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Reidy KJ, Guillet R, Selewski DT, Defreitas M, Stone S, Starr MC, Harer MW, Todurkar N, Vuong KT, Gogcu S, Askenazi D, Tipple TE, Charlton JR. Advocating for the inclusion of kidney health outcomes in neonatal research: best practice recommendations by the Neonatal Kidney Collaborative. J Perinatol 2024:10.1038/s41372-024-02030-1. [PMID: 38969825 DOI: 10.1038/s41372-024-02030-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/21/2024] [Accepted: 06/06/2024] [Indexed: 07/07/2024]
Abstract
Acute kidney injury (AKI) occurs in nearly 30% of sick neonates. Chronic kidney disease (CKD) can be detected in certain populations of sick neonates as early as 2 years. AKI is often part of a multisystem syndrome that negatively impacts developing organs resulting in short- and long-term pulmonary, neurodevelopmental, and cardiovascular morbidities. It is critical to incorporate kidney-related data into neonatal clinical trials in a uniform manner to better understand how neonatal AKI or CKD could affect an outcome of interest. Here, we provide expert opinion recommendations and rationales to support the inclusion of short- and long-term neonatal kidney outcomes using a tiered approach based on study design: (1) observational studies (prospective or retrospective) limited to data available within a center's standard practice, (2) observational studies involving prospective data collection where prespecified kidney outcomes are included in the design, (3) interventional studies with non-nephrotoxic agents, and (4) interventional studies with known nephrotoxic agents. We also provide recommendations for biospecimen collection to facilitate ancillary kidney specific research initiatives. This approach balances the costs of AKI and CKD ascertainment with knowledge gained. We advocate that kidney outcomes be included routinely in neonatal clinical study design. Consistent incorporation of kidney outcomes across studies will increase our knowledge of neonatal morbidity.
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Affiliation(s)
- Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, 10467, USA
| | - Ronnie Guillet
- Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Marissa Defreitas
- Division of Nephrology, Department of Pediatrics, University of Miami/Holtz Children's Hospital, Miami, FL, USA
| | - Sadie Stone
- Department of Pharmacy, Children's of Alabama, Birmingham, AL, UK
| | - Michelle C Starr
- Division of Pediatric Nephrology, Division of Child Health Service Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Matthew W Harer
- Division of Neonatology, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Namrata Todurkar
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Kim T Vuong
- Division of Pediatric Nephrology, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Semsa Gogcu
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Box 800386, Charlottesville, VA, 22903, USA.
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Gorga SM, Selewski DT, Goldstein SL, Menon S. An update on the role of fluid overload in the prediction of outcome in acute kidney injury. Pediatr Nephrol 2024; 39:2033-2048. [PMID: 37861865 DOI: 10.1007/s00467-023-06161-z] [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: 05/25/2023] [Revised: 08/29/2023] [Accepted: 08/29/2023] [Indexed: 10/21/2023]
Abstract
Over the past two decades, our understanding of the impact of acute kidney injury, disorders of fluid balance, and their interplay have increased significantly. In recent years, the epidemiology and impact of fluid balance, including the pathologic state of fluid overload on outcomes has been studied extensively across multiple pediatric and neonatal populations. A detailed understating of fluid balance has become increasingly important as it is recognized as a target for intervention to continue to work to improve outcomes in these populations. In this review, we provide an update on the epidemiology and outcomes associated with fluid balance disorders and the development of fluid overload in children with acute kidney injury (AKI). This will include a detailed review of consensus definitions of fluid balance, fluid overload, and the methodologies to define them, impact of fluid balance on the diagnosis of AKI and the concept of fluid corrected serum creatinine. This review will also provide detailed descriptions of future directions and the changing paradigms around fluid balance and AKI in critical care nephrology, including the incorporation of the sequential utilization of risk stratification, novel biomarkers, and functional kidney tests (furosemide stress test) into research and ultimately clinical care. Finally, the review will conclude with novel methods currently under study to assess fluid balance and distribution (point of care ultrasound and bioimpedance).
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Affiliation(s)
- Stephen M Gorga
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, 125 Doughty St., MSC 608 Ste 690, Charleston, SC, 29425, USA.
| | - Stuart L Goldstein
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Shina Menon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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3
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Slagle C, Askenazi D, Starr M. Recent Advances in Kidney Replacement Therapy in Infants: A Review. Am J Kidney Dis 2024; 83:519-530. [PMID: 38147895 DOI: 10.1053/j.ajkd.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/10/2023] [Accepted: 10/14/2023] [Indexed: 12/28/2023]
Abstract
Kidney replacement therapy (KRT) is used to treat children and adults with acute kidney injury (AKI), fluid overload, kidney failure, inborn errors of metabolism, and severe electrolyte abnormalities. Peritoneal dialysis and extracorporeal hemodialysis/filtration can be performed for different durations (intermittent, prolonged intermittent, and continuous) through either adaptation of adult devices or use of infant-specific devices. Each of these modalities have advantages and disadvantages, and often multiple modalities are used depending on the scenario and patient-specific needs. Traditionally, these therapies have been challenging to deliver in infants due the lack of infant-specific devices, small patient size, required extracorporeal volumes, and the risk of hemodynamic stability during the initiation of KRT. In this review, we discuss challenges, recent advancements, and optimal approaches to provide KRT in hospitalized infants, including a discussion of peritoneal dialysis and extracorporeal therapies. We discuss each specific KRT modality, review newer infant-specific devices, and highlight the benefits and limitations of each modality. We also discuss the ethical implications for the care of infants who need KRT and areas for future research.
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Affiliation(s)
- Cara Slagle
- Division of Neonatology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana
| | - David Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Michelle Starr
- Division of Nephrology and Division of Child Health Service Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana.
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4
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Selewski DT, Barhight MF, Bjornstad EC, Ricci Z, de Sousa Tavares M, Akcan-Arikan A, Goldstein SL, Basu R, Bagshaw SM. Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference. Pediatr Nephrol 2024; 39:955-979. [PMID: 37934274 PMCID: PMC10817849 DOI: 10.1007/s00467-023-06156-w] [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: 06/26/2023] [Revised: 08/14/2023] [Accepted: 08/29/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND The impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology. METHODS The 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed. CONCLUSIONS The 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Erica C Bjornstad
- Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Zaccaria Ricci
- Department of Emergency and Intensive Care, Pediatric Intensive Care Unit, Azienda Ospedaliero Universitaria Meyer, Florence, Italy.
- Department of Health Science, University of Florence, Florence, Italy.
| | - Marcelo de Sousa Tavares
- Pediatric Nephrology Unit, Nephrology Center of Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
| | - Ayse Akcan-Arikan
- Division of Nephrology, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rajit Basu
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
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5
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Raina R, Sethi SK, Agrawal G, Wazir S, Bajaj N, Gupta NP, Tibrewal A, Vadhera A, Mirgunde S, Balachandran B, Sahoo J, Afzal K, Shrivastava A, Bagla J, Krishnegowda S, Konapur A, Soni K, Alhasan K, McCulloch M, Bunchman T. Use of furosemide in preterm neonates with acute kidney injury is associated with increased mortality: results from the TINKER registry. Pediatr Nephrol 2024; 39:857-865. [PMID: 37581700 DOI: 10.1007/s00467-023-06086-7] [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: 10/18/2022] [Revised: 06/30/2023] [Accepted: 06/30/2023] [Indexed: 08/16/2023]
Abstract
BACKGROUND Diuretics are commonly used in neonatal AKI with the rationale to decrease positive fluid balance in critically sick neonates. The patterns of furosemide use vary among hospitals, which necessitates the need for a well-designed study. METHODS The TINKER (The Indian Iconic Neonatal Kidney Educational Registry) study provides a database, spanning 14 centres across India since August 2018. Admitted neonates (≤ 28 days) receiving intravenous fluids for at least 48 h were included. Neonatal KDIGO criteria were used for the AKI diagnosis. Detailed clinical and laboratory parameters were collected, including the indications of furosemide use, detailed dosing, and the duration of furosemide use (in days). RESULTS A total of 600 neonates with AKI were included. Furosemide was used in 8.8% of the neonates (53/600). Common indications of furosemide use were significant cardiac disease, fluid overload, oliguria, BPD, RDS, hypertension, and hyperkalemia. The odds of mortality was higher in neonates < 37 weeks gestational age with AKI who received furosemide compared to those who did not receive furosemide 3.78 [(1.60-8.94); p = 0.003; univariate analysis] and [3.30 (1.11-9.82); p = 0.03]; multivariate logistic regression]. CONCLUSIONS In preterm neonates with AKI, mortality was independently associated with furosemide treatment. The furosemide usage rates were higher in neonates with associated co-morbidities, i.e. significant cardiac diseases or surgical interventions. Sicker babies needed more resuscitation at birth, and died early, and hence needed shorter furosemide courses. Thus, survival probability was higher in neonates treated with long furosemide courses vs. short courses.
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Affiliation(s)
- Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308-1062, USA.
