylxanthines may prevent AKI in a variety of high-risk populations. One of the most exciting developments in neonatal AKI is the advancement in technology to provide KST to neonates with severe AKI. In this comprehensive review we will provide an overview of recent work and advances in the field of neonatal AKI. This will include a detailed review of (1) the definition of neonatal AKI, (2) the epidemiology, risk factors, and outcomes associated with neonatal AKI, (3) improvements in risk stratification and diagnostics, (4) mitigation and treatment, (5) advancements in the provision of KST to neonates, and (6) the incidence and risk of subsequent CKD.
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Affiliation(s)
- Cassandra Coleman
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Anita Tambay Perez
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - David T. Selewski
- Division of Pediatric Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Heidi J. Steflik
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
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9
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Advances in pediatric acute kidney injury. Pediatr Res 2022; 91:44-55. [PMID: 33731820 DOI: 10.1038/s41390-021-01452-3] [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: 09/23/2020] [Revised: 01/26/2021] [Accepted: 02/16/2021] [Indexed: 01/10/2023]
Abstract
The objective of this study was to inform the pediatric nephrologists of recent advances in acute kidney injury (AKI) epidemiology, pathophysiology, novel biomarkers, diagnostic tools, and management modalities. Studies were identified from PubMed, EMBASE, and Google Scholar for topics relevant to AKI. The bibliographies of relevant studies were also reviewed for potential articles. Pediatric (0-18 years) articles from 2000 to May 2020 in the English language were included. For epidemiological outcomes analysis, a meta-analysis on data regarding AKI incidence, mortality, and proportion of kidney replacement therapy was performed and an overall pooled estimate was calculated using the random-effects model. Other sections were created highlighting pathophysiology, novel biomarkers, changing definitions of AKI, evolving tools for AKI diagnosis, and various management modalities. AKI is a common condition seen in hospitalized children and the diagnosis and management have shown to be quite a challenge. However, new standardized definitions, advancements in diagnostic tools, and the development of novel management modalities have led to increased survival benefits in children with AKI. IMPACT: This review highlights the recent innovations in the field of AKI, especially in regard to epidemiology, pathophysiology, novel biomarkers, diagnostic tools, and management modalities.
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10
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Surmeli Onay O, Gunes D, Aydemir O, Tekin N. A single dose of aminophylline administration during therapeutic hypothermia; does it make a difference in glomerular filtration rate? Eur J Pediatr 2021; 180:3367-3377. [PMID: 34046718 DOI: 10.1007/s00431-021-04128-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/15/2021] [Accepted: 05/19/2021] [Indexed: 10/21/2022]
Abstract
Aminophylline has been demonstrated to be effective in improving renal functions of the infants suffering from acute kidney injury (AKI) due to perinatal asphyxia. We aimed to evaluate the effect of a single-dose aminophylline on estimated glomerular filtration rate (eGFR), urine output (UO), and incidence and severity of AKI according to the pediatric-modified RIFLE and neonatal RIFLE criteria in newborns with perinatal asphyxia under therapeutic hypothermia. This was a single-center, retrospective cohort study including newborns (gestational age ≥36 weeks) who underwent therapeutic hypothermia due to hypoxic ischemic encephalopathy between 2016 and 2019. Demographic and clinical data were obtained from electronic medical records and patient files. Two patient groups were established: aminophylline group and control group which were only under therapeutic hypothermia. Twenty-one newborns were in the aminophylline group and 13 newborns were in the control group. Our study revealed that on the third day of life (DOL), eGFR was significantly higher in the control group (p=0.025), but UO was significantly higher in the aminophylline group (p=0.021). In the aminophylline group, eGFR on the first DOL was higher than the value on the second DOL (p=0.017) while UO was higher on the second and third DOL compared to the first DOL (1-2 DOL p=0.006, and 1-3 DOL p=0.004). However, in the control group, there was no statistically significant difference in UO over the four DOL. Both groups were similar in the presence, severity, and outcome of AKI.Conclusion: This study demonstrated that aminophylline increases UO even in the infants under therapeutic hypothermia. However, the eGFR did not significantly increase in the aminophylline group. Understanding how therapeutic hypothermia affects pharmacokinetics may help us improve our results in future studies. What is known: • Therapeutic hypothermia (TH) reduces the incidence of acute kidney injury in asphyxiated newborns. • Aminophylline is effective in improving renal functions in asphyxiated newborns. What is new: • This is the first study evaluating the effect of a single dose of aminophylline on renal functions in newborns under TH. • A single dose of aminophylline administration in newborns under TH was associated with increased urine output especially on the third day of life. However, no significant increase was detected in glomerular filtration rate associated with aminophylline administration.
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Affiliation(s)
- Ozge Surmeli Onay
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey.
| | - Damla Gunes
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Ozge Aydemir
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Neslihan Tekin
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
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11
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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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12
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Piastra M, Tempera A, De Carolis MP, Pezza L, Genovese O, Benassi C, Morena TC, Picconi E, Zito G, De Rosa G, Conti G, De Luca D. Neonatal Life-Threatening Nonoliguric Hyperkalemia Under Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2021; 11:238-241. [PMID: 34619071 DOI: 10.1089/ther.2021.0009] [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: 11/13/2022] Open
Abstract
To illustrate our experience with two cases of neonatal life-threatening hyperkalemia during therapeutic hypothermia (TH) despite a normal acid-base status, urine output, and preserved renal function. Clinical cases are presented from Pediatric Intensive Care Unit (PICU) admission to the onset of the hyperkalemia, with related complications and after resolution. Similar cases were not retrieved from a critical review of pertinent literature. Severe hyperkalemia pathophysiology and risk factors have been debated. Two full-term adequate for weight female neonates were admitted to PICU because of perinatal asphyxia who underwent TH. Prenatal history was completely uneventful, nor hereditary genetic conditions were reported; moreover, long-term follow-up ruled out any metabolic or renal disease. Despite an accurate evaluation of previous clinical series and literature on TH and perinatal asphyxia, these hyperkalemic episodes remain unexplained. The hypoxic-ischemic insult may affect multiple organs, mainly central nervous system, heart, lung, and kidneys; acute muscle breakdown and consequent rising of myoglobin may also have a precipitating role in acute kidney failure (AKF) and hyperkalemia. Electrolyte imbalance is a possible finding as a consequence of combined cell injury and AKF. In contrast, an isolated severe hyperkalemia is exceedingly rare in nonoliguric neonates.
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Affiliation(s)
- Marco Piastra
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Alessia Tempera
- Neonatal Intensive Care Unit, Maternal-Fetal Department, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Maria Pia De Carolis
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucilla Pezza
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Orazio Genovese
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cristina Benassi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tony C Morena
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Enzo Picconi
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Gabriella De Rosa
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Institute of Anesthesia and Intensive Care, Catholic University of the Sacred Heart of Rome, Rome, Italy
| | - Daniele De Luca
- Division of Pediatrics and Neonatal Critical Care, Centre Antoine Beclere, Paris-Saclay University Hospitals APHP, Paris, Ile-de France, France.,Physiopathology and Therapeutic Innovation Unit INSERUM U999 Paris, Université Paris-Saclay APHP, Ile-de France, France
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13
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Iqbal N, Younus J, Malik M, Fatima B, Imran A, Maqbool S, Irfan Waheed KA, Haque K. The Neuroprotective Efficacy of Postnatal Magnesium Sulfate in Term or Near-Term Infants With Moderate-to-Severe Birth Asphyxia. Cureus 2021; 13:e16826. [PMID: 34513419 PMCID: PMC8407416 DOI: 10.7759/cureus.16826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 11/05/2022] Open
Abstract
Background In Pakistan, the neonatal mortality rate is 41 per 1,000 live births and birth asphyxia is one of the leading causes of neonatal mortality and morbidity. The goal of this study was to determine whether postnatal magnesium sulfate therapy can improve short- and long-term neurological outcomes in term or near-term neonates with moderate-to-severe birth asphyxia. Methodology This prospective double-blind randomized controlled trial was conducted in the Neonatology Department of the Children's Hospital & The Institute of Child Health, Lahore. A total of 62 neonates (31 in each group) were randomized to receive either three doses of magnesium sulfate infusion at 250 mg/kg per dose, 24 hours apart (treatment group), or three doses of injection 10% distilled water infusion at 3 mL/kg, 24 hours apart (placebo group). Both groups received similar supportive care. The neurodevelopmental assessment was done at six months of age using the ShaMaq Developmental Inventory. Results Demographic data such as gestational age, mean weight, age at presentation, gender, hypoxic-ischemic encephalopathy grade, mode of delivery, and the presence of seizures at presentation were comparable between both groups. In the magnesium sulfate group, statistically significant results were seen in terms of early seizure control (p = 0.001), early initiation of feed (p = 0.002), and shorter duration of hospital stay (p = 0.003). Moreover, the magnesium sulfate group had lower mortality compared to the control group, though it was not statistically significant (p = 0.390). There was no significant difference in terms of cranial ultrasound findings between the two groups (p = 0.783) at the time of discharge. Regarding the neurodevelopmental delay, there was no significant difference between the magnesium sulfate and control groups (p = 0.535). Conclusions Postnatal magnesium sulfate treatment improves short-term neurologic outcomes at discharge in term or near-term neonates with moderate-to-severe perinatal asphyxia. However, no difference was noted in the neurodevelopmental outcome at six months.
