Therapeutic closure of the ductus arteriosus: benefits and limitations

Cost-effectiveness Analysis of Ibuprofen versus Indomethacin or Paracetamol for the Treatment of Patent Ductus Arteriosus in Preterm Neonates

OBJECTIVE

This was a first-time evaluation that sought to analyze the cost-effectiveness of oral paracetamol and intravenous (IV) indomethacin as alternatives to ibuprofen for PDA in neonates.

METHODS

Decision-analytic, literature-based, economic simulation models were constructed, to follow up the use and consequences of oral/IV ibuprofen versus IV indomethacin, and oral/IV ibuprofen versus oral paracetamol, as first-line therapies for PDA closure. Model outcomes of interest were 'success', defined as PDA closure with/without adverse events, or 'failure' due to no response to the first course of treatment, death or premature discontinuation of therapy due to AEs.

RESULTS

Oral ibuprofen is dominant/cost-effective over IV indomethacin in 97.9% of simulated cases, but oral paracetamol was 75.2% dominant/cost-effective over oral ibuprofen. Against IV ibuprofen, IV indomethacin was 55.3% dominant/cost-effective, whereas oral paracetamol was dominant/cost-effective in 98.5% of the cases. Sensitivity analyses confirmed the robustness of the study results.

CONCLUSION

For PDA closure, while IV indomethacin was cost-effective against IV ibuprofen, oral paracetamol was cost-effective against both oral and IV ibuprofen.

Ligation of patent ductus arteriosus through left anterior mini-thoracotomy in preterm infants

OBJECTIVE

Patent ductus arteriosus is an important cause of morbidity and mortality, especially in very low birth weight infants. The aim of the study is to report our single-centre short-term results of preterm patients who underwent ligation through left anterior mini-thoracotomy .

METHODS

Data of 27 preterm infants operated by the same surgeon who underwent Patent ductus arteriosus (PDA) closure with left anterior mini-thoracotomy technique between November 2020 and January 2022 at a single institution were reviewed. The patients were divided into two groups according to their weight at the time of surgery. Data on early postoperative outcomes and survival rates after discharge were collected.

RESULTS

Twenty-seven patients with a mean (±SD) gestational age of 25.8 (±2.0) weeks and a mean birth weight of 1027 (±423) g were operated using left anterior mini-thoracotomy technique. The lowest body weight was 480 g. Complications such as bleeding, abnormal healing of incision, or pneumothorax were not seen. There were 8 mortalities after the operation (29,6 %). The causes of the deaths were sepsis, necrotising enterocolitis, hydrops fetalis, hepatoblastoma, and intracranial bleeding. There was no statistically significant difference in the rates of complication between the groups.

CONCLUSIONS

Left anterior mini-thoracotomy technique can be performed as the first choice when transcatheter intervention cannot be applied in preterm infants. It provides easy access to the PDA, a good exposure, minimal contact with the lungs, good cosmetic results in early and mid-term and shortens the operation time, especially in very low birth weight preterm babies. However, early ligation may be helpful to minimise the complications related to PDA.

Intravenous acetaminophen (at 15 mg/kg/dose every 6 hours) in critically ill preterm neonates with patent ductus arteriosus: A prospective study

WHAT IS KNOWN AND OBJECTIVES

Acetaminophen has been increasingly used in treating patent ductus arteriosus (PDA) in preterm neonates. Variations were observed in the dosing regimen of acetaminophen across the studies. There is hardly any data available for a relatively higher dose of intravenous acetaminophen (15 mg/kg/dose every 6 hours) in the preterm population. We present here the results of a prospective study with this dose of intravenous acetaminophen for treating PDA in critically ill preterm neonates.

METHODS

Preterm neonates (≤37 weeks of gestational age) with haemodynamically significant PDA were enrolled. Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was administered. Echocardiographic monitoring, liver and renal function tests were carried out. Standard definitions were adhered for defining acute kidney injury (AKI) and hepatotoxicity.

RESULTS

Fifty-five neonates were recruited. Following the first dose, less than half had their serum acetaminophen concentrations in the therapeutic range. Extreme preterm neonates were less likely to have a sustained therapeutic acetaminophen concentration after the first dose. Following multiple doses and at steady state, 97.2% and 98.8% respectively were in the therapeutic range. Forty-three (78.2%) neonates had successful closure of the ductus arteriosus of which 22 were extreme preterm, 17 were very preterm and 4 were late preterm neonates; and considering their birthweights, 21 were extremely low, 16 were very low and 6 were low birthweight categories. Ten neonates had elevated alanine aminotransferase levels with three in the low-to-moderate risk of hepatotoxicity category. Eight neonates had altered renal function tests indicating AKI.