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India, 122001
| | - Gopal Agrawal
- Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India, 122001
| | - Sanjay Wazir
- Neonatology, Motherhood Hospitals, 122011, Gurgaon, India
| | - Naveen Bajaj
- Neonatology, Deep Hospital, Ludhiana, Punjab, India
| | | | - Abhishek Tibrewal
- Pediatric Nephrology, Akron Children's Hospital, One Perkins Square, Akron, OH, 44308-1062, USA
| | | | | | | | - Jagdish Sahoo
- Department of Neonatology, AIIMS, Bhubaneswar, India
| | - Kamran Afzal
- Department of Pediatrics, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, Aligarh, India
| | | | - Jyoti Bagla
- ESI Post Graduate Institute of Medical Science Research, Basaidarapur, New Delhi, India
| | - Sushma Krishnegowda
- JSS Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | | | - Kritika Soni
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India, 122001
| | - Khalid Alhasan
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Solid Organ Transplant Center of Excellence, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Mignon McCulloch
- Paediatric Renal and Solid Organ Transplant, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
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6
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Niknafs N, Kuan MTY, Mammen C, Skarsgard E, Ting JY. Fluid overload in newborns undergoing abdominal surgery: a retrospective study. J Matern Fetal Neonatal Med 2023; 36:2206940. [PMID: 37121907 DOI: 10.1080/14767058.2023.2206940] [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: 05/02/2023]
Abstract
BACKGROUND Fluid management in newborns undergoing surgery can be challenging due to difficulties in accurately assessing volume status in context of high fluid needs perioperatively and postoperative third-space fluid loss. Fluid overload can be associated with an increase in neonatal morbidity and mortality. OBJECTIVE Our objective was to determine the burden of fluid overload and to evaluate their associations with adverse effects among infants undergoing abdominal surgery at a tertiary perinatal center. METHODS Patients from our Neonatal Intensive Care Unit who underwent abdominal surgery from January 2017 to June 2019 were included in this retrospective cohort study. Fluid balance was assessed based on the maximum percentage change in body weight at 3- and 7-postoperative days. RESULTS Sixty infants were included, with a median [interquartile range] gestational age (GA) of 29 [25-36] weeks and birth weight of 1240 [721-2871] grams. The median daily actual fluid intake was significantly higher than the prescribed fluid intake in the first 7 postoperative days (163 vs. 145 mL/kg, p < .01). The median maximum change of body weight by postoperative days 3 and 7 were 6% [3-13] and 11% [5-17], respectively. A 1% increase in weight within the first 3 postoperative days was associated with a 0.6-day increase for invasive ventilatory support (p = .012). The correlation was still significant after adjusting for GA (p = .033). CONCLUSION Fluid overload within the first 3 postoperative days was associated with an increase in ventilator support among infants. Careful attention to fluid management may affect the optimization of outcomes for newborns undergoing abdominal surgery.
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Affiliation(s)
- Nikoo Niknafs
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Mimi T Y Kuan
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Cherry Mammen
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Erik Skarsgard
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Joseph Y Ting
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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7
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Sinha R, Saha R, Dasgupta D, Bose N, Ghosh S, Modi A, Das B, McCulloch M, Tse Y. Improving acute peritoneal dialysis outcome with use of soft peritoneal dialysis catheter (Cook Mac-Loc Multipurpose Drainage catheter®) among infants < 1500 g in a low resource setting. Pediatr Nephrol 2023; 38:1241-1248. [PMID: 35925426 DOI: 10.1007/s00467-022-05700-4] [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: 06/12/2022] [Revised: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Despite its utility, uncertainty exists on the feasibility of acute peritoneal dialysis (PD) and optimal PD catheter type for very low birth weight (VLBW < 1500 g) and extremely low birth weight (ELBW < 1000 g) infants. We hereby report our experience of acute PD among these high-risk infants and compare the outcome between stylet-based rigid catheter (SRC) and Cook Mac-Loc Multipurpose Drainage catheters® (CMMDC). METHODS Case notes of infants < 1500 g undergoing PD between 2012 and 2021 in a network of five participating neonatal units supported by a tertiary paediatric nephrology centre in Kolkata, India, were retrospectively reviewed. PD was conducted either with SRC or after 2018 with CMMDC. Outcome parameters included complications, survival during PD, and survival to discharge. RESULTS 24 infants (VLBW: n = 13 and ELBW: n = 11) underwent PD at median age 4.5 days (IQR 3-6) with either CMMDC (n = 14) or SRC (n = 10). Significant improvement in biochemical parameters and fluid removal was seen in both ELBW and VLBW infants. CMMDC was associated with significantly fewer PD-related complications 7/14 (50%) vs. 9/10 (90%) (p = 0.04) and higher survival during PD 13/14 (93%) vs. 5/10 (50%) (p = 0.02), without significant difference in survival to hospital discharge 8/14 (57%) vs. 3/10 (30%) (p = 0.25). CMMDC also enabled longer duration of PD, higher ultrafiltration, and better control of acidosis. Consumable cost was higher for CMMDC (USD$60) than SRC (USD$14). CONCLUSIONS In a low resource setting, CMMDC had lower PD complications and superior short-term survival among ELBW/VLBW infants. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Rajiv Sinha
- Institute of Child Health, Kolkata, India. .,Apollo Glenagles Hospital, Kolkata, India.
| | - Rana Saha
- Institute of Child Health, Kolkata, India.,AMRI Hospital, Mukundapur, Kolkata, India.,Bhagirathi Neotia Women and Child Care Hospital, Kolkata, India
| | | | | | | | - Ashok Modi
- Bhagirathi Neotia Women and Child Care Hospital, Kolkata, India
| | - Bikramjit Das
- Bhagirathi Neotia Women and Child Care Hospital, Kolkata, India
| | - Mignon McCulloch
- Red Cross War Memorial Children's Hospital, Cape Town, South Africa
| | - Yincent Tse
- Great North Children's Hospital, Newcastle upon Tyne, UK
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Neumayr TM, Alten JA, Bailly DK, Bhat PN, Brandewie KL, Diddle JW, Ghbeis M, Krawczeski CD, Mah KE, Raymond TT, Reichle G, Zang H, Selewski DT. Assessment of fluid balance after neonatal cardiac surgery: a description of intake/output vs. weight-based methods. Pediatr Nephrol 2023; 38:1355-1364. [PMID: 36066771 DOI: 10.1007/s00467-022-05697-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 07/18/2022] [Accepted: 07/18/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Fluid overload associates with poor outcomes after neonatal cardiac surgery, but consensus does not exist for the most clinically relevant method of measuring fluid balance (FB). While weight change-based FB (FB-W) is standard in neonatal intensive care units, weighing infants after cardiac surgery may be challenging. We aimed to identify characteristics associated with obtaining weights and to understand how intake/output-based FB (FB-IO) and FB-W compare in the early postoperative period in this population. METHODS Observational retrospective study of 2235 neonates undergoing cardiac surgery from 22 hospitals comprising the NEonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) database. RESULTS Forty-five percent (n = 998) of patients were weighed on postoperative day (POD) 2, varying from 2 to 98% among centers. Odds of being weighed were lower for STAT categories 4 and 5 (OR 0.72; 95% CI 0.53-0.98), cardiopulmonary bypass (0.59; 0.42-0.83), delayed sternal closure (0.27; 0.19-0.38), prophylactic peritoneal dialysis use (0.58; 0.34-0.99), and mechanical ventilation on POD 2 (0.23; 0.16-0.33). Correlation between FB-IO and FB-W was weak for every POD 1-6 and within the entire cohort (correlation coefficient 0.15; 95% CI 0.12-0.17). FB-W measured higher than paired FB-IO (mean bias 12.5%; 95% CI 11.6-13.4%) with wide 95% limits of agreement (- 15.4-40.4%). CONCLUSIONS Weighing neonates early after cardiac surgery is uncommon, with significant practice variation among centers. Patients with increased severity of illness are less likely to be weighed. FB-W and FB-IO have weak correlation, and further study is needed to determine which cumulative FB metric most associates with adverse outcomes. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Tara M Neumayr
- Department of Pediatrics, Divisions of Pediatric Critical Care Medicine and Pediatric Nephrology, Washington University School of Medicine, St. Louis, MO, USA.