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Affiliation(s)
- Nadeem Iqbal
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Javaria Younus
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Muneeba Malik
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Bushra Fatima
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Ahmed Imran
- Pediatric Radiology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | - Shazia Maqbool
- Developmental and Behavioural Pediatrics, The Children's Hospital & The Institute of Child Health, Lahore, PAK
| | | | - Khalid Haque
- Neonatology, The Children's Hospital & The Institute of Child Health, Lahore, PAK
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14
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Soares H, Moita R, Maneira P, Gonçalves A, Gomes A, Flor-de-Lima F, Costa S, Soares P, Pissarra S, Rocha G, Silva J, Clemente F, Pinto H, Guimarães H. Nephrotoxicity in Neonates. Neoreviews 2021; 22:e506-e520. [PMID: 34341158 DOI: 10.1542/neo.22-8-e506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute kidney injury (AKI) is classified based on prerenal, intrinsic, and postrenal causes. In the newborn, AKI can occur after an insult during the prenatal, perinatal, or postnatal period. AKI is usually an underrecognized condition and its true incidence is unknown. AKI may result from the administration of a number of different nephrotoxic medications, which are often used concurrently in critically ill neonates, exponentially increasing the risk of renal injury. Drug toxicity may also compromise the formation and development of nephrons, and this is particularly important in preterm infants, who have incomplete nephrogenesis. Little is known about the pharmacokinetics and pharmacodynamics of different medications used in neonates, especially for the most immature infant, and the use of most medications in this population is off label. Strategies to prevent AKI include the avoidance of hypotension, hypovolemia, fluid imbalances, hypoxia, and sepsis as well as judicious use of nephrotoxic medications. Treatment strategies aim to maintain fluids and electrolytic and acid-base homeostasis, along with an adequate nutritional status. Neonates are especially prone to long-term sequelae of AKI and benefit from long-term follow-up. This review summarizes the most relevant aspects of nephrotoxicity in neonates and describes the prevention, treatment, and follow-up of AKI in neonates.
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Affiliation(s)
- Henrique Soares
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Rita Moita
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Pedro Maneira
- Neonatal Intensive Care Unit, Neonatology Department
| | | | - Ana Gomes
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Filipa Flor-de-Lima
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Sandra Costa
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Paulo Soares
- Neonatal Intensive Care Unit, Neonatology Department
| | - Susana Pissarra
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Gustavo Rocha
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Jorge Silva
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Fátima Clemente
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Helena Pinto
- Neonatal Intensive Care Unit, Neonatology Department.,Pediatrics Nephrology Unit, Pediatric Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Hercília Guimarães
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
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15
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Bozkurt O, Yucesoy E. Acute Kidney Injury in Neonates with Perinatal Asphyxia Receiving Therapeutic Hypothermia. Am J Perinatol 2021; 38:922-929. [PMID: 31986537 DOI: 10.1055/s-0039-1701024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To assess the incidence and severity of acute kidney injury (AKI) and evaluate risk factors that predict AKI in asphyxiated infants receiving therapeutic hypothermia. STUDY DESIGN Infants ≥36 weeks' gestation diagnosed with moderate-to-severe perinatal asphyxia and received therapeutic hypothermia were reviewed retrospectively (n = 166). Modified Acute Kidney Injury Network criteria were used to diagnose AKI. The results of infants with AKI were compared with the infants who did not develop AKI. RESULTS AKI developed in 49 (29.5%) infants, of whom 22 had stage I, 13 had stage II, and 14 had stage III AKI. The overall mortality rate was 15.7% and was significantly higher in infants with AKI when compared with infants without AKI (41 vs. 5%; p < 0.001). Asystole at birth (p = 0.044), placental abruption (p = 0.041), outborn status (p = 0.041), need for vasopressor support (p = 0.031), increased bleeding tendency (p = 0.031), initial lactate level (p = 0.015), and 12-hour lactate level (p = 0.029) were independent risk factors for the development of AKI. Receiver operating characteristic curve analysis demonstrated a good predictive value for initial lactate level (>15 mmol/L), with 69% sensitivity (95% CI: 55-82) and 82% specificity (95% CI: 74-89), and for 12-hour lactate level (>6 mmol/L), with 83.7% sensitivity (95% CI: 70-93) and 73.5% specificity (95% CI: 64.5-81), to predict AKI. CONCLUSION AKI is still a common complication of perinatal asphyxia despite treatment with therapeutic hypothermia. Identification of risk factors associated with the development of AKI in asphyxiated infants would be potentially beneficial to reduce morbidity and mortality. Besides perinatal risk factors, initial and 12-hour lactate concentrations can be used for the early prediction of AKI.
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Affiliation(s)
- Ozlem Bozkurt
- Division of Neonatology, Department of Pediatrics, Faculty of Medicine, Demiroglu Bilim University, Istanbul, Turkey
| | - Ebru Yucesoy
- Division of Neonatology, Department of Pediatrics, Sanliurfa Training and Research Hospital, Sanliurfa, Turkey
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16
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Sethi SK, Bunchman T, Chakraborty R, Raina R. Pediatric acute kidney injury: new advances in the last decade. Kidney Res Clin Pract 2021; 40:40-51. [PMID: 33663033 PMCID: PMC8041642 DOI: 10.23876/j.krcp.20.074] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/19/2020] [Accepted: 08/28/2020] [Indexed: 12/25/2022] Open
Abstract
Pediatric acute kidney injury (AKI) is a frequently missed complication. AKI has a significant impact on both short- and long-term outcomes in children. Within the last decade, there have been major landmark developments in this field of critical care pediatric nephrology. The topic was searched by two independent researchers using Google Scholar and PubMed and related studies published in the last 10 years. The terms used for the search were 'pediatric acute kidney injury,' 'pediatric acute renal failure,' 'pediatric dialysis,' 'biomarkers,' 'nephrotoxins,' 'nephrotoxicity in children,' and 'pediatric critical care nephrology.' We found that AKI is common in critically ill neonates and children. Among the various definitions, the Kidney Disease: Improving Global Outcomes (KDIGO) definition is most commonly used. In addition, it is imperative to risk stratify sick children at admission in the hospital to predict AKI and worse outcomes as this aids in early management. There are now major landmark trials that describe the epidemiology, prevention, and management guidelines in this field and health care professionals need to be aware they should diagnose AKI early. Overall, this review highlights the landmark studies in the last decade and shows that early diagnosis and management of AKI in 'at risk' children can improve outcomes.
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Affiliation(s)
- Sidharth K. Sethi
- Department of Pediatric Nephrology, Kidney Institute, Medanta-The Medicity Hospital, Gurgaon, India
| | - Timothy Bunchman
- Departments of Pediatric Nephrology and Transplantation, Children’s Hospital of Richmond at VCU, Richmond, VA, USA
| | - Ronith Chakraborty
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Rupesh Raina
- Akron Nephrology Associates and Cleveland Clinic Akron General Medical Center, Akron, OH, USA
- Department of Nephrology, Akron Children’s Hospital, Akron, OH, USA
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17
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Chock VY, Cho SH, Frymoyer A. Aminophylline for renal protection in neonatal hypoxic-ischemic encephalopathy in the era of therapeutic hypothermia. Pediatr Res 2021; 89:974-980. [PMID: 32503030 PMCID: PMC7718287 DOI: 10.1038/s41390-020-0999-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/20/2020] [Accepted: 05/26/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Neonates with hypoxic-ischemic encephalopathy (HIE) frequently develop acute kidney injury (AKI). Aminophylline has been shown to reduce severe renal dysfunction in neonates after perinatal asphyxia. However, the effect of aminophylline on renal function in neonates undergoing hypothermia has not been studied. METHODS A single-center, retrospective chart review of neonates cooled for moderate/severe HIE who received aminophylline for AKI was conducted to assess changes in urine output (UOP) and serum creatinine (SCr). Comparisons were also made to control neonates matched for hours of life who were cooled but unexposed to aminophylline. RESULTS Sixteen neonates cooled for HIE received aminophylline starting at 25 ± 14 h of life. Within 12 h of starting aminophylline, UOP increased by 2.6 ± 1.9 mL/kg/h. SCr declined by 0.4 ± 0.2 mg/dL in survivors over the first 4 days. When compared to control neonates, UOP increase was greater in the aminophylline group (p < 0.001). SCr declined in survivors in both groups, although baseline SCr was higher in the aminophylline group. CONCLUSIONS Aminophylline use in neonates with HIE undergoing hypothermia was associated with an increase in UOP and a decline in SCr. A randomized trial will be needed to establish a potential renal protective role of aminophylline. IMPACT The renal protective effect of aminophylline in neonates with HIE has not yet been studied in the context of therapeutic hypothermia. Aminophylline exposure in neonates cooled for HIE was associated with increased UOP and a similar decline in SCr when compared to control infants unexposed to aminophylline. Improved renal function after receiving aminophylline in this observational cohort study suggests the need for future randomized trials to establish the potential benefit of aminophylline in the HIE population undergoing hypothermia.