WHAT IS NEW AND CONCLUSION

Intravenous acetaminophen at 15 mg/kg/dose every 6 hours was efficacious in 78.2% of the preterm neonates with PDA. We observed a lower incidence of hepatotoxicity, and AKI in the study population. No association was observed between the serum acetaminophen concentrations and PDA closure.

Bedside surgical ligation of the patent ductus arteriosus in very-low-birth-weight premature infants: Limited upper ministernotomy as an alternative approach

BACKGROUND

Patent ductus arteriosus (PDA) is an important cause of morbidity and mortality, especially in very-low-birth-weight infants. The aim of the present study was to evaluate the outcomes of bedside surgical ligation of PDA via limited upper ministernotomy as an alternative approach to thoracotomy.

MATERIALS AND METHODS

A total of 23 low-birth-weight premature infants, who underwent bedside ligation of PDA in the neonatal intensive care unit between January 2017 and April 2020, were enrolled. The patients were divided into two groups: those with thoracotomy (n = 13) and those with limited upper ministernotomy (n = 10). These patients were evaluated retrospectively in terms of clinical and preoperative, intraoperative, postoperative parameters between the groups.

RESULTS

Mean birth weight was 1059 ± 275 g in the thoracotomy group and 1035 ± 285 g in the ministernotomy group. There was no statistically significant difference in the age at surgery, weight at surgery, preoperative mechanical ventilation (MV) support, inotropic score onset of surgery, and total procedure time between the groups. There was a statistically significant difference in the hospital length of stay, postoperative MV time, and complications in the intensive care unit in favor of the ministernotomy group (p = .04, p = .03, p = .034, respectively). The study showed no statistically significant difference in the mortality rate between the two groups (two patients in the thoracotomy group and one patient in the ministernotomy group).

CONCLUSION

The limited upper ministernotomy is an anatomically and technically feasible alternative to classical left posterolateral thoracotomy for bedside surgical PDA ligation.

Echocardiographic predictors of acute kidney injury in neonates with a patent ductus arteriosus

OBJECTIVE

To investigate acute kidney injury (AKI) in neonates with a patent ductus arteriosus (PDA) including incidence, risk factors, and possible correlations between PDA-related echocardiographic measurements and AKI incidence.

STUDY DESIGN

We conducted a single-center retrospective cohort study of infants admitted to the neonatal intensive care unit with a diagnosis of a PDA between July 2015 and July 2017. Infants were evaluated for development of AKI based on the KDIGO criteria and a multivariable logistic regression analysis was performed.

RESULTS

A total of 142 neonates with moderate or large PDAs were included, 43 (30%) developed AKI. Patients who developed AKI had longer length of stay, lower birth weights, lengths, and gestational ages. No echocardiographic measurements were predictive of an increased risk for developing AKI.

CONCLUSION

There are no significant differences in commonly measured echocardiographic markers of PDA hemodynamic significance in neonates who develop AKI.

Association of Placebo, Indomethacin, Ibuprofen, and Acetaminophen With Closure of Hemodynamically Significant Patent Ductus Arteriosus in Preterm Infants: A Systematic Review and Meta-analysis

IMPORTANCE

Despite increasing emphasis on conservative management of patent ductus arteriosus (PDA) in preterm infants, different pharmacotherapeutic interventions are used to treat those developing a hemodynamically significant PDA.

OBJECTIVES

To estimate the relative likelihood of hemodynamically significant PDA closure with common pharmacotherapeutic interventions and to compare adverse event rates.

DATA SOURCES AND STUDY SELECTION

The databases of MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until August 15, 2015, and updated on December 31, 2017, along with conference proceedings up to December 2017. Randomized clinical trials that enrolled preterm infants with a gestational age younger than 37 weeks treated with intravenous or oral indomethacin, ibuprofen, or acetaminophen vs each other, placebo, or no treatment for a clinically or echocardiographically diagnosed hemodynamically significant PDA.

DATA EXTRACTION AND SYNTHESIS

Data were independently extracted in pairs by 6 reviewers and synthesized with Bayesian random-effects network meta-analyses.

MAIN OUTCOMES AND MEASURES

Primary outcome: hemodynamically significant PDA closure; secondary: included surgical closure, mortality, necrotizing enterocolitis, and intraventricular hemorrhage.