| | - Jeffrey A Alten
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Priya N Bhat
- Department of Pediatrics, Sections of Critical Care Medicine and Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX, USA
| | - Katie L Brandewie
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - J Wesley Diddle
- Division of Cardiac Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Muhammad Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Catherine D Krawczeski
- Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kenneth E Mah
- Stanford University School of Medicine, Palo Alto, CA, USA
| | - Tia T Raymond
- Pediatric Cardiac Intensive Care, Medical City Children's Hospital, Dallas, TX, USA
| | | | - Huaiyu Zang
- University of Cincinnati College of Medicine, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David T Selewski
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
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9
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Liberio BM, Rose RS. EBNEO commentary: Fluid balance as a critical factor in neonatal outcomes. Acta Paediatr 2023; 112:1354-1355. [PMID: 36929493 DOI: 10.1111/apa.16754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Brianna M Liberio
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Rebecca S Rose
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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10
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Wright ML, Klamer BG, Bonachea E, Spencer JD, Slaughter JL, Mohamed TH. Positive fluid balance and diuretic therapy are associated with mechanical ventilation and mortality in preterm neonates in the first fourteen postnatal days. Pediatr Nephrol 2023:10.1007/s00467-022-05861-2. [PMID: 36598600 DOI: 10.1007/s00467-022-05861-2] [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: 02/22/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND Fluid overload leads to poor neonatal outcomes. Diuretics may lower the rates of mechanical ventilation (MV) and mortality in neonates with fluid overload. METHODS This is a retrospective study of preterm neonates ≤ 36 weeks of gestational age (GA) in the first 14 postnatal days in a level IV NICU in 2014-2020. We evaluated the epidemiology of fluid balance in the first 14 postnatal days and its association with MV and mortality and studied the association of diuretics with fluid balance, MV, and mortality. RESULTS In 1383 included neonates, the overall median lowest and peak fluid balances were - 7.8% (IQR: - 11.7, - 4.6) and 8% (3, 16) on days 3 (2, 5) and 13 (5, 14), respectively. Fluid balance distribution varied significantly by GA. Peak fluid balance of ≥ 10% was associated with increased odds of MV on days 7 and 14 with highest odds ratios (OR) of MV in neonates with fluid balance ≥ 15%. Peak fluid balance of ≥ 15% was associated with the greatest odds of mortality. Diuretics were used more frequently in neonates with younger GA, smaller birthweight, positive fluid balance, and those on MV. CONCLUSIONS Positive fluid balance negatively impacts pulmonary status. The odds of MV and death increase significantly as peak fluid balance percentage increases in all GA groups. The impact of diuretics on MV and death in preterm neonates needs further evaluation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Mariah L Wright
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, USA
| | - Brett G Klamer
- Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA.,The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH, USA.,Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Elizabeth Bonachea
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, USA
| | - John D Spencer
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, USA.,Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA.,The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH, USA
| | - Jonathan L Slaughter
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, USA.,The Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.,Division of Epidemiology, College of Public Health, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Tahagod H Mohamed
- Department of Pediatrics, The Ohio State University College of Medicine and Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, USA. .,Division of Nephrology and Hypertension, Nationwide Children's Hospital, Columbus, OH, USA. .,The Kidney and Urinary Tract Center, Nationwide Children's Hospital, Columbus, OH, USA.
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Weaver LJ, Travers CP, Ambalavanan N, Askenazi D. Neonatal fluid overload-ignorance is no longer bliss. Pediatr Nephrol 2023; 38:47-60. [PMID: 35348902 PMCID: PMC10578312 DOI: 10.1007/s00467-022-05514-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/26/2022] [Accepted: 02/21/2022] [Indexed: 01/10/2023]
Abstract
Excessive accumulation of fluid may result in interstitial edema and multiorgan dysfunction. Over the past few decades, the detrimental impact of fluid overload has been further defined in adult and pediatric populations. Growing evidence highlights the importance of monitoring, preventing, managing, and treating fluid overload appropriately. Translating this knowledge to neonates is difficult as they have different disease pathophysiologies, and because neonatal physiology changes rapidly postnatally in many of the organ systems (i.e., skin, kidneys, and cardiovascular, pulmonary, and gastrointestinal). Thus, evaluations of the optimal targets for fluid balance need to consider the disease state as well as the gestational and postmenstrual age of the infant. Integration of what is known about neonatal fluid overload with individual alterations in physiology is imperative in clinical management. This comprehensive review will address what is known about the epidemiology and pathophysiology of neonatal fluid overload and highlight the known knowledge gaps. Finally, we provide clinical recommendations for monitoring, prevention, and treatment of fluid overload.
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Affiliation(s)
| | - Colm P Travers
- University of Alabama at Birmingham, Birmingham, AL, USA.
| | | | - David Askenazi
- University of Alabama at Birmingham, Birmingham, AL, USA
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12
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Starr MC, Griffin R, Gist KM, Segar JL, Raina R, Guillet R, Nesargi S, Menon S, Anderson N, Askenazi DJ, Selewski DT. Association of Fluid Balance With Short- and Long-term Respiratory Outcomes in Extremely Premature Neonates: A Secondary Analysis of a Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2248826. [PMID: 36580332 PMCID: PMC9856967 DOI: 10.1001/jamanetworkopen.2022.48826] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Extremely low gestational age neonates are at risk of disorders of fluid balance (FB), defined as change in fluid weight over a specific period. Few data exist on the association between FB and respiratory outcomes in this population. OBJECTIVE To describe FB patterns and evaluate the association of FB with respiratory outcomes in a cohort of extremely low gestational age neonates. DESIGN, SETTING, AND PARTICIPANTS This study is a secondary analysis of the Preterm Erythropoietin Neuroprotection Trial (PENUT), a phase 3 placebo-controlled randomized clinical trial of erythropoietin in extremely premature neonates conducted in 30 neonatal intensive care units in the US from December 1, 2013, to September 31, 2016. This analysis included 874 extremely premature neonates born at 24 to 27 weeks' gestation who were enrolled in the PENUT study. Secondary analysis was performed in November 2021. EXPOSURES Primary exposure was peak FB during the first 14 postnatal days. The FB was calculated as percent change in weight from birth weight (BW) as a surrogate for FB. MAIN OUTCOMES AND MEASURES The primary outcome was mechanical ventilation on postnatal day 14. The secondary outcome was a composite of severe bronchopulmonary dysplasia (BPD) or death. RESULTS A total of 874 neonates (449 [51.4%] male; mean [SD] BW, 801 [188] g; 187 [21.4%] Hispanic, 676 [77.3%] non-Hispanic, and 11 [1.3%] of unknown ethnicity; 226 [25.9%] Black, 569 [65.1%] White, 51 [5.8%] of other race, and 28 [3.2%] of unknown race) were included in this analysis. Of these 874 neonates, 458 (52.4%) received mechanical ventilation on postnatal day 14, and 291 (33.3%) had severe BPD or had died. Median peak positive FB was 11% (IQR, 4%-20%), occurring on postnatal day 13 (IQR, 9-14). A total of 93 (10.6%) never decreased below their BW. Neonates requiring mechanical ventilation at postnatal day 14 had a higher peak FB compared with those who did not require mechanical ventilation (15% above BW vs 8% above BW, P < .001). On postnatal day 3, neonates requiring mechanical ventilation were more likely to have a higher FB (5% below BW vs 8% below BW, P < .001). The median time to return to BW was shorter in neonates who received mechanical ventilation (7 vs 8 days, P < .001) and those with severe BPD (7 vs 8 days, P < .001). After adjusting for confounding variables, for every 10% increase in peak FB during the first 14 postnatal days, there was 103% increased odds of receiving mechanical ventilation at postnatal day 14 (adjusted odds ratio, 2.03; 95% CI, 1.64-2.51). CONCLUSIONS AND RELEVANCE In this secondary analysis of a randomized clinical trial, peak FB was associated with mechanical ventilation on postnatal day 14 and severe BPD or death. Fluid balance in the first 3 postnatal days and time to return to BW may be potential targets to help guide management and improve respiratory outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01378273.
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Affiliation(s)
- Michelle C. Starr
- Division of Nephrology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis
- Pediatric and Adolescent Comparative Effectiveness Research, Department of Pediatrics, Indiana University School of Medicine, Indianapolis
| | - Russell Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Katja M. Gist
- Division of Cardiology, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio
| | - Jeffrey L. Segar
- Division of Neonatology, Departments of Pediatrics and Physiology, Medical College of Wisconsin, Milwaukee
| | - Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, Ohio
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - Saudamini Nesargi
- Department of Neonatology, St Johns Medical College Hospital, Bangalore, Karnataka, India
| | - Shina Menon
- Division of Nephrology, University of Washington and Seattle Children's Hospital, Seattle
| | - Nekayla Anderson
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - David J. Askenazi
- Division of Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham
| | - David T. Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston
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13
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Basalely AM, Griffin R, Gist KM, Guillet R, Askenazi DJ, Charlton JR, Selewski DT, Fuloria M, Kaskel FJ, Reidy KJ. Association of early dysnatremia with mortality in the neonatal intensive care unit: results from the AWAKEN study. J Perinatol 2022; 42:1353-1360. [PMID: 34775486 PMCID: PMC10228559 DOI: 10.1038/s41372-021-01260-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 10/12/2021] [Accepted: 10/20/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To determine the association of dysnatremia in the first postnatal week and risk of acute kidney injury (AKI) and mortality. STUDY DESIGN A secondary analysis of 1979 neonates in the AWAKEN cohort evaluated the association of dysnatremia with (1) AKI in the first postnatal week and (2) mortality, utilizing time-varying Cox proportional hazard models. RESULT Dysnatremia developed in 50.2% of the cohort and was not associated with AKI. Mortality was associated with hyponatremia (HR 2.15, 95% CI 1.07-4.31), hypernatremia (HR 4.23, 95% CI 2.07-8.65), and combined hypo/hypernatremia (HR 6.39, 95% CI 2.01-14.01). In stratified models by AKI-status, hypernatremia and hypo/hypernatremia increased risk of mortality in neonates without AKI. CONCLUSION Dysnatremia within the first postnatal week was associated with increased risk of mortality. Hypernatremia and combined hypo/hypernatremia remained significantly associated with mortality in neonates without AKI. This may reflect fluid strategies kidney injury independent of creatinine and urine-output defined AKI, and/or systemic inflammation.
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Affiliation(s)
- Abby M Basalely
- Division of Pediatric Nephrology, Department of Pediatrics, Cohen Children's Medical Center of New York, New Hyde Park, NY, USA.