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Affiliation(s)
- Valerie Y Chock
- Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
| | - Seo-Ho Cho
- Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Adam Frymoyer
- Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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18
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Frymoyer A, Van Meurs KP, Drover DR, Klawitter J, Christians U, Chock VY. Theophylline dosing and pharmacokinetics for renal protection in neonates with hypoxic-ischemic encephalopathy undergoing therapeutic hypothermia. Pediatr Res 2020; 88:871-877. [PMID: 32919393 PMCID: PMC7704857 DOI: 10.1038/s41390-020-01140-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/10/2020] [Accepted: 08/13/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Theophylline, a non-selective adenosine receptor antagonist, improves renal perfusion in the setting of hypoxia-ischemia and may offer therapeutic benefit in neonates with hypoxic-ischemic encephalopathy (HIE) undergoing hypothermia. We evaluated the pharmacokinetics and dose-exposure relationships of theophylline in this population to guide dosing strategies. METHODS A population pharmacokinetic analysis was performed in 22 neonates with HIE undergoing hypothermia who were part of a prospective study or retrospective chart review. Aminophylline (intravenous salt form of theophylline) was given per institutional standard of care for low urine output and/or rising serum creatinine (5 mg/kg intravenous (i.v.) load then 1.8 mg/kg i.v. q6h). The ability of different dosing regimens to achieve target concentrations (4-10 mg/L) associated with clinical response was examined. RESULTS Birth weight was a significant predictor of theophylline clearance and volume of distribution (p < 0.05). The median half-life was 39.5 h (range 27.2-50.4). An aminophylline loading dose of 7 mg/kg followed by 1.6 mg/kg q12h was predicted to achieve target concentrations in 84% of simulated neonates. CONCLUSIONS In neonates with HIE undergoing hypothermia, theophylline clearance was low with a 50% longer half-life compared to full-term normothermic neonates without HIE. Dosing strategies need to consider the unique pharmacokinetic needs of this population. IMPACT Theophylline is a potential renal-protective therapy in neonates with HIE undergoing therapeutic hypothermia; however, the pharmacokinetics and dose needs in this population are not known. Theophylline clearance was low in neonates with HIE undergoing therapeutic hypothermia with a 50% longer half-life compared to full-term normothermic neonates without HIE. As theophylline is advanced in clinical development, dosing strategies will need to consider the unique pharmacokinetic needs of neonates with HIE undergoing therapeutic hypothermia.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Krisa P Van Meurs
- Department of Pediatrics, Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - David R Drover
- Department Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Jelena Klawitter
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
| | - Uwe Christians
- Department of Anesthesiology, University of Colorado, Aurora, CO, USA
| | - Valerie Y Chock
- Department of Pediatrics, Neonatal and Developmental Medicine, Stanford University School of Medicine, Stanford, CA, USA
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19
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Murphy HJ, Thomas B, Van Wyk B, Tierney SB, Selewski DT, Jetton JG. Nephrotoxic medications and acute kidney injury risk factors in the neonatal intensive care unit: clinical challenges for neonatologists and nephrologists. Pediatr Nephrol 2020; 35:2077-2088. [PMID: 31605211 DOI: 10.1007/s00467-019-04350-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 08/21/2019] [Accepted: 09/02/2019] [Indexed: 02/07/2023]
Abstract
Neonatal acute kidney injury (AKI) is common. Critically ill neonates are at risk for AKI for many reasons including the severity of their underlying illnesses, prematurity, and nephrotoxic medications. In this educational review, we highlight four clinical scenarios in which both the illness itself and the medications indicated for their treatment are risk factors for AKI: sepsis, perinatal asphyxia, patent ductus arteriosus, and necrotizing enterocolitis. We review the available evidence regarding medications commonly used in the neonatal period with known nephrotoxic potential, including gentamicin, acyclovir, indomethacin, vancomycin, piperacillin-tazobactam, and amphotericin. We aim to illustrate the complexity of decision-making involved for both neonatologists and pediatric nephrologists when managing infants with these conditions and advocate for ongoing multidisciplinary collaboration in the development of better AKI surveillance protocols and AKI mitigation strategies to improve care for these vulnerable patients.
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Affiliation(s)
- Heidi J Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Brady Thomas
- Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
| | - Brynna Van Wyk
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA
| | - Sarah B Tierney
- Department of Pharmaceutical Care, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA, 52241, USA.
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20
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Peri-transplant aminophylline in pediatric kidney transplant recipients of donation after brain death: a double-blinded placebo-controlled randomized clinical trial. Pediatr Nephrol 2020; 35:1729-1736. [PMID: 32418145 DOI: 10.1007/s00467-020-04561-z] [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: 10/17/2019] [Revised: 03/23/2020] [Accepted: 03/30/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND During kidney transplantation, the transplanted kidney undergoes ischemia reperfusion injury, with adenosine being a major mediator. This study aimed to assess whether aminophylline, an adenosine receptor antagonist, improves early graft function and reduces incidence of delayed graft function (DGF) and slow graft function (SGF). METHODS Single center, double-blinded, placebo-controlled randomized clinical trial. Pediatric patients admitted for renal transplantation from donation after brain death donors were randomized into a treatment arm receiving aminophylline and a placebo arm receiving normal saline infusions. Primary outcome was estimated glomerular filtration rate (eGFR) at 5 days post-transplant. Secondary outcomes were rates of DGF/SGF and urinary neutrophil gelatinase-associated lipocalin (NGAL) levels. RESULTS Twenty-three patients were randomized to aminophylline and 27 to placebo. There was no difference in day 5 eGFR, rate of DGF/SGF, or urine NGAL/Creatinine level between aminophylline vs. placebo arm (eGFR 67.39 ± 38.9 ml/min/1.73m2 vs. 80.48 ± 52.1 ml/min/1.73m2p = 0.32; DGF/SGF 5/23 (21.7%) vs. 3/27 (11.1%) p = 0.31; urine NGAL/creatinine 300.5 ng/mg IQR 105.5-1464.5 ng/mg vs. 425.4 ng/mg IQR 140.3-1126.2 ng/mg, p = 0.95; respectively). At 12 months, there was 100% patient survival and 98% graft survival. eGFR at 12 months was similar between the two arms. CONCLUSIONS There was no benefit in peri-transplant aminophylline administration. Our results are limited by small sample size, since sample calculations were based on primary outcome of day 5 eGFR and low rate of DGF/SGF, which may have precluded us from demonstrating efficacy. Further clinical studies are necessary to determine any benefit of aminophylline in kidney transplant recipients, particularly from high-risk donors.
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21
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Saboute M, Balasi J, Tajalli S, Hajipour M, Heshmat S, Khalesi N, Allahqoli L. Effect of Aminophylline in Preventing Renal Dysfunction among Neonates with Prenatal Asphyxia: A Clinical Trial. ARCHIVES OF IRANIAN MEDICINE 2020; 23:312-318. [PMID: 32383615 DOI: 10.34172/aim.2020.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 01/26/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND As there are different views on the effects of aminophylline on neonatal renal function, we intended to observe the effects of aminophylline on renal dysfunction in neonates with prenatal asphyxia. METHODS This randomized trial was conducted in the Obstetrics and Gynecology Hospital, Tehran, Iran, from June 2016 to May 2017, in neonates with moderate to severe asphyxia during birth. Fifty-six neonates were divided randomly into two groups. The intervention group received one dose of 5mg/kg slow intravenous aminophylline injection and the placebo group received 2 mL/kg of intravenous 10% solution of dextrose saline during the first hour of life. They were monitored and compared for renal functional indices, electrolytes, and complications of asphyxia during the three days of life. RESULTS The mean of Cr (37.9 ± 8.8 vs 38.5 ± 9.4 and 20.8 ± 4.8 vs 30.1 ± 5.2 μmol/L), GFR (21.55 ± 4.7 vs 20.25 ± 4.4 and 30.8 ± 7.1 vs 20.1 ± 6.5 mL/minute/1.73 m2), Na (135.1 ± 12.4 vs134.5 ± 11.2 and 128.9 ± 11.5 vs 134.2 ± 10.9 mEq/L), and urine output (98.2 ± 25 vs 96.8 ± 23 and 148.7 ± 35 vs 108.8 ± 20 cc) were in the aminophylline treated and placebo group on the 1st and 3rd days, respectively. The mean difference of Cr (-9.3 (-8.9; -9.7) μmol/L); (P = 0.02), GFR (10.7 (10.1; 11.3) mL/minute/1.73 m2) (P = 0.009), Na (-5.3 (-5.9; -4.7) mEq/L) (P = 0.002), and urine volume (39.9 (24.9; 54.9) cc) (P = 0.001) presented statistically significant differences on the third day between the intervention and placebo group. CONCLUSION Aminophylline was effective in preventing renal dysfunction in neonates with asphyxia. Neonates who received aminophylline indicated a significant improvement in GFR and urine output on the first day of life.