RESULTS

In 68 randomized clinical trials of 4802 infants, 14 different variations of indomethacin, ibuprofen, or acetaminophen were used as treatment modalities. The overall PDA closure rate was 67.4% (2867 of 4256 infants). A high dose of oral ibuprofen was associated with a significantly higher odds of PDA closure vs a standard dose of intravenous ibuprofen (odds ratio [OR], 3.59; 95% credible interval [CrI], 1.64-8.17; absolute risk difference, 199 [95% CrI, 95-258] more per 1000 infants) and a standard dose of intravenous indomethacin (OR, 2.35 [95% CrI, 1.08-5.31]; absolute risk difference, 124 [95% CrI, 14-188] more per 1000 infants). Based on the ranking statistics, a high dose of oral ibuprofen ranked as the best pharmacotherapeutic option for PDA closure (mean surface under the cumulative ranking [SUCRA] curve, 0.89 [SD, 0.12]) and to prevent surgical PDA ligation (mean SUCRA, 0.98 [SD, 0.08]). There was no significant difference in the odds of mortality, necrotizing enterocolitis, or intraventricular hemorrhage with use of placebo or no treatment compared with any of the other treatment modalities.

CONCLUSIONS AND RELEVANCE

A high dose of oral ibuprofen was associated with a higher likelihood of hemodynamically significant PDA closure vs standard doses of intravenous ibuprofen or intravenous indomethacin; placebo or no treatment did not significantly change the likelihood of mortality, necrotizing enterocolitis, or intraventricular hemorrhage.

TRIAL REGISTRATION

PROSPERO Identifier: CRD42015015797.

Spontaneous Closure of Patent Ductus Arteriosus in Infants ≤1500 g

OBJECTIVES

Patent ductus arteriosus (PDA) remains a challenging issue in very low birth weight (VLBW) infants, and its management varies widely. Our aim in this study was to document the natural course of ductus arteriosus in a cohort of VLBW infants who underwent conservative PDA management with no medical or surgical intervention.

METHODS

A retrospective cohort study conducted in 2 European level-3 neonatal units.

RESULTS

A total of 368 VLBW infants were born within the study period. Two hundred and ninety-seven infants were free of congenital malformations or heart defects and survived to hospital discharge. Out of those, 280 infants received truly conservative PDA management. In 237 (85%) of nontreated infants, the PDA closed before hospital discharge. The Kaplan-Meier model was used to document the incidence proportion of PDA closure over time for different gestational age groups. The median time to ductal closure was 71, 13, 8, and 6 days in <26+0, 26+0 to 27+6, 28+0 to 29+6, and ≥30 weeks, respectively. For different birth weight groups, the median was 48, 22, 9, and 8 days in infants weighing <750, 750 to 999, 1000 to 1249, and 1250 to 1500 g, respectively. No statistically significant relationship was found between PDA closure before hospital discharge and neonatal morbidities.

CONCLUSIONS

The likelihood of PDA spontaneous closure in VLBW infants is extremely high. We provide in our findings a platform for future placebo-controlled trials focused on the smallest and youngest infants.

Bedside PDA ligation in premature infants less than 28 weeks and 1000 grams

Background

PDA(Patent ductus arteriosus) is a common and clinically important condition which is presented with a number of hemodynamic and respiratory problems such as intraventricular hemorrhage, pulmonary hemorrhage and necrotizing enterocolitis due to increased pulmonary blood flow and stealing from systemic circulation. The incidence of PDA among the infants that were born before the 28th gestational week is as high as 70 %; and spontaneous closure rates in very-low-birth-weight premature neonates(VLBWPN) is around 34 %. The onset, duration, and repeat number of consecutive courses of the prostaglandin synthesis inhibitor medication for PDA closure are still issues of debate. Bed-side PDA closure is a safe surgical procedure in both mature and premature babies. Here we aim to retrospectively present our 26 cases which were less than 28 weeks and 1000 grams that underwent bed-side PDA ligation.

Methods

This retrospective study included 26 VLBWPN with PDA that underwent bed-side ligation between 2012 and 2015. Babies were born before the 28th gestational week (23–27 weeks) and less than 1000 grams (489–970 gr). Of the 26, 15 were female and 11 were male. Indomethacin was administered to all of the cases as the medical closing agent. The medication was stopped due to unwanted effects in 6 cases. All of the patients took medical treatment before surgery.

Results

No surgical mortality occurred during our study. One case of pneumothorax was recorded as late surgical complication. Five of the 26 patients were lost, and the most common cause of mortality was sepsis (in 3 cases). The remaining 21 cases were discharged on days 86–238. The follow-up periods of the patients were 2 moths - 3 years. The most frequent problems encountered after discharge was chronic lung problems.