- Division of Nephrology, Department of Pediatrics, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA.
| | - Russell Griffin
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ronnie Guillet
- Division of Neonatology, University of Rochester Medical Center, Rochester, NY, USA
| | - David J Askenazi
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Mamta Fuloria
- Division of Pediatric Neonatology, Department of Pediatrics, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Frederick J Kaskel
- Division of Nephrology, Department of Pediatrics, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kimberly J Reidy
- Division of Nephrology, Department of Pediatrics, The Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
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14
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Goldstein SL, Akcan-Arikan A, Alobaidi R, Askenazi DJ, Bagshaw SM, Barhight M, Barreto E, Bayrakci B, Bignall ONR, Bjornstad E, Brophy PD, Chanchlani R, Charlton JR, Conroy AL, Deep A, Devarajan P, Dolan K, Fuhrman DY, Gist KM, Gorga SM, Greenberg JH, Hasson D, Ulrich EH, Iyengar A, Jetton JG, Krawczeski C, Meigs L, Menon S, Morgan J, Morgan CJ, Mottes T, Neumayr TM, Ricci Z, Selewski D, Soranno DE, Starr M, Stanski NL, Sutherland SM, Symons J, Tavares MS, Vega MW, Zappitelli M, Ronco C, Mehta RL, Kellum J, Ostermann M, Basu RK. Consensus-Based Recommendations on Priority Activities to Address Acute Kidney Injury in Children: A Modified Delphi Consensus Statement. JAMA Netw Open 2022; 5:e2229442. [PMID: 36178697 PMCID: PMC9756303 DOI: 10.1001/jamanetworkopen.2022.29442] [Citation(s) in RCA: 66] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
IMPORTANCE Increasing evidence indicates that acute kidney injury (AKI) occurs frequently in children and young adults and is associated with poor short-term and long-term outcomes. Guidance is required to focus efforts related to expansion of pediatric AKI knowledge. OBJECTIVE To develop expert-driven pediatric specific recommendations on needed AKI research, education, practice, and advocacy. EVIDENCE REVIEW At the 26th Acute Disease Quality Initiative meeting conducted in November 2021 by 47 multiprofessional international experts in general pediatrics, nephrology, and critical care, the panel focused on 6 areas: (1) epidemiology; (2) diagnostics; (3) fluid overload; (4) kidney support therapies; (5) biology, pharmacology, and nutrition; and (6) education and advocacy. An objective scientific review and distillation of literature through September 2021 was performed of (1) epidemiology, (2) risk assessment and diagnosis, (3) fluid assessment, (4) kidney support and extracorporeal therapies, (5) pathobiology, nutrition, and pharmacology, and (6) education and advocacy. Using an established modified Delphi process based on existing data, workgroups derived consensus statements with recommendations. FINDINGS The meeting developed 12 consensus statements and 29 research recommendations. Principal suggestions were to address gaps of knowledge by including data from varying socioeconomic groups, broadening definition of AKI phenotypes, adjudicating fluid balance by disease severity, integrating biopathology of child growth and development, and partnering with families and communities in AKI advocacy. CONCLUSIONS AND RELEVANCE Existing evidence across observational study supports further efforts to increase knowledge related to AKI in childhood. Significant gaps of knowledge may be addressed by focused efforts.
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Affiliation(s)
- Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ayse Akcan-Arikan
- Division of Critical Care Medicine and Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | - Rashid Alobaidi
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | | | - Sean M Bagshaw
- Alberta Health Sciences University, Edmonton, Alberta, Canada
| | - Matthew Barhight
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | | | - Benan Bayrakci
- Department of Pediatric Intensive Care Medicine, Life Support Center, Hacettepe University, Ankara, Turkey
| | | | | | - Patrick D Brophy
- Golisano Children's Hospital, Rochester University Medical Center, Rochester, New York
| | | | | | | | - Akash Deep
- King's College London, London, United Kingdom
| | - Prasad Devarajan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kristin Dolan
- Mercy Children's Hospital Kansas City, Kansas City, Missouri
| | - Dana Y Fuhrman
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Katja M Gist
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen M Gorga
- C.S. Mott Children's Hospital, University of Michigan, Ann Arbor
| | | | - Denise Hasson
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Arpana Iyengar
- St John's Academy of Health Sciences, Bangalore, Karnataka, India
| | | | | | - Leslie Meigs
- Stead Family Children's Hospital, The University of Iowa, Iowa City
| | - Shina Menon
- Seattle Children's Hospital, Seattle, Washington
| | - Jolyn Morgan
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Theresa Mottes
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
| | - Tara M Neumayr
- Washington University School of Medicine, St Louis, Missouri
| | | | | | | | - Michelle Starr
- Riley Children's Hospital, Indiana University, Bloomington
| | - Natalja L Stanski
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Scott M Sutherland
- Lucille Packard Children's Hospital, Stanford University, Stanford, California
| | | | | | - Molly Wong Vega
- Division of Nephrology, Texas Children's Hospital, Baylor College of Medicine, Houston
| | | | - Claudio Ronco
- Universiti di Padova, San Bartolo Hospital, Vicenza, Italy
| | | | - John Kellum
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Rajit K Basu
- Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois
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15
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Nada A, Askenazi D, Kupferman JC, Mhanna M, Mahan JD, Boohaker L, Li L, Griffin RL. Low albumin levels are independently associated with neonatal acute kidney injury: a report from AWAKEN Study Group. Pediatr Nephrol 2022; 37:1675-1686. [PMID: 34657971 PMCID: PMC9986677 DOI: 10.1007/s00467-021-05295-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 08/09/2021] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Data from adult and pediatric literature have shown an association between albumin levels and AKI. Whether hypoalbuminemia and neonatal AKI are associated has not been studied. METHODS We evaluated the association of albumin with early (during the first postnatal week) and late (after the first postnatal week) AKI for 531 neonates from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database and for 3 gestational age (GA) subgroups: < 29, 29 to < 36, and ≥ 36 weeks GA. RESULTS Low albumin levels were associated with increased odds of neonatal AKI; for every 0.1 g/dL decrease in albumin, the odds of late AKI increased by 12% on continuous analysis. After adjustment for potential confounders, neonates with albumin values in the lowest quartiles (< 2.2 g/dL) had an increased odds of early [Adjusted Odd Ratio (AdjOR) 2.5, 95% CI = 1.1-5.3, p < 0.03] and late AKI [AdjOR 13.4, 95% CI = 3.6-49.9, p < 0.0001] compared to those with albumin in the highest quartile (> 3.1 g/dL). This held true for albumin levels 2.3 to 2.6 g/dL for early [AdjOR 2.5, 95% CI = 1.2-5.5, p < 0.02] and late AKI [AdjOR 6.4, 95% CI = 1.9-21.6, p < 0.01]. Albumin quartiles of (2.7 to 3.0 g/dL) were associated with increased odds of late AKI. Albumin levels of 2.6 g/dL and 2.4 g/dL best predicted early (AUC = 0.59) and late AKI (AUC = 0.64), respectively. Analysis of albumin association with AKI by GA is described. CONCLUSIONS Low albumin levels are independently associated with early and late neonatal AKI. Albumin could be a potential modifiable risk factor for neonatal AKI.
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Affiliation(s)
- Arwa Nada
- Department of Pediatrics, Division of Nephrology & Hypertension, Le Bonheur Children's Hospital, The University of Tennessee Health Science Center, 49 North Dunlap St FOB 326, Memphis, TN, 38105, USA.
| | - David Askenazi
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Juan C Kupferman
- Department of Pediatrics, Division of Pediatric Nephrology & Hypertension, Maimonides Medical Center, Brooklyn, NY, USA
| | - Maroun Mhanna
- Department of Pediatrics, Division of Neonatology, Louisiana State University Health in Shreveport, Shreveport, LA, USA
| | - John D Mahan
- Department of Pediatrics, Division of Nephrology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Louis Boohaker
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Linzi Li
- Department of Pediatrics, Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Russell L Griffin
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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16
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Sethi SK, Wazir S, Sahoo J, Agrawal G, Bajaj N, Gupta NP, Mirgunde S, Balachandran B, Afzal K, Shrivastava A, Bagla J, Krishnegowda S, Konapur A, Sultana A, Soni K, Nair N, Sharma D, Khooblall P, Pandey A, Alhasan K, McCulloch M, Bunchman T, Tibrewal A, Raina R. Risk factors and outcomes of neonates with acute kidney injury needing peritoneal dialysis: Results from the prospective TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) study. Perit Dial Int 2022; 42:460-469. [PMID: 35574693 DOI: 10.1177/08968608221091023] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is common in neonates admitted to neonatal intensive care units (NICUs). There is a need to have prospective data on the risk factors and outcomes of acute peritoneal dialysis (PD) in neonates. The use of kidney replacement therapy in this population compared to older populations has been associated with worse outcomes (mortality rates 17-24%) along with a longer stay in the NICU and/or hospital. METHODS The following multicentre, prospective study was derived from the TINKER (The Indian PCRRT-ICONIC Neonatal Kidney Educational Registry) database, assessing all admitted neonates ≤28 days who received intravenous fluids for at least 48 h. The following neonates were excluded: death within 48 h, presence of any lethal chromosomal anomaly, requirement of congenital heart surgery within the first 7 days of life and those receiving only routine care in nursery. Demographic data (maternal and neonatal) and daily clinical and laboratory parameters were recorded. AKI was defined according to the Neonatal Kidney Disease: Improving Global Outcomes criteria. RESULTS Of the included 1600 neonates, a total of 491 (30.7%) had AKI. Of these 491 neonates with AKI, 44 (9%) required PD. Among neonates with AKI, the odds of needing PD was significantly higher among those with significant cardiac disease (odds ratio (95% confidence interval): 4.95 (2.39-10.27); p < 0.001), inotropes usage (4.77 (1.98-11.51); p < 0.001), severe peripartum event (4.37 (1.31-14.57); p = 0.02), requirement of respiratory support in NICU (4.17 (1.00-17.59); p = 0.04), necrotising enterocolitis (3.96 (1.21-13.02); p = 0.03), any grade of intraventricular haemorrhage (3.71 (1.63-8.45); p = 0.001), evidence of fluid overload during the first 12 h in NICU (3.69 (1.27-10.70); p = 0.02) and requirement of resuscitation in the delivery room (2.72 (1.45-5.12); p = 0.001). AKI neonates with PD as compared to those without PD had a significantly lower median (interquartile range) duration of stay in NICU (7 (4-14) vs. 11 (6-21) days; p = 0.004), but significantly higher mortality (31 (70.5%) vs. 50 (3.2%); p < 0.001). This discrepancy is likely attributable to the critical state of the neonates with AKI. CONCLUSIONS This is the largest prospective, multicentre study specifically looking at neonatal AKI and need for dialysis in neonates. AKI was seen in 30.7% of neonates (with the need for acute PD in 9% of the AKI group). The odds of needing acute PD were significantly higher among those with significant cardiac disease, inotropes usage, severe peripartum event, requirement of respiratory support in NICU, necrotising enterocolitis, any grade of intraventricular haemorrhage, evidence of fluid overload more than 10% during the first 12 h in NICU and requirement of resuscitation in the delivery room. AKI neonates with PD as compared to AKI neonates without PD had a significantly higher mortality. There is a need to keep a vigilant watch in neonates with risk factors for the development of AKI and need for PD.