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Affiliation(s)
- Maryam Saboute
- Department of Neonatology, Akbar Abadi Hospital, Iran University of Medical Sciences, (IUMS), Tehran, Iran
| | - Javad Balasi
- Department of Neonatology, Ali Asghar Hospital, Iran University of Medical Sciences, (IUMS), Tehran, Iran
| | - Saleheh Tajalli
- School of Nursing and Midwifery, Iran University of Medical Sciences, (IUMS), Tehran, Iran
| | - Mahmoud Hajipour
- Student Research Committee, Epidemiology Department, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shaghayegh Heshmat
- Department of Neonatology, Ali Asghar Hospital, Iran University of Medical Sciences, (IUMS), Tehran, Iran
| | - Nasrin Khalesi
- Department of Neonatology, Ali Asghar Hospital, Iran University of Medical Sciences, (IUMS), Tehran, Iran
| | - Leila Allahqoli
- Endometriosis Research Center, Iran University of Medical Sciences (IUMS), Tehran, Iran
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22
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Flores S, Culichia CN, Villarreal EG, Savorgnan F, Checchia PA, Loomba RS. Xanthine Derivatives for Kidney Protection in the Critically Ill Pediatric Population: A Systematic Review. J Pediatr Intensive Care 2020; 9:155-161. [PMID: 32685242 DOI: 10.1055/s-0040-1705178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/27/2020] [Indexed: 10/24/2022] Open
Abstract
Different types of diuretics have been used to minimize fluid overload after resuscitation. This meta-analysis determined the effects of xanthine derivatives on creatinine, creatinine clearance, and urine output. Studies included data from pediatric patients, whoused theophylline or aminophylline, and included pre- and postxanthine data for at least one of the outcomes of interest. A total of 13 studies with 198 patients were included in the pooled analyses. The study recorded data prior, and a mean of 36 hours after xanthine administration. This meta-analysis demonstrates that xanthine derivatives in critically ill children, using a dose of approximately5 mg/kg, lead to a statistically significant increase in creatinine clearance and urine output without significantly altering serum creatinine. Xanthine derivatives may be beneficial for fluid management in critically ill children. Further studies are warranted assessing the association with additional clinical outcomes.
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Affiliation(s)
- Saul Flores
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, United States
| | - Corissa N Culichia
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, Illinois, United States
| | - Enrique G Villarreal
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, United States.,Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Monterrey, Nuevo Leon, Mexico
| | - Fabio Savorgnan
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, United States
| | - Paul A Checchia
- Division of Critical Care and Cardiology, Department of Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas, United States
| | - Rohit S Loomba
- Division of Cardiology, Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, Illinois, United States
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23
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Bellos I, Pandita A, Yachha M. Effectiveness of theophylline administration in neonates with perinatal asphyxia: a meta-analysis. J Matern Fetal Neonatal Med 2019; 34:3080-3088. [PMID: 31558088 DOI: 10.1080/14767058.2019.1673722] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIM To evaluate the effects of prophylactic theophylline in renal function and survival rates of asphyxiated newborns. METHODS Medline, Scopus, Cochrane Central Register of Controlled Trials, Clinicaltrials.gov and Google Scholar databases were systematically searched. All randomized controlled trials evaluating the efficacy of theophylline in the prevention of perinatal asphyxia were selected. RESULTS A total of seven studies were included with a total of 458 asphyxiated neonates. Incidence of acute kidney injury was significantly lower in neonates receiving theophylline (OR: 0.24, 95% CI: [0.16, 0.36]), while mortality rates were similar between the two groups (OR: 0.86, 95% CI: [0.46, 1.62]). Theophylline administration was associated with significantly decreased serum creatinine levels (MD: -0.57 mg/dl, 95% CI: [-0.68, -0.46]) and elevated glomerular filtration rate (MD: 13.79 ml/min/1.73 m2, 95% CI: [11.91, 15.68]) in the third day of life. Theophylline also lead to lower β2-microglobulin levels, higher urine output and negative fluid balance. CONCLUSIONS The present findings suggest the effectiveness of theophylline in ameliorating renal function of asphyxiated neonates. Future large-scale trials should assess potential long-term adverse outcomes in clinical practice.KeynotesAsphyxia is a major cause of acute kidney injury in neonatesAcute kidney injury is associated with adverse clinical outcomes in asphyxiated neonates.Theophylline administration leads to significantly lower incidence of acute kidney injury in asphyxiated neonates.
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Affiliation(s)
- Ioannis Bellos
- Laboratory of Experimental Surgery and Surgical Research NS Christeas, Athens University Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Aakash Pandita
- Department of Neonatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Monika Yachha
- Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Bhatt GC, Gogia P, Bitzan M, Das RR. Theophylline and aminophylline for prevention of acute kidney injury in neonates and children: a systematic review. Arch Dis Child 2019; 104:670-679. [PMID: 30798259 DOI: 10.1136/archdischild-2018-315805] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 11/26/2018] [Accepted: 01/22/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of theophylline or aminophylline for prevention of acute kidney injury (AKI) in neonates and children. DESIGN Systematic review and meta-analysis with application of Grading of Recommendations, Assessment, Development and Evaluation system. DATA SOURCES PubMed/MEDLINE, Embase, Google Scholar and Cochrane renal group were searched from 1970 to May 2018. ELIGIBILITY CRITERIA Randomised clinical trials and quasi-randomised trials comparing the efficacy and safety of prophylactic theophylline or aminophylline for prevention of AKI in neonates and children were included. The primary outcomes were: incidence of AKI, serum creatinine levels and all-cause mortality. RESULTS A total of nine trials were included in the qualitative synthesis. Six trials including 436 term neonates with birth asphyxia who received a single dose of theophylline were finally included in the meta-analysis. The pooled estimate showed 60% reduction in the incidence of AKI in neonates with severe birth asphyxia (RR: 0.40; 95% CI 0.3 to 0.54; heterogeneity: I2=0%) (moderate quality evidence), decrease in serum creatinine over days 2-5 (very low to low quality evidence) without significant difference in all-cause mortality (RR: 0.88; 95% CI 0.52 to 1.50; heterogeneity: I2=0%) (very low-quality evidence). A significant difference in the negative fluid balance, increase in GFR and decrease in urinary β2 microglobulin was seen in favour of theophylline. CONCLUSION AND RELEVANCE A single dose of prophylactic theophylline helps in prevention of AKI/severe renal dysfunction in term neonates with severe birth asphyxia (moderate quality evidence) without increasing the risk of complications and without affecting all-cause mortality (very low-quality evidence). TRIAL REGISTRATION NUMBER CRD 42017073600.
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Affiliation(s)
- Girish Chandra Bhatt
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Priya Gogia
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
| | - Martin Bitzan
- Department of Pediatrics, Division of Nephrology, Montreal Children's Hospital and McGill University, Montreal, Quebec, Canada
| | - Rashmi Ranjan Das
- Department of Pediatrics, All India Institute of Medical Sciences (AIIMS), Bhubaneswar, Odisha, India
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Aviles-Otero N, Kumar R, Khalsa DD, Green G, Carmody JB. Caffeine exposure and acute kidney injury in premature infants with necrotizing enterocolitis and spontaneous intestinal perforation. Pediatr Nephrol 2019; 34:729-736. [PMID: 30415418 DOI: 10.1007/s00467-018-4140-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 10/06/2018] [Accepted: 11/06/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in preterm infants, but specific therapies remain scarce. Recent studies have demonstrated an association between caffeine exposure and less frequent AKI in the first 7-10 days after birth. We hypothesized that patients with necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) would provide a better natural model of AKI to evaluate this association. METHODS We reviewed all premature patients diagnosed with NEC or SIP at our institution from 2008 to 2014. AKI was defined by change in serum creatinine using the neonatal Kidney Disease: Improving Global Outcomes definition. Caffeine was prescribed for apnea of prematurity and caffeine exposure was determined by chart review. RESULTS A total of 146 patients with NEC/SIP were reviewed. Of these, 119 (81.5%) received caffeine, and 91 (62.3%) developed AKI. AKI occurred less frequently in patients who received caffeine than in those who did not (55.5% vs. 92.6%; odds ratio (OR) 0.10; 95% confidence interval (CI) 0.02-0.44). This association persisted in multivariable models after adjustment for potential confounders (adjusted OR 0.08; 95% CI 0.01-0.42; number needed to be exposed to caffeine to prevent one case of AKI = 2.6). Although baseline serum creatinine did not differ by caffeine exposure, patients receiving caffeine had lower peak creatinine (median 1.0 mg/dl vs. 1.5 mg/dl; p = 0.008) and absolute creatinine change (median 0.42 mg/dl vs. 0.68 mg/dl; p = 0.003) than those who did not. CONCLUSIONS Caffeine exposure in preterm infants with NEC/SIP is associated with decreased incidence and severity of AKI.
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Affiliation(s)
- Noelia Aviles-Otero
- Department of Pediatrics, Division of Neonatology, University of Virginia, Charlottesville, VA, USA
| | - Reeti Kumar
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Dev Darshan Khalsa
- Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - Glen Green
- Department of Pediatrics, Division of Neonatology, Eastern Virginia Medical School, Norfolk, VA, USA
| | - J Bryan Carmody
- Department of Pediatrics, Division of Nephrology, Eastern Virginia Medical School, 601 Children's Lane, Norfolk, VA, 23507, USA.
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Kasdorf E, Perlman JM. General Supportive Management of the Term Infant With Neonatal Encephalopathy Following Intrapartum Hypoxia-Ischemia. Neurology 2019. [DOI: 10.1016/b978-0-323-54392-7.00005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Kirkley MJ, Boohaker L, Griffin R, Soranno DE, Gien J, Askenazi D, Gist KM. Acute kidney injury in neonatal encephalopathy: an evaluation of the AWAKEN database. Pediatr Nephrol 2019; 34:169-176. [PMID: 30155763 PMCID: PMC6986688 DOI: 10.1007/s00467-018-4068-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is common in neonatal encephalopathy (NE) and is associated with worse outcomes. Our objectives were to determine the incidence, risk factors, and outcomes of AKI in infants with NE. METHODS We performed a retrospective analysis of infants ≥ 34 weeks' gestational age with a diagnosis of NE from the Analysis of Worldwide Acute Kidney injury Epidemiology in Neonates (AWAKEN) database. AKI was defined using the modified Kidney Disease Improving Global Outcomes criteria. Perinatal and postnatal factors were evaluated. Multivariate logistic and linear regressions were performed. RESULTS One hundred and thirteen patients with NE were included. 41.6% (47) developed AKI. Being born outside the admitting institution (OR 4.3; 95% CI 1.2-14.8; p = 0.02), intrauterine growth restriction (OR 10.3, 95% CI 1.1-100.5; p = 0.04), and meconium at delivery (OR 2.8, 95% CI 1.04-7.7; p = 0.04) conferred increased odds of AKI. After controlling for confounders, infants with AKI stayed in the hospital an average of 8.5 days longer than infants without AKI (95% CI 0.79-16.2 days; p = 0.03). CONCLUSIONS In this multi-national analysis, several important perinatal factors were associated with AKI and infants with both NE and AKI had longer length of stay than NE alone. Future research aimed at early AKI detection, renoprotective management strategies, and understanding the long-term renal consequences is warranted in this high-risk group of patients.
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Affiliation(s)
- Megan J. Kirkley
- Section of Neonatology, University of Colorado Department of Pediatrics, Aurora, Colorado
| | - Louis Boohaker
- Pediatric and Infant Center for Acute Nephrology, University of Alabama, Birmingham, Alabama
| | - Russell Griffin
- Department of Epidemiology, University of Alabama, Birmingham, Alabama
| | - Danielle E. Soranno
- Section of Nephrology, University of Colorado Department of Pediatrics, Aurora, Colorado
| | - Jason Gien
- Section of Neonatology, University of Colorado Department of Pediatrics, Aurora, Colorado
| | - David Askenazi
- Pediatric and Infant Center for Acute Nephrology, University of Alabama Department of Pediatrics, Birmingham, Alabama
| | - Katja M. Gist
- Section of Pediatric Cardiology, University of Colorado Department of Pediatrics, Aurora, Colorado
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Harer MW, Askenazi DJ, Boohaker LJ, Carmody JB, Griffin RL, Guillet R, Selewski DT, Swanson JR, Charlton JR. Association Between Early Caffeine Citrate Administration and Risk of Acute Kidney Injury in Preterm Neonates: Results From the AWAKEN Study. JAMA Pediatr 2018; 172:e180322. [PMID: 29610830 PMCID: PMC6137530 DOI: 10.1001/jamapediatrics.2018.0322] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/31/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Matthew W. Harer
- Division of Neonatology, Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin–Madison
| | - David J. Askenazi
- Division of Nephrology, Department of Pediatrics, The University of Alabama at Birmingham
| | - Louis J. Boohaker
- Division of Nephrology, Department of Pediatrics, The University of Alabama at Birmingham
| | - J. Bryan Carmody
- Division of Nephrology, Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Russell L. Griffin
- Division of Nephrology, Department of Pediatrics, The University of Alabama at Birmingham
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children’s Hospital, University of Rochester, Rochester, New York
| | - David T. Selewski
- Division of Nephrology, Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor
| | - Jonathan R. Swanson
- Division of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville
| | - Jennifer R. Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville
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Raina A, Pandita A, Harish R, Yachha M, Jamwal A. Treating perinatal asphyxia with theophylline at birth helps to reduce the severity of renal dysfunction in term neonates. Acta Paediatr 2016; 105:e448-51. [PMID: 27173369 DOI: 10.1111/apa.13469] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/14/2016] [Accepted: 05/10/2016] [Indexed: 11/30/2022]
Abstract
AIM Perinatal asphyxia is a common neonatal problem and contributes significantly to neonatal morbidity and mortality. This study was designed to determine whether theophylline could prevent or ameliorate renal dysfunction in term neonates with perinatal asphyxia. METHODS We randomised 159 severely asphyxiated term newborns to receive a single dose of 5 mg/kg intravenous theophylline (n = 78) or a placebo (n = 81) during the first hour of life. The infant's 24-hour fluid intake, urine volume, serum creatinine, creatinine clearance and sodium excretion were recorded during days one, three and five of life, starting 12 hours after the theophylline or placebo infusion. RESULTS Neonates in the theophylline group had lower serum creatinine levels (0.83 ± 0.35 versus 1.47 ± 0.61; p = 0.00) and higher endogenous creatinine clearance (32.16 ± 16.34 versus 17.73 ± 7.92; p = 0.00) than the placebo group. Severe renal dysfunction, namely acute kidney injury, was present in 36 (15%) of the neonates in the theophylline group versus 117 (48%) in the placebo group (p < 0.01). CONCLUSION A single dose of intravenous theophylline administered to term neonates with perinatal asphyxia within the first hour of life significantly decreased serum creatinine levels and significantly increased creatinine clearance.
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Affiliation(s)
- Alok Raina
- Department of Pediatrics; SMGS Hospital; Government Medical College; Jammu Jammu and Kashmir India
| | - Aakash Pandita
- Department of Pediatrics; SMGS Hospital; Government Medical College; Jammu Jammu and Kashmir India
| | - Rekha Harish
- Department of Pediatrics; SMGS Hospital; Government Medical College; Jammu Jammu and Kashmir India
| | | | - Ashu Jamwal
- Department of Pediatrics; SMGS Hospital; Government Medical College; Jammu Jammu and Kashmir India
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Comparison of Intraoperative Aminophylline Versus Furosemide in Treatment of Oliguria During Pediatric Cardiac Surgery. Pediatr Crit Care Med 2016; 17:753-63. [PMID: 27355823 PMCID: PMC5515381 DOI: 10.1097/pcc.0000000000000834] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To determine if intraoperative aminophylline was superior to furosemide to prevent or attenuate postoperative cardiac surgery-associated acute kidney injury. DESIGN Single-center, historical control, retrospective cohort study. SETTING PICU, university-affiliated children's hospital. PATIENTS Children with congenital heart disease in PICU who received furosemide or aminophylline to treat intraoperative oliguria. INTERVENTIONS Intraoperative oliguria was treated either with furosemide (September 2007 to February 2012) or with aminophylline (February 2012 to June 2013). The postoperative 48 hours renal outcomes of the aminophylline group were compared with the furosemide group. The primary outcomes were acute kidney injury and renal replacement therapy use at 48 hours postoperatively. Surgical complexity was accounted for by the use of Risk Adjustment for Congenital Heart Surgery-1 score. MEASUREMENTS AND MAIN RESULTS The study involves 69 months of observation. There were 200 cases younger than 21 years old reviewed for this study. Eighty-five cases (42.5%) developed acute kidney injury. The aminophylline group patients produced significantly more urine (mL/kg/hr) during the first 8 hours postoperatively than furosemide patients (5.1 vs 3.4 mL/kg/hr; p = 0.01). The urine output at 48 hours postoperatively was similar between the two groups. There was no difference in acute kidney injury incidence at 48 hours between the aminophylline and furosemide groups (38% vs 47%, respectively; p = 0.29). Fewer aminophylline group subjects required renal replacement therapy compared to the furosemide group subjects (n = 1 vs 7, respectively; p = 0.03). In the multi-variant predictive model, intraoperative aminophylline infusion was noted as a negative predictive factor for renal replacement therapy, but not for cardiac surgery-associated acute kidney injury. CONCLUSION The intraoperative use of aminophylline was more effective than furosemide in reversal of oliguria in the early postoperative period. There were less renal replacement therapy-requiring acute kidney injury in children in the aminophylline group. Future prospective studies of intraoperative aminophylline to prevent cardiac surgery-associated acute kidney injury may be warranted.