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Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Sanjay Wazir
- Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Jagdish Sahoo
- Department of Neonatology, IMS & SUM Hospital, Bhubaneswar, Odisha, India
| | - Gopal Agrawal
- Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India
| | - Naveen Bajaj
- Neonatology, Deep Hospital, Ludhiana, Punjab, India
| | | | | | | | - Kamran Afzal
- Department of Pediatrics, Jawaharlal Nehru Medical College, Aligarh Muslim University, Uttar Pradesh, India
| | | | - Jyoti Bagla
- ESI Post Graduate Institute of Medical Science Research, Basaidarapur, New Delhi, India
| | - Sushma Krishnegowda
- JSS Hospital, JSS Academy of Higher Education and Research, Mysuru, Karnataka, India
| | | | - Azmeri Sultana
- Paediatric Nephrology, Dr. M R Khan Children Hospital and Institute of Child Health, Dhaka, Bangladesh
| | - Kritika Soni
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity Hospital, Gurgaon, Haryana, India
| | - Nikhil Nair
- Akron Nephrology Associates at AGMC Cleveland Clinic, Case Western Reserve University School of Medicine, OH, USA
| | - Divya Sharma
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Prajit Khooblall
- Department of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | | | - Khalid Alhasan
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mignon McCulloch
- Renal and Organ Transplant, Red Cross War Memorial Children's Hospital, Rondebosch, Cape Town, South Africa
| | | | | | - Rupesh Raina
- Pediatric Nephrology, Akron's Children Hospital, OH, USA
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17
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Association between fluid overload and mortality in newborns: a systematic review and meta-analysis. Pediatr Nephrol 2022; 37:983-992. [PMID: 34727245 DOI: 10.1007/s00467-021-05281-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/06/2021] [Accepted: 09/06/2021] [Indexed: 10/19/2022]
Abstract
Fluid overload (FO) is associated with higher rates of mortality and morbidity in pediatric and adult populations. The aim of this systematic review and meta-analysis was to investigate the association between FO and mortality in critically ill neonates. Systematic search of Ovid MEDLINE, EMBASE, Cochrane Library, trial registries, and gray literature from inception to January 2021. We included all studies that examined neonates admitted to neonatal intensive care units and described FO and outcomes of interest. We identified 17 observational studies with a total of 4772 critically ill neonates who met the inclusion criteria. FO was associated with higher mortality (OR, 4.95 [95% CI, 2.26-10.87]), and survivors had a lower percentage of FO compared with nonsurvivors (WMD, - 4.33 [95% CI, - 8.34 to - 0.32]). Neonates who did not develop acute kidney injury (AKI) had lower FO compared with AKI patients (WMD, - 2.29 [95% CI, - 4.47 to - 0.10]). Neonates who did not require mechanical ventilation on postnatal day 7 had lower fluid balance (WMD, - 1.54 [95% CI, - 2.21 to - 0.88]). FO is associated with higher mortality, AKI, and need for mechanical ventilation in critically ill neonates in the intensive care unit. Strict control of fluid balance to prevent FO is essential. A higher resolution version of the Graphical abstract is available as Supplementary information.
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18
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Slagle C, Gist KM, Starr MC, Hemmelgarn TS, Goldstein SL, Kent AL. Fluid Homeostasis and Diuretic Therapy in the Neonate. Neoreviews 2022; 23:e189-e204. [PMID: 35229135 DOI: 10.1542/neo.23-3-e189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Understanding physiologic water balance and homeostasis mechanisms in the neonate is critical for clinicians in the NICU as pathologic fluid accumulation increases the risk for morbidity and mortality. In addition, once this process occurs, treatment is limited. In this review, we will cover fluid homeostasis in the neonate, explain the implications of prematurity on this process, discuss the complexity of fluid accumulation and the development of fluid overload, identify mitigation strategies, and review treatment options.
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Affiliation(s)
- Cara Slagle
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Katja M Gist
- Division of Cardiology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, IN
| | - Trina S Hemmelgarn
- Division of Pharmacology, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Pharmacy, Cincinnati, OH
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center and the University of Cincinnati, College of Medicine, Cincinnati, OH
| | - Alison L Kent
- Department of Pediatrics, University of Rochester, NY, and Australian National University Medical School, Canberra, ACT, Australia
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19
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Al-Jebawi Y, Karalic K, Shekhawat P, Mhanna MJ. The concomitant use of vancomycin and piperacillin-tazobactam is associated with acute kidney injury (AKI) in extremely low birth weight infants (ELBW). J Neonatal Perinatal Med 2021; 15:303-309. [PMID: 34864693 DOI: 10.3233/npm-210866] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Late-onset sepsis is common in extremely low birth weight (ELBW) infants, and it leads to the use of antibiotics to cover resistant organisms, which can be nephrotoxic. Here we have investigated the role of vancomycin plus piperacillin-tazobactam on the rate of acute kidney injury (AKI). METHODS In a retrospective case-control study, medical records of all ELBW infants who were admitted to our Neonatal Intensive Care Unit (NICU) with late onset sepsis who were prescribed vancomycin plus piperacillin-tazobactam were reviewed for demographics, clinical characteristics, use of potential nephrotoxic medications and outcomes. RESULTS During the study period, 264 patients were admitted, of whom 28.4%(75/264) received vancomycin plus piperacillin-tazobactam and were matched with 64 controls. There were no differences in gestational age or birth weight between cases and controls [688±160 vs. 689±162 grams (p = 0.99), and 24.7±1.8 vs. 24.7±1.6 weeks (p = 0.99) respectively]. There was no difference in the rate of sepsis between cases and controls [76%(55/72) vs. 64%(41/64) respectively, p = 0.11]. Infants exposed to vancomycin plus piperacillin-tazobactam had a higher percentage of concomitant use of vasopressors and amphotericin. To adjust for confounders, a logistic regression analysis was conducted with AKI as the dependent variable. Use of vasopressors and vancomycin plus piperacillin-tazobactam were the only risk factors associated with AKI with an adjusted OR (95%CI) of 4.08 (1.90-8.74), p < 0.001; and 2.87 (1.26-6.53), p = 0.01 respectively. CONCLUSION The use of vancomycin plus piperacillin-tazobactam in ELBW infants is associated with an increased risk for AKI.
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Affiliation(s)
- Y Al-Jebawi
- Division of Neonatology, Joe Di Maggio Children'sHospital, Hollywood, FL, USA.,Pediatrix Medical Group of Florida, Hollywood, FL, USA
| | - K Karalic
- Ohio University Heritage College of Osteopathic Medicine, Cleveland, OH, USA
| | - P Shekhawat
- Professor of Pediatrics, Case Western ReserveUniversity, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - M J Mhanna
- Professor of Pediatrics, Louisiana State University Health in Shreveport, LA, USA
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20
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Segar J, Jetton JG. Diuretic use, acute kidney injury, and premature infants: the call for evidence-based guidelines. Pediatr Nephrol 2021; 36:3807-3811. [PMID: 34258644 DOI: 10.1007/s00467-021-05201-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Jeffrey Segar
- Departments of Pediatrics and Physiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jennifer G Jetton
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA, USA.