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Carmody JB, Harer MW, Denotti AR, Swanson JR, Charlton JR. Caffeine Exposure and Risk of Acute Kidney Injury in a Retrospective Cohort of Very Low Birth Weight Neonates. J Pediatr 2016; 172:63-68.e1. [PMID: 26898806 DOI: 10.1016/j.jpeds.2016.01.051] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Revised: 11/25/2015] [Accepted: 01/20/2016] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- J Bryan Carmody
- Division of Nephrology, Department of Pediatrics, Eastern Virginia Medical School, Norfolk, VA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, VA
| | - Anna R Denotti
- Department of Pediatrics, Ospedale Regionale per le Microcitemie, University of Cagliari, Cagliari, Italy
| | - Jonathan R Swanson
- Division of Neonatology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, VA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia Children's Hospital, Charlottesville, VA.
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Frymoyer A, Su F, Grimm PC, Sutherland SM, Axelrod DM. Theophylline Population Pharmacokinetics and Dosing in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass. J Clin Pharmacol 2016; 56:1084-93. [PMID: 26712558 DOI: 10.1002/jcph.697] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 12/17/2015] [Indexed: 01/11/2023]
Abstract
Children undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) frequently develop acute kidney injury due to renal ischemia. Theophylline, which improves renal perfusion via adenosine receptor inhibition, is a potential targeted therapy. However, children undergoing cardiac surgery and CPB commonly have alterations in drug pharmacokinetics. To help understand optimal aminophylline (salt formulation of theophylline) dosing strategies in this population, a population-based pharmacokinetic model was developed using nonlinear mixed-effects modeling (NONMEM) from 71 children (median age 5 months; 90% range 1 week to 10 years) who underwent cardiac surgery requiring CPB and received aminophylline as part of a previous randomized controlled trial. A 1-compartment model with linear elimination adequately described the pharmacokinetics of theophylline. Weight scaled via allometry was a significant predictor of clearance and volume. In addition, allometric scaled clearance increased with age implemented as a power maturation function. Compared to prior reports in noncardiac children, theophylline clearance was markedly reduced across age. In the final population pharmacokinetic model, optimized empiric dosing regimens were developed via Monte Carlo simulations. Doses 50% to 75% lower than those recommended in noncardiac children were needed to achieve target serum concentrations of 5 to 10 mg/L.
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Affiliation(s)
- Adam Frymoyer
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Felice Su
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | - Paul C Grimm
- Department of Pediatrics, Stanford University, Stanford, CA, USA
| | | | - David M Axelrod
- Department of Pediatrics, Stanford University, Stanford, CA, USA
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A Double-Blinded, Randomized, Placebo-Controlled Clinical Trial of Aminophylline to Prevent Acute Kidney Injury in Children Following Congenital Heart Surgery With Cardiopulmonary Bypass. Pediatr Crit Care Med 2016; 17:135-43. [PMID: 26669642 PMCID: PMC4740222 DOI: 10.1097/pcc.0000000000000612] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Acute kidney injury occurs commonly in children following congenital cardiac surgery with cardiopulmonary bypass and has been associated with increased morbidity and mortality. Aminophylline, a methylxanthine nonselective adenosine receptor antagonist, has been effective in the management of acute kidney injury in certain populations. This study sought to determine whether postoperative administration of aminophylline attenuates acute kidney injury in children undergoing congenital cardiac surgery with cardiopulmonary bypass. DESIGN Single-center, double-blinded, placebo-controlled, randomized clinical trial. SETTING Tertiary center, pediatric cardiovascular ICU. PATIENTS A total of 144 children after congenital heart surgery with cardiopulmonary bypass. INTERVENTIONS Seventy-two patients were randomized to receive aminophylline and 72 patients received placebo. Study drug was administered every 6 hours for 72 hours. MEASUREMENTS AND MAIN RESULTS The primary outcome variable was the development of any acute kidney injury, defined by the serum creatinine criteria of the Kidney Diseases: Improving Global Outcomes. Secondary outcomes included the development of severe acute kidney injury, time between cardiovascular ICU admission and first successful extubation, percent fluid overload, total fluid balance, urine output, bioelectrical impedance, and serum neutrophil gelatinase-associated lipocalin. The unadjusted rate and severity of acute kidney injury were not different between groups; 43 of 72 (60%) of the treatment group and 36 of 72 (50%) of the placebo group developed acute kidney injury (p = 0.32). Stage 2/3 acute kidney injury occurred in 23 of 72 (32%) of the treatment group and 15 of 72 (21%) of the placebo group (p = 0.18). Secondary outcome measures also demonstrated no significant difference between treatment and placebo groups. Aminophylline administration was safe; no deaths occurred in either group, and rates of adverse events were similar (14% in the treatment group vs 18% in the placebo group; p = 0.30). CONCLUSIONS In this placebo-controlled randomized clinical trial, we found no effect of aminophylline to prevent acute kidney injury in children recovering from cardiac surgery performed with cardiopulmonary bypass. Future study of preoperative aminophylline administration to prevent acute kidney injury may be warranted.
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Role of methylxanthines in preventing acute renal failure in hypoxic newborns. APOLLO MEDICINE 2015. [DOI: 10.1016/j.apme.2015.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ozturk SA, Ceylan C, Serel TA, Doluoglu OG, Soyupek AS, Guzel A, Özorak A, Uz E, Savas HB, Baspinar S. Protective effect of theophylline on renal functions in experimental pneumoperitoneum model. Ren Fail 2015; 37:1044-9. [PMID: 25959022 DOI: 10.3109/0886022x.2015.1040706] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Our objective in this experimental study is to research the effect of the intra-abdominal pressure which rises following pneumoperitoneum and whether Theophylline has a possible protective activity on this situation. In our study, 24 Wistar Albino rats were used. Rats were divided into two groups. The first group was set for only pneumoperitoneum model. The second group was given 15 mg/kg of Theophylline intraperitoneally before setting pneumoperitoneum model. Then urea, creatinine, cystatin-C, tissue and serum total antioxidant capacity, total oxidant capacity and oxidative stress index in two groups were measured and compared with each other. Apoptosis and histopathological conditions in the renal tissues were examined. The differences between the groups were analyzed with the Mann-Whitney U test. Results were considered significant at p < 0.05. No statistically significant difference was determined between tissue and serum averages in two groups in terms of TAS, TOS and OSI values (p > 0.05). The mean value of urea were similar in pneumoperitoneum and pneumoperitoneum + theophylline groups (p = 0.12). The mean cystatin-C value was 2.2 ± 0.3 µg/mL in pneumoperitoneum, 1.74 ± 0.33 µg/mL in pneumoperitoneum + theophylline (p = 0.002). According to our study, lower cystatin-C levels in the group, where Theophylline was given, are suggestive of lower renal injury in this group. However, this opinion is interrogated as there is no difference in terms of tissue and serum TAS, TOS, OSI and urea values between the groups.
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Affiliation(s)
- Sefa Alperen Ozturk
- a Department of Urology Clinic , Suleyman Demirel University, Medical Faculty , Isparta , Turkey
| | - Cavit Ceylan
- b Department of Urology Clinic , Yüksek Ihtisas Training and Research Hospital , Ankara , Turkey
| | - Tekin Ahmet Serel
- a Department of Urology Clinic , Suleyman Demirel University, Medical Faculty , Isparta , Turkey
| | - Omer Gokhan Doluoglu
- c Department of Urology Clinic , Ankara Training and Research Hospital , Ankara , Turkey
| | - Arap Sedat Soyupek
- a Department of Urology Clinic , Suleyman Demirel University, Medical Faculty , Isparta , Turkey
| | - Ahmet Guzel
- a Department of Urology Clinic , Suleyman Demirel University, Medical Faculty , Isparta , Turkey
| | - Alper Özorak
- a Department of Urology Clinic , Suleyman Demirel University, Medical Faculty , Isparta , Turkey
| | - Efkan Uz
- d Department of Biochemistry , and
| | | | - Sirin Baspinar
- e Department of Pathology , Medical Faculty, Suleyman Demirel University , Isparta , Turkey
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Ashraf M, Shahzad N, Irshad M, Hussain SQ, Ahmed P. Pediatric acute kidney injury: A syndrome under paradigm shift. Indian J Crit Care Med 2014; 18:518-26. [PMID: 25136191 PMCID: PMC4134626 DOI: 10.4103/0972-5229.138156] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The recent standardization and validation of definitions of pediatric acute kidney injury (pAKI) has ignited new dimensions of pAKI epidemiology and its risk factors. pAKI causes increased morbidity and mortality in critically ill-children. Among the hospitalized patients incidence of pAKI ranges from 1% to 31%, while mortality ranges from 28% to 82%, presenting a broad range due to lack of uniformly acceptable pAKI definition. In addition, cumulative data regarding the progression of pAKI to chronic kidney disease in children is rising. Despite these alarming figures, treatment modalities have failed to deliver significantly. In this review, we will summarize the latest developments of pAKI and highlight important aspects of pAKI management.
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Affiliation(s)
- Mohd Ashraf
- Pediatric Nephrology Division, Department of Pediatrics, GB Pant Hospital, Government Medical College Srinagar, Jammu and Kashmir, India
| | - Naveed Shahzad
- Pediatric Nephrology Division, Department of Pediatrics, GB Pant Hospital, Government Medical College Srinagar, Jammu and Kashmir, India
| | - Mohd Irshad
- Pediatric Nephrology Division, Department of Pediatrics, GB Pant Hospital, Government Medical College Srinagar, Jammu and Kashmir, India
| | - Sheikh Quyoom Hussain
- Pediatric Nephrology Division, Department of Pediatrics, GB Pant Hospital, Government Medical College Srinagar, Jammu and Kashmir, India
| | - Parvez Ahmed
- Pediatric Nephrology Division, Department of Pediatrics, GB Pant Hospital, Government Medical College Srinagar, Jammu and Kashmir, India
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Symons JM. Moving beyond supportive care--current status of specific therapies in pediatric acute kidney injury. Pediatr Nephrol 2014; 29:173-81. [PMID: 23407998 DOI: 10.1007/s00467-013-2425-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 01/19/2013] [Accepted: 01/22/2013] [Indexed: 12/29/2022]
Abstract
Acute kidney injury (AKI) remains a significant challenge, leading to increased morbidity, mortality, and medical costs. Therapy for AKI to this point has largely been supportive; specific interventions to treat established AKI have had minimal effect. Review of the pathogenesis of AKI reveals complex, interacting mechanisms, including changes in microcirculation, the immune system, and inflammation, and cell death from both necrosis and apoptosis. Past definitions of AKI have been imprecise; newer methods for AKI identification and classification, including novel biomarkers and improved criteria for defining AKI, may permit earlier intervention with greater potential for success. With improved understanding of pathophysiology and the opportunity for intervention before AKI is fully established, clinicians may be able to move beyond supportive care and improve outcomes.
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Affiliation(s)
- Jordan M Symons
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA,
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Abstract
OBJECTIVE To determine if aminophylline administration is associated with improved creatinine clearance and greater urine output in children with acute kidney injury in the cardiovascular ICU. DESIGN Single-center retrospective cohort study. SETTING Pediatric cardiovascular ICU, university-affiliated children's hospital. PATIENTS Children with congenital or acquired heart disease in the cardiovascular ICU who received aminophylline to treat oliguric acute kidney injury and fluid overload. INTERVENTIONS Patients received aminophylline after consultation with a pediatric nephrologist. Data were collected retrospectively over 7 days to assess if aminophylline was associated with improvement in creatinine clearance, urine output, and fluid overload. MEASUREMENTS AND MAIN RESULTS Thirty-one patients received 52 aminophylline courses. Over the 7-day study period, serum creatinine decreased from a mean of 1.13 ± 0.91 to 0.87 ± 0.83 mg/dL (-0.05 mg/dL/d, p < 0.001). A concomitant increase was seen in estimated glomerular filtration rate from a mean of 50.0 ± 30.0 to 70.6 ± 58.1 mL/min/1.73 m (+3.66 mL/min/1.73 m/d, p < 0.001). Average daily urine output increased by 0.22 mL/kg/hr (p < 0.001), and fluid overload decreased on average by 0.42% per day in the 7-day study period (p = 0.005). Although mean furosemide dose increased slightly (0.12 mg/kg/d, p = 0.01), hydrochlorothiazide dosing did not significantly change over the study period. There were no complications related to aminophylline administration. CONCLUSIONS Our study suggests that aminophylline therapy may be associated with significantly improved renal excretory function and may augment urine output in children who experience oliguric acute kidney injury in the cardiovascular ICU. Additionally, we did not identify any aminophylline-related side effects in this high-risk cardiac population. Future prospective studies are necessary to confirm the safety profile and to ensure that the beneficial effects are independent of other clinical interventions.
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Treiber M, Gorenjak M, Pecovnik Balon B. Serum cystatin-C as a marker of acute kidney injury in the newborn after perinatal hypoxia/asphyxia. Ther Apher Dial 2013; 18:57-67. [PMID: 24499085 DOI: 10.1111/1744-9987.12054] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We evaluated cystatin-C (cysC) in the umbilical blood as a predictor of acute kidney injury (AKI) after perinatal hypoxia/asphyxia compared with creatinine (Cr). One hundred full-term newborns were enrolled in the study (50 in a group affected by perinatal hypoxia/asphyxia [AS] and 50 controls). CysC and Cr were measured in blood samples from the umbilical cord at birth (cysC-umb and Cr-umb) and from a peripheral vein 3 days later (cysC-3 and Cr-3). At birth, the mean level of cysC in healthy term babies was found to be 1.39 ± 0.19 mg/L and 1.34 ± 0.21 mg/L after 3 days of life, not significantly decreased (P = 0.137). The mean of cysC in the AS group was 2.12 ± 0.53 mg/L in cord blood and 1.56 ± 0.32 g/L in day 3 blood samples, also decreased (P < 0.001) and different from the control (P < 0.001). Cr levels, determined simultaneously at birth were different (P = 0.001) between the control (62.74 ± 12.84 μmol/L) and AS (72.60 ± 15.55 μmol/L) group, significantly decreased after 3 days in both groups (P < 0.001). The receiver-operating characteristic curve analysis, comparing AS and the control group, showed area under the curve for cysC-umb, cysC-3, Cr-umb and Cr-3 (0.918; 0.698; 0.692; 0.660). The highest diagnostic accuracy was achieved with a chosen cut-off for cysC-umb of 1.67 mg/L (sensitivity of 84.0%, specificity of 90.0%) or 1.69 mg/L (sensitivity of 82.0%, specificity of 94.0%). Our results indicate serum CysC is a more sensitive marker of glomerular filtration rate than Cr in the newborns.
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Affiliation(s)
- Milena Treiber
- Clinical Department of Gynecology and Perinatology, Unit of Neonatology, Maribor, Slovenia
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Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, Tolwani AJ, Waikar SS, Weisbord SD. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury. Am J Kidney Dis 2013; 61:649-72. [DOI: 10.1053/j.ajkd.2013.02.349] [Citation(s) in RCA: 439] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 01/22/2023]
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Prophylactic theophylline for the prevention of severe renal dysfunction in term and post-term neonates with perinatal asphyxia: a systematic review and meta-analysis of randomized controlled trials. J Perinatol 2013; 33:271-7. [PMID: 22836872 DOI: 10.1038/jp.2012.97] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the effect of prophylactic theophylline for the prevention of severe renal dysfunction in post-asphyxiated term and post-term infants. STUDY DESIGN Systematic review and meta-analysis of randomized controlled trials (RCTs) comparing prophylactic theophylline vs placebo in term infants following perinatal asphyxia. RESULT Four RCTs involving 197 infants were included in the meta-analysis. Compared with placebo, prophylactic theophylline was associated with a significant reduction in the incidence of severe renal dysfunction (pooled relative risk) using fixed-effects model was 0.38 (95% confidence interval, 0.25 to 0.57; P<0.001). CONCLUSION The meta-analysis provides evidence that prophylactic theophylline significantly reduce the incidence of severe renal dysfunction. However, because of the lack of information on the long-term renal and neurodevelopmental outcome and measured theophylline levels with relation to adverse effects observed, prudence with the clinical use of prophylactic theophylline is required. Additionally, the included trials were prior to the era of therapeutic hypothermia and thus inference of renal benefit in an infant undergoing hypothermia therapy cannot be made.