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21
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Starr MC, Charlton JR, Guillet R, Reidy K, Tipple TE, Jetton JG, Kent AL, Abitbol CL, Ambalavanan N, Mhanna MJ, Askenazi DJ, Selewski DT, Harer MW. Advances in Neonatal Acute Kidney Injury. Pediatrics 2021; 148:peds.2021-051220. [PMID: 34599008 DOI: 10.1542/peds.2021-051220] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 01/14/2023] Open
Abstract
In this state-of-the-art review, we highlight the major advances over the last 5 years in neonatal acute kidney injury (AKI). Large multicenter studies reveal that neonatal AKI is common and independently associated with increased morbidity and mortality. The natural course of neonatal AKI, along with the risk factors, mitigation strategies, and the role of AKI on short- and long-term outcomes, is becoming clearer. Specific progress has been made in identifying potential preventive strategies for AKI, such as the use of caffeine in premature neonates, theophylline in neonates with hypoxic-ischemic encephalopathy, and nephrotoxic medication monitoring programs. New evidence highlights the importance of the kidney in "crosstalk" between other organs and how AKI likely plays a critical role in other organ development and injury, such as intraventricular hemorrhage and lung disease. New technology has resulted in advancement in prevention and improvements in the current management in neonates with severe AKI. With specific continuous renal replacement therapy machines designed for neonates, this therapy is now available and is being used with increasing frequency in NICUs. Moving forward, biomarkers, such as urinary neutrophil gelatinase-associated lipocalin, and other new technologies, such as monitoring of renal tissue oxygenation and nephron counting, will likely play an increased role in identification of AKI and those most vulnerable for chronic kidney disease. Future research needs to be focused on determining the optimal follow-up strategy for neonates with a history of AKI to detect chronic kidney disease.
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Affiliation(s)
- Michelle C Starr
- Division of Pediatric Nephrology, Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Jennifer R Charlton
- Division of Nephrology, Department of Pediatrics, University of Virginia, Charlottesville, Virginia
| | - Ronnie Guillet
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York
| | - Kimberly Reidy
- Division of Pediatric Nephrology, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Trent E Tipple
- Section of Neonatal-Perinatal Medicine, Department of Pediatrics, College of Medicine, The University of Oklahoma, Oklahoma City, Oklahoma
| | - Jennifer G Jetton
- Division of Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, Iowa
| | - Alison L Kent
- Division of Neonatology, Department of Pediatrics, Golisano Children's Hospital, University of Rochester Medical Center, Rochester, New York.,College of Health and Medicine, The Australian National University, Canberra, Australia Capitol Territory, Australia
| | - Carolyn L Abitbol
- Division of Pediatric Nephrology, Department of Pediatrics, Miller School of Medicine, University of Miami and Holtz Children's Hospital, Miami, Florida
| | | | - Maroun J Mhanna
- Department of Pediatrics, Louisiana State University Shreveport, Shreveport, Louisiana
| | - David J Askenazi
- Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - David T Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
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22
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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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23
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Filler G, Ferris MEDGD. Discrepant changes of urinary cystatin C and other urinary biomarkers in preterm neonates. J Pediatr (Rio J) 2021; 97:473-475. [PMID: 33639089 PMCID: PMC9432192 DOI: 10.1016/j.jped.2021.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Guido Filler
- Western University, Schulich School of Medicine & Dentistry, Departments of Paediatrics and Medicine, London, Canada; Western University, The Lilibeth Caberto Kidney Clinical Research Unit, London, Canada; Western University, Schulich School of Medicine & Dentistry, Department of Pathology and Laboratory Medicine, London, Ontario, Canada.
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24
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Kavanaugh KJ, Jetton JG, Kent AL. Neonatal Acute Kidney Injury: Understanding of the Impact on the Smallest Patients. Crit Care Clin 2021; 37:349-363. [PMID: 33752860 DOI: 10.1016/j.ccc.2020.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The study of neonatal acute kidney injury (AKI) has transitioned from small, single-center studies to the development of a large, multicenter cohort. The scope of research has expanded from assessment of incidence and mortality to analysis of more specific risk factors, novel urinary biomarkers, interplay between AKI and other organ systems, impact of fluid overload, and quality improvement efforts. The intensification has occurred through collaboration between the neonatology and nephrology communities. This review discusses 2 case scenarios to illustrate the clinical presentation of neonatal AKI, important risk factors, and approaches to minimize AKI events and adverse long-term outcomes.
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Affiliation(s)
- Keegan J Kavanaugh
- Stead Family Department of Pediatrics, University of Iowa, 200 Hawkins Drive, 2015-26 BT, Iowa City, IA 52241, USA
| | - Jennifer G Jetton
- Division of Pediatric Nephrology, Dialysis, and Transplantation, Stead Family Department of Pediatrics, University of Iowa, 200 Hawkins Drive, 2029 BT, Iowa City, IA 52241, USA.
| | - Alison L Kent
- Division of Neonatology, Golisano Children's Hospital, University of Rochester School of Medicine, 601 Elmwood Avenue, Box 651, Rochester, NY 14642, USA; College of Health and Medicine, Australian National University, Canberra, Australian Capital Territory 2601, Australia. https://twitter.com/Aussiekidney
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25
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Fluid management, electrolytes imbalance and renal management in neonates with neonatal encephalopathy treated with hypothermia. Semin Fetal Neonatal Med 2021; 26:101261. [PMID: 34140246 DOI: 10.1016/j.siny.2021.101261] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Kidney dysfunction and acute kidney injury (AKI) frequently accompanies neonatal encephalopathy and contributes to neonatal morbidity and mortality. While there are currently no proven therapies for the treatment of AKI, understanding the pathophysiology along with early recognition and treatment of alterations in fluid, electrolyte and metabolic homeostasis that accompany AKI offer opportunity to reduce associated morbidity. Promising new tests and technologies, including urine and serum biomarkers and renal near-infrared spectroscopy offer opportunities to improve diagnosis and monitoring of neonates at risk for kidney injury. Furthermore, recent advances in neonatal kidney supportive therapies such as hemofiltration and hemodialysis may further improve outcomes in this population. This chapter provides an overview of disorders of fluid balance, electrolyte homeostasis and kidney function associated with neonatal encephalopathy and therapeutic hypothermia. Recommendations for fluid and electrolyte management based upon published literature and authors' opinions are provided.
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26
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Ottolini KM, Basu SK, Herrera N, Govindan V, Mashat S, Vezina G, Ridore M, Bost J, Chang T, Massaro AN. Positive fluid balance is associated with death and severity of brain injury in neonates with hypoxic-ischemic encephalopathy. J Perinatol 2021; 41:1331-1338. [PMID: 33649446 PMCID: PMC10363283 DOI: 10.1038/s41372-021-00988-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 01/15/2021] [Accepted: 02/03/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To investigate the association between fluid balance during therapeutic hypothermia (TH) and severity of brain injury on magnetic resonance imaging (MRI) in neonates with hypoxic-ischemic encephalopathy (HIE). STUDY DESIGN This is a secondary analysis of data from a prospective observational study in neonates with HIE. Daily net positive fluid balance during TH was investigated for association with the adverse primary outcome of death or moderate-to-severe brain injury on MRI using multivariable logistic regression. RESULTS Of the 150 neonates included, 50 suffered adverse outcome and had significantly higher net positive fluid balance (53 vs. 19 ml/kg/day, p < 0.01) during first 24 hours of TH. Neonates with a net positive fluid balance (>25 ml/kg/day) at 24 hours of TH had 3.4 (95% CI 1.3-9) times higher odds of adverse outcome. CONCLUSIONS Positive fluid balance during TH in neonates with HIE is independently associated with death or moderate-to-severe brain injury on MRI.
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Affiliation(s)
- Katherine M Ottolini
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Neonatology, 18th Healthcare Operations Squadron, Kadena AB, Okinawa, Japan
- Department of Pediatrics, Division of Neonatology, Uniformed Services University, Bethesda, MD, USA
| | - Sudeepta K Basu
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
| | - Nicole Herrera
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Vedavalli Govindan
- Division of Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA
| | - Suleiman Mashat
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - Gilbert Vezina
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA
| | - Michelande Ridore
- Division of Neonatology, Children's National Hospital, Washington, DC, USA
| | - James Bost
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA
- Division of Epilepsy, Neurophysiology & Critical Care, Children's National Hospital, Washington, DC, USA
| | - An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA.
- Department of Pediatrics, The George Washington University School of Medicine, Washington, DC, USA.
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27
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Rutledge A, Murphy HJ, Harer MW, Jetton JG. Fluid Balance in the Critically Ill Child Section: "How Bad Is Fluid in Neonates?". Front Pediatr 2021; 9:651458. [PMID: 33959572 PMCID: PMC8093499 DOI: 10.3389/fped.2021.651458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 03/15/2021] [Indexed: 12/16/2022] Open
Abstract
Fluid overload (FO) in neonates is understudied, and its management requires nuanced care and an understanding of the complexity of neonatal fluid dynamics. Recent studies suggest neonates are susceptible to developing FO, and neonatal fluid balance is impacted by multiple factors including functional renal immaturity in the newborn period, physiologic postnatal diuresis and weight loss, and pathologies that require fluid administration. FO also has a deleterious impact on other organ systems, particularly the lung, and appears to impact survival. However, assessing fluid balance in the postnatal period can be challenging, particularly in extremely low birth weight infants (ELBWs), given the confounding role of maternal serum creatinine (Scr), physiologic weight changes, insensible losses that can be difficult to quantify, and difficulty in obtaining accurate intake and output measurements given mixed diaper output. Although significant FO may be an indication for kidney replacement therapy (KRT) in older children and adults, KRT may not be technically feasible in the smallest infants and much remains to be learned about optimal KRT utilization in neonates. This article, though not a meta-analysis or systematic review, presents a comprehensive review of the current evidence describing the effects of FO on outcomes in neonates and highlights areas where additional research is needed.