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Kellum JA, Lameire N. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:204. [PMID: 23394211 PMCID: PMC4057151 DOI: 10.1186/cc11454] [Citation(s) in RCA: 1602] [Impact Index Per Article: 145.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a common and serious problem affecting millions and causing death and disability for many. In 2012, Kidney Disease: Improving Global Outcomes completed the first ever, international, multidisciplinary, clinical practice guideline for AKI. The guideline is based on evidence review and appraisal, and covers AKI definition, risk assessment, evaluation, prevention, and treatment. In this review we summarize key aspects of the guideline including definition and staging of AKI, as well as evaluation and nondialytic management. Contrast-induced AKI and management of renal replacement therapy will be addressed in a separate review. Treatment recommendations are based on systematic reviews of relevant trials. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendations Assessment, Development and Evaluation approach. Limitations of the evidence are discussed and a detailed rationale for each recommendation is provided.
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Abstract
The interruption of placental blood flow induces circulatory responses to maintain cerebral, cardiac, and adrenal blood flow with reduced renal, hepatic, intestinal, and skin blood flow. If placental compromise is prolonged and/or severe, total circulatory failure is likely with cerebral hypoperfusion and resultant hypoxic ischemic cerebral injury with collateral renal, cardiac, and hepatic injury. Management strategies should be targeted at restoring cerebral perfusion and oxygen delivery and minimizing the extent of secondary injury. Specifically, the focus should include the judicious use of supplemental oxygen, avoidance of hypoglycemia and elevated temperature in the delivery room, and the early administration of therapeutic hypothermia to high-risk infants.
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Affiliation(s)
- Jeffrey M Perlman
- Division of Newborn Medicine, Department of Pediatrics, Weill Cornell Medical College, 525 East 68th Street, Suite N-506, New York, NY 10065, USA.
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Lynch BA, Gal P, Ransom JL, Carlos RQ, Dimaguila MAVT, Smith MS, Wimmer JE, Imm MD. Low-dose aminophylline for the treatment of neonatal non-oliguric renal failure-case series and review of the literature. J Pediatr Pharmacol Ther 2012; 13:80-7. [PMID: 23055869 DOI: 10.5863/1551-6776-13.2.80] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Aminophylline is a methylxanthine with multiple physiologic actions. At low doses, aminophylline can antagonize adenosine and improve renal function via increased glomerular filtration rate. Despite its clinical use, little data exists in neonates for this indication. Therefore, the objective of this report is to describe the impact of aminophylline on renal function indices in a series of neonates with acute renal failure. MATERIALS AND METHODS This was a retrospective chart review of 13 neonates with acute renal failure who received aminophylline during a 15-month study period. Aminophylline was administered at 1 mg/kg intravenously or orally every twelve hours. Forty-six percent (n = 6) of the patients received a 5 mg/kg loading dose before initiation of maintenance therapy. Most patients had already received other treatments for renal failure, including diuretics and dopamine. RESULTS Resolution of acute renal failure (with normalization of serum creatinine and blood urea nitrogen) was documented in 10 patients (77%). Four of the thirteen patients died from complications due to their prematurity. Failure of low-dose aminophylline was observed in 3 of the 4 patients who died. CONCLUSIONS Low-dose aminophylline in neonates with acute renal failure is associated with an improvement in renal function indices.
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Affiliation(s)
- Bethany A Lynch
- Departments of Neonatal Medicine and Pharmacy, Women's Hospital, Greensboro, North Carolina
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Abstract
BACKGROUND Lung edema may complicate respiratory distress syndrome (RDS) in preterm infants. OBJECTIVES The aim of this review was to assess the risks and benefits of diuretic administration in preterm infants with RDS. SEARCH METHODS The standard search method of the Cochrane Neonatal Review Group was used. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), MEDLINE and EMBASE were searched. These searches were updated in April 2003, March 2007, January 2011. In addition, the abstract books of the American Thoracic Society and Society for Pediatric Research were searched. MEDLINE and CENTRAL search was conducted using the keyword "Respiratory Distress Syndrome" alone, to find studies of medications recently classified as diuretics, such as theophylline. In addition, EMBASE, controlled-trials.com and clinicaltrials.gov searches were completed in January 2011. MEDLINE search updated to August 2011. SELECTION CRITERIA Trials were included in which preterm infants with RDS and less than five days of age were randomly allocated to diuretic administration. Of those trials, studies were only included in which at least one of the following outcomes measures was evaluated: mortality, patent ductus arteriosus, hypovolemic shock, intraventricular hemorrhage, renal failure, duration of oxygen supplementation, duration of mechanical ventilation, need for oxygen supplementation at 28 days of life, oxygen supplementation at 36 weeks of postmenstrual age (gestational age + postnatal age), length of stay, number of rehospitalizations during the first year of life, and neurodevelopmental outcome. DATA COLLECTION AND ANALYSIS The standard method for the Cochrane Collaboration, which is described in the Cochrane Collaboration Handbook, was used. Two investigators extracted, assessed and coded separately all data for each study. Any disagreement was resolved by discussion. MAIN RESULTS Seven studies met inclusion criteria. Six studies using furosemide were done before the current era of prenatal steroids, surfactant and fluid restriction. Furosemide administration had no long-term benefits. Furosemide-induced transient improvement in pulmonary function did not outweigh an increased risk for patent ductus arteriosus and for hemodynamic instability. In one recent study, theophylline had no long-term benefits. Theophylline significantly decreased the risk of oligoanuria and transiently increased renal function, but did not significantly affect renal function at discharge or other outcomes. AUTHORS' CONCLUSIONS There are no data to support routine administration of furosemide in preterm infants with RDS. Elective administration of furosemide to any patient with RDS should be carefully weighed against the risk of precipitating hypovolemia or developing a symptomatic patent ductus arteriosus. There are not enough data to support routine administration of low-dose theophylline in preterm infants with RDS.
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Affiliation(s)
- Audra Stewart
- University of Texas Southwestern Medical Center at DallasNeonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | - Luc P Brion
- University of Texas Southwestern at DallasDivision of Neonatal‐Perinatal Medicine5323 Harry Hines BoulevardDallasTexasUSA75390‐9063
| | - Roger Soll
- University of VermontDivision of Neonatal‐Perinatal MedicineFletcher Allen Health Care, Smith 552A111 Colchester AvenueBurlingtonVermontUSA05401
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da Silva PSL, de Aguiar VE, Fonseca MCM. Additive diuretic response of concurrent aminophylline and furosemide in children: a case series and a brief literature review. J Anesth 2011; 26:118-23. [PMID: 22005755 DOI: 10.1007/s00540-011-1250-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Accepted: 09/20/2011] [Indexed: 01/11/2023]
Abstract
Aminophylline exerts a renovascular effect, acting by adenosine receptor blockade or type IV phosphodiesterase inhibition. Clinically, these drugs have been used with furosemide to induce diuresis in adults and neonates. However, reports on use of aminophylline in diuretic-dependent children are limited to a few studies. We report a case series of four critically ill children unresponsive to furosemide continuous infusion who were subsequently given aminophylline as an adjunct diuretic in the treatment of fluid overload. No side effects were evident. Administration of aminophylline at low doses (3 mg/kg) successfully promoted increased urine output over the 6-h study period in all four children.
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Affiliation(s)
- Paulo Sérgio Lucas da Silva
- Department of Pediatrics, Pediatric Intensive Care Unit, Hospital do Servidor Público Municipal, Rua Castro Alves, 60, São Paulo, 01532-900, Brazil.
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Abstract
Infants of birth weight ≤2500 g are termed low birth weight (LBW). These children often have considerable morbidity from prematurity and intra-uterine growth restriction. Additionally, LBW infants have increased risk for cardiac and noncardiac congenital anomalies and may require surgery. Primary rather than palliative surgical repair of cardiac lesions has been preferred in recent years. However, LBW remains a risk factor for increased mortality and morbidity after open-heart surgery (OHS). There is a paucity of information about the anesthetic challenges presented by LBW infants undergoing OHS. This review summarizes the perioperative issues of relevance to anesthesiologists who manage these high-risk patients. Emphasis is placed on management concerns that are unique to LBW infants. Retrospective data from the authors' institution are provided for those aspects of anesthetic care that lack published studies. Successful outcome often requires substantial hospital resources and collaborative multi-disciplinary effort.
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Affiliation(s)
- Glyn D Williams
- Department of Anesthesiology, Stanford University, Lucile Packard Children’s Hospital, Stanford, CA, USA
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