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Affiliation(s)
- Austin Rutledge
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Heidi J. Murphy
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, United States
| | - Matthew W. Harer
- Department of Pediatrics (Neonatology), University of Wisconsin, Madison, WI, United States
| | - Jennifer G. Jetton
- Stead Family Department of Pediatrics (Nephrology), University of Iowa Health Care, Iowa City, IA, United States
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28
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Respiratory Variation in Aortic Blood Flow Velocity in Hemodynamically Unstable, Ventilated Neonates: A Pilot Study of Fluid Responsiveness. Pediatr Crit Care Med 2021; 22:380-391. [PMID: 33315755 DOI: 10.1097/pcc.0000000000002628] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To assess whether respiratory variation in aortic blood flow peak velocity can predict preload responsiveness in mechanically ventilated and hemodynamically unstable neonates. DESIGN Prospective observational diagnostic accuracy study. SETTING Third-level neonatal ICU. PATIENTS Hemodynamically unstable neonates under mechanical ventilation. INTERVENTIONS Fluid challenge with 10 mL/kg of normal saline over 20 minutes. MEASUREMENTS AND MAIN RESULTS Respiratory variation in aortic blood flow peak velocity and superior vena cava flow were measured at baseline (T0), immediately upon completion of the fluid infusion (T1), and at 1 hour after fluid administration (T2). Our main outcome was preload responsiveness which was defined as an increase in superior vena cava flow of at least 10% from T0 to T1. Forty-six infants with a median (interquartile range) gestational age of 30.5 weeks (28-36 wk) were included. Twenty-nine infants (63%) were fluid responders, and 17 (37%) were nonresponders Fluid responders had a higher baseline (T0) respiratory variation in aortic blood flow peak velocity than nonresponders (9% [8.2-10.8] vs 5.5% [3.7-6.6]; p < 0.001). Baseline respiratory variation in aortic blood flow peak velocity was correlated with the increase in superior vena cava flow from T0 to T1 (rho = 0.841; p < 0.001). The area under the receiver operating characteristic curve of respiratory variation in aortic blood flow peak velocity to predict preload responsiveness was 0.912 (95% CI, 0.82-1). A respiratory variation in aortic blood flow peak velocity cut-off point of 7.8% provided a 90% sensitivity (95% CI, 71-97), 88% specificity (95% CI, 62-98), 7.6 positive likelihood ratio (95% CI, 2-28), and 0.11 negative likelihood ratio (95% CI, 0.03-0.34) to predict preload responsiveness. CONCLUSIONS Respiratory variation in aortic blood flow velocity may be useful to predict the immediate response to a fluid challenge in hemodynamically unstable neonates under mechanical ventilation. If our results are confirmed, this measurement could be used to guide safe and individualized fluid resuscitation in critically ill neonates.
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29
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Vernamonti J, Gadepalli SK. Non-cardiac surgical considerations in pediatric patients with congenital heart disease. Semin Pediatr Surg 2021; 30:151036. [PMID: 33992307 DOI: 10.1016/j.sempedsurg.2021.151036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Jack Vernamonti
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, Ann Arbor, MI, USA.
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30
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Low hemoglobin levels are independently associated with neonatal acute kidney injury: a report from the AWAKEN Study Group. Pediatr Res 2021; 89:922-931. [PMID: 32526767 PMCID: PMC8730540 DOI: 10.1038/s41390-020-0963-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 04/30/2020] [Accepted: 05/03/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Studies in adults showed a relationship between low hemoglobin (Hb) and acute kidney injury (AKI). We performed this study to evaluate this association in newborns. METHODS We evaluated 1891 newborns from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database. We evaluated the associations for the entire cohort and 3 gestational age (GA) groups: <29, 29-<36, and ≥36 weeks' GA. RESULTS Minimum Hb in the first postnatal week was significantly lower in neonates with AKI after the first postnatal week (late AKI). After controlling for multiple potential confounders, compared to neonates with a minimum Hb ≥17.0 g/dL, both those with minimum Hb ≤12.6 and 12.7-14.8 g/dL had an adjusted increased odds of late AKI (aOR 3.16, 95% CI 1.44-6.96, p = 0.04) and (aOR 2.03, 95% CI 1.05-3.93; p = 0.04), respectively. This association was no longer evident after controlling for fluid balance. The ability of minimum Hb to predict late AKI was moderate (c-statistic 0.68, 95% CI 0.64-0.72) with a sensitivity of 65.9%, a specificity of 69.7%, and a PPV of 20.8%. CONCLUSIONS Lower Hb in the first postnatal week was associated with late AKI, though the association no longer remained after fluid balance was included. IMPACT The current study suggests a possible novel association between low serum hemoglobin (Hb) and neonatal acute kidney injury (AKI). The study shows that low serum Hb levels in the first postnatal week are associated with increased risk of AKI after the first postnatal week. This study is the first to show this relationship in neonates. Because this study is retrospective, our observations cannot be considered proof of a causative role but do raise important questions and deserve further investigation. Whether the correction of low Hb levels might confer short- and/or long-term renal benefits in neonates was beyond the scope of this study.
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31
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Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 2021; 41:185-195. [PMID: 32892210 DOI: 10.1038/s41372-020-00810-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/03/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
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32
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Leghrouz B, Kaddourah A. Impact of Acute Kidney Injury on Critically Ill Children and Neonates. Front Pediatr 2021; 9:635631. [PMID: 33981652 PMCID: PMC8107239 DOI: 10.3389/fped.2021.635631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 03/16/2021] [Indexed: 11/13/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome that manifests as an abrupt impairment of kidney function. AKI is common in critically ill pediatric patients admitted to the pediatric intensive care units. AKI is a deleterious complication in critically ill children as it is associated with increased morbidity and mortality. This review provides an overview of the incidence, morbidity, and mortality of AKI in critically ill children in general and specific cohorts such as post-cardiac surgeries, sepsis, critically ill neonates, and post stem cell transplantation.
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Affiliation(s)
- Bassil Leghrouz
- Pediatric Nephrology and Hypertension Division, Sidra Medicine, Doha, Qatar
| | - Ahmad Kaddourah
- Pediatric Nephrology and Hypertension Division, Sidra Medicine, Doha, Qatar.,Weill Cornel Medical College, Ar-Rayyan, Qatar
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33
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Matsushita FY, Krebs VLJ, Ferraro AA, de Carvalho WB. Early fluid overload is associated with mortality and prolonged mechanical ventilation in extremely low birth weight infants. Eur J Pediatr 2020; 179:1665-1671. [PMID: 32382790 DOI: 10.1007/s00431-020-03654-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/13/2020] [Accepted: 04/16/2020] [Indexed: 12/31/2022]
Abstract
Recent studies revealed that fluid overload is associated with higher mortality in critically ill children and adults. This study aimed to evaluate the association between fluid overload in the first 3 days of life and mortality in extremely low birth weight infants. This single-center retrospective cohort study included two hundred nineteen newborns with birth weight less than 1000 g who were admitted to the neonatal intensive care between January 2012 and December 2017. Overall mortality was 32.4%, the median gestational age was 27.3 (26.1-29.4) weeks, and birth weight was 770 (610-900) grams. In the group with severe fluid overload, we found a higher rate of deaths (72.2%); mean airway pressure was significantly higher and with longer invasive mechanical ventilation necessity.Conclusion: Early fluid overload in extremely low birth weight infants is associated with higher mortality rate, higher mean airway pressure in invasive mechanically ventilated patients, and longer mechanical ventilation duration in the first 7 days of life. What is Known: • Fluid overload is associated with a higher mortality rate and prolonged mechanical ventilation in children and adults. What is New: • Fluid overload in the first 72 h of life in an extremely premature infant is associated with higher mortality rate, higher mean airway pressure in invasive mechanically ventilated patients, and longer mechanical ventilation duration the first 7 days of life.
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Affiliation(s)
- Felipe Yu Matsushita
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar 647, São Paulo, SP, 05403-000, Brazil
| | - Vera Lúcia Jornada Krebs
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar 647, São Paulo, SP, 05403-000, Brazil
| | - Alexandre Archanjo Ferraro
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar 647, São Paulo, SP, 05403-000, Brazil
| | - Werther Brunow de Carvalho
- Department of Pediatrics, Neonatology Division, Faculty of Medicine of the University of São Paulo, Instituto da Criança, Av. Dr. Enéas de Carvalho Aguiar 647, São Paulo, SP, 05403-000, Brazil.
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34
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McCulloch M, Luyckx VA, Cullis B, Davies SJ, Finkelstein FO, Yap HK, Feehally J, Smoyer WE. Challenges of access to kidney care for children in low-resource settings. Nat Rev Nephrol 2020; 17:33-45. [PMID: 33005036 DOI: 10.1038/s41581-020-00338-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2020] [Indexed: 12/11/2022]
Abstract
Kidney disease is a global public health concern across the age spectrum, including in children. However, our understanding of the true burden of kidney disease in low-resource areas is often hampered by a lack of disease awareness and access to diagnosis. Chronic kidney disease (CKD) in low-resource settings poses multiple challenges, including late diagnosis, the need for ongoing access to care and the frequent unavailability of costly therapies such as dialysis and transplantation. Moreover, children in such settings are at particular risk of acute kidney injury (AKI) owing to preventable and/or reversible causes - many children likely die from potentially reversible kidney disease because they lack access to appropriate care. Acute peritoneal dialysis (PD) is an important low-cost treatment option. Initiatives, such as the Saving Young Lives programme, to train local medical staff from low-resource areas to provide care for AKI, including acute PD, have already saved hundreds of children. Future priorities include capacity building for both educational purposes and to provide further resources for AKI management. As local knowledge and confidence increase, CKD management strategies should also develop. Increased awareness and advocacy at both the local government and international levels will be required to continue to improve the diagnosis and treatment of AKI and CKD in children worldwide.
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Affiliation(s)
- Mignon McCulloch
- Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa.
| | - Valerie A Luyckx
- Institute of Biomedical Ethics and the History of Medicine, University of Zurich, Zurich, Switzerland.,Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric and Adult Renal Units, University of Cape Town, Cape Town, South Africa
| | - Brett Cullis
- Pediatric and Adult Renal Units, University of Cape Town, Cape Town, South Africa.,Nelson Mandela School of Medicine, University of Kwazulu Natal, Durban, South Africa
| | - Simon J Davies
- Faculty of Medicine and Health Sciences, Keele University, Keele, UK
| | | | - Hui Kim Yap
- Khoo Teck Puat - National University Children's Medical Institute, National University Hospital, Kent Ridge, Singapore
| | - John Feehally
- International Society of Nephrology, Brussels, Belgium
| | - William E Smoyer
- Nationwide Children's Hospital, Columbus, OH, USA.,The Ohio State University, Columbus, OH, USA
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Abstract
Many questions surround fluid bolus therapy and subsequent fluid management in neonatal critical care as they do in pediatric and adult critical care. This review explores the known key clinical aspects of fluid bolus therapy and fluid balance in the first 7 days of life and provides suggestions for further work in this area. It draws on the pediatric and adult critical care literature to provide thought-provoking data around the potential harms of excessive intravenous fluids, which may prove relevant to neonatology. Current data suggest that fluid bolus therapy and early-life positive fluid balance in neonates may be associated with harm.
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Affiliation(s)
- Erin Grace
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia
| | - Amy K Keir
- Department of Neonatal Medicine, Women's and Children's Hospital, North Adelaide, South Australia; SAHMRI Women and Kids, South Australian Health and Medical Research Institute, Adelaide, South Australia; Adelaide Medical School and the Robinson Research Institute, University of Adelaide, Adelaide, South Australia.
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36
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Koyner JL, Zarbock A, Basu RK, Ronco C. The impact of biomarkers of acute kidney injury on individual patient care. Nephrol Dial Transplant 2020; 35:1295-1305. [PMID: 31725154 PMCID: PMC7828472 DOI: 10.1093/ndt/gfz188] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 08/10/2019] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) remains a common clinical syndrome associated with increased morbidity and mortality. In the last several years there have been several advances in the identification of patients at increased risk for AKI through the use of traditional and newer functional and damage biomarkers of AKI. This article will specifically focus on the impact of biomarkers of AKI on individual patient care, focusing predominantly on the markers with the most expansive breadth of study in patients and reported literature evidence. Several studies have demonstrated that close monitoring of widely available biomarkers such as serum creatinine and urine output is strongly associated with improved patient outcomes. An integrated approach to these biomarkers used in context with patient risk factors (identifiable using electronic health record monitoring) and with tests of renal reserve may guide implementation and targeting of care bundles to optimize patient care. Besides traditional functional markers, biochemical injury biomarkers have been increasingly utilized in clinical trials both as a measure of kidney injury as well as a trigger to initiate other treatment options (e.g. care bundles and novel therapies). As the novel measures are becoming globally available, the clinical implementation of hospital-based real-time biomarker measurements involves a multidisciplinary approach. This literature review discusses the data evidence supporting both the strengths and limitations in the clinical implementation of biomarkers based on the authors' collective clinical experiences and opinions.
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Affiliation(s)
- Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Rajit K Basu
- Division of Critical Care Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
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37
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Mishra OP, Prasad R. Acute Peritoneal Dialysis in Neonates with Acute Kidney Injury. Indian Pediatr 2020. [DOI: 10.1007/s13312-020-1810-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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38
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Selewski DT, Gist KM, Nathan AT, Goldstein SL, Boohaker LJ, Akcan-Arikan A, Bonachea EM, Hanna M, Joseph C, Mahan JD, Mammen C, Nada A, Reidy K, Staples A, Wintermark P, Griffin R, Askenazi DJ, Guillet R. The impact of fluid balance on outcomes in premature neonates: a report from the AWAKEN study group. Pediatr Res 2020; 87:550-557. [PMID: 31537009 PMCID: PMC7036003 DOI: 10.1038/s41390-019-0579-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 06/26/2019] [Accepted: 08/30/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND We evaluated the epidemiology of fluid balance (FB) over the first postnatal week and its impact on outcomes in a multi-center cohort of premature neonates from the AWAKEN study. METHODS Retrospective analysis of infants <36 weeks' gestational age from the AWAKEN study (N = 1007). FB was defined by percentage of change from birth weight. OUTCOME Mechanical ventilation (MV) at postnatal day 7. RESULTS One hundred and forty-nine (14.8%) were on MV at postnatal day 7. The median peak FB was 0% (IQR: -2.9, 2) and occurred on postnatal day 2 (IQR: 1,5). Multivariable models showed that the peak FB (aOR 1.14, 95% CI 1.10-1.19), lowest FB in first postnatal week (aOR 1.12, 95% CI 1.07-1.16), and FB on postnatal day 7 (aOR 1.10, 95% CI 1.06-1.13) were independently associated with MV on postnatal day 7. In a similar analysis, a negative FB at postnatal day 7 protected against the need for MV at postnatal day 7 (aOR 0.21, 95% CI 0.12-0.35). CONCLUSIONS Positive peak FB during the first postnatal week and more positive FB on postnatal day 7 were independently associated with MV at postnatal day 7. Those with a negative FB at postnatal day 7 were less likely to require MV.
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Affiliation(s)
- David T Selewski
- Division of Nephrology, Department of Pediatric, Medical University of South Carolina, Charleston, SC, USA.
| | - Katja M Gist
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Amy T Nathan
- Perinatal Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Louis J Boohaker
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Ayse Akcan-Arikan
- Sections of Pediatric Critical Care Medicine and Renal, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth M Bonachea
- Department of Pediatrics, Section of Neonatology, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Mina Hanna
- Department Pediatrics, University of Kentucky, Lexington, KY, USA
| | - Catherine Joseph
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - John D Mahan
- Nationwide Children's Hospital, The Ohio State University, College of Medicine, Columbus, OH, USA
| | - Cherry Mammen
- Division of Nephrology, British Columbia Children's Hospital (BCCH), Vancouver, BC, Canada
| | - Arwa Nada
- Department of Pediatrics, Division of Nephrology, LeBonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kimberly Reidy
- Division of Nephrology, Department of Pediatrics, Children's Hospital at Montefiore/Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amy Staples
- Department of Pediatrics, University of New Mexico, Albuquerque, NM, USA
| | - Pia Wintermark
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Russell Griffin
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - David J Askenazi
- Pediatric and Infant Center for Acute Nephrology (PICAN) Department of Pediatrics, University of Alabama Birmingham, Birmingham, AL, USA
| | - Ronnie Guillet
- Department of Pediatrics, Division of Neonatology, Golisano Children's Hospital, University of Rochester, Rochester, NY, USA
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39
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Abstract
In 2013, literature about the epidemiology of neonatal acute kidney injury (AKI) was limited to primarily retrospective, single center studies that suggested that AKI was common and that those with AKI had higher rates of mortality. We developed a 24-center retrospective cohort of neonates admitted to the NICU between January 1 and March 31, 2014. Analysis of the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) cohort, has allowed us to describe the prevalence, risk factors and impact of neonatal AKI for different gestational age cohorts. The ample sample size allows us to provide convincing data to show that those with AKI have an increase independent higher odds of death and prolonged hospitalization time (1). This data mirrors similar studies in pediatric (2) and adult (3) critically ill populations which collectively suggest that patients do not just die with AKI, but instead, AKI is directly linked to hard clinical outcomes. This study has allowed us to answer multiple other questions in the field which has expanded our understanding of the risk factors, complications, impact of fluid overload, the definition of neonatal AKI and suggests interventions for improving outcomes. Furthermore, this project brought together neonatologist and nephrologist within and across centers. Finally, the AWAKEN project has enabled us to build relationships and infrastructure that has launched the Neonatal Kidney Collaborative http://babykidney.org/ on its way to accomplish its stated mission to improve the health of newborns with or at risk for kidney disease through multidisciplinary collaborative research, advocacy, and education.
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Affiliation(s)
- David Joseph Askenazi
- Section of Pediatric Nephrology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States.,Pediatric and Infant Center for Acute Nephrology, Children's of Alabama, Birmingham, AL, United States
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