Conclusions

Bed side PDA ligation surgery in the ICU is a safe method for VLBWPN with clinically significant PDA.

Population pharmacokinetic study of gentamicin in a large cohort of premature and term neonates

AIM

This study aims to investigate the clinical and demographic factors influencing gentamicin pharmacokinetics in a large cohort of unselected premature and term newborns and to evaluate optimal regimens in this population.

METHODS

All gentamicin concentration data, along with clinical and demographic characteristics, were retrieved from medical charts in a Neonatal Intensive Care Unit over 5 years within the frame of a routine therapeutic drug monitoring programme. Data were described using non-linear mixed-effects regression analysis ( nonmem®).

RESULTS

A total of 3039 gentamicin concentrations collected in 994 preterm and 455 term newborns were included in the analysis. A two compartment model best characterized gentamicin disposition. The average parameter estimates, for a median body weight of 2170 g, were clearance (CL) 0.089 l h(-1) (CV 28%), central volume of distribution (Vc ) 0.908 l (CV 18%), intercompartmental clearance (Q) 0.157 l h(-1) and peripheral volume of distribution (Vp ) 0.560 l. Body weight, gestational age and post-natal age positively influenced CL. Dopamine co-administration had a significant negative effect on CL, whereas the influence of indomethacin and furosemide was not significant. Both body weight and gestational age significantly influenced Vc . Model-based simulations confirmed that, compared with term neonates, preterm infants need higher doses, superior to 4 mg kg(-1) , at extended intervals to achieve adequate concentrations.

CONCLUSIONS

This observational study conducted in a large cohort of newborns confirms the importance of body weight and gestational age for dosage adjustment. The model will serve to set up dosing recommendations and elaborate a Bayesian tool for dosage individualization based on concentration monitoring.

Drug Closure of a Patent Ductus Arteriosus in An Extremely Low Birth Weight Premature Newborn. A Case Report

Introduction

Patent ductus arteriosus involves maintaining the permeability of the vascular ductus located between the pulmonary artery and the descending aorta, due to the failure of transition from foetal to adult type circulation. This malformation is characteristic to premature newborns with extremely low birth weight. The main pathophysiological factors identified in this pathology are immaturity of the smooth muscles, presence of vasodilator mediators and persistent hypoxaemia. Ductal-dependent cardiac malformations require drug therapy for keeping the permeability of the ductus arteriosus until the time of corrective surgery.

Case presentation

We present the case of an extremely low birth weight premature newborn, derived from twin pregnancy with suspected specific pathology, respectively feto-fetal transfusion syndrome, admitted to the Regional Centre of Neonatal Intensive Care Unit Tîrgu-Mureş.Premature newborn with gestational age 31-32 weeks, extremely low birth weight, derived from twin pregnancy, with adequate prenatal follow up, was born by caesarean section for severe intrauterine growth restriction secondary to feto-fetal transfusion syndrome suspicion. The newborn developed respiratory distress syndrome by surfactant deficiency, intraventricular-haemorrhage grade I/II, and severe retinopathy. The detection of a systolic murmur in the second week of life, the diastolic theft revealed by trans-fontanellar ultrasound as well as lowered diastolic blood pressure values raised the suspicion of a patent ductus arteriosus and therefore specific treatment with ibuprofen, a cyclooxygenase inhibitor, was initiated. Progressive alteration of the newborn's condition and the evidence of a coarctation of the aorta imposed the initiation of Prostaglandin E1 therapy and subsequent surgical correction.

Conclusions

Although beneficial, prophylactic or therapeutic closure of persistent ductus arteriosus may worsen the evolution of a newborn with a "silent" cardiac malformation and associated pathology.

A Novel Echocardiographic Marker (PDAM) Incorporating the Diameter of the Patent Foramen Ovale to Assess Hemodynamically Significant Patent Ductus Arteriosus

Persistent hemodynamically significant patent ductus arteriosus (PDA) in preterm infants may lead to significant morbidity and increased mortality. This report proposes a new composite marker to predict a hemodynamically significant PDA, termed the PDA marker (PDAM) score, which incorporates the diameter of the patent foramen ovale (PFO) in addition to the ratio of the diameter of the left atrium to the diameter of the root of the aorta (LA/Ao) and ratio of the size of the patent ductus arteriosus to the left pulmonary artery (PDA/LPA) diameter. PDA was suspected in 191 infants between 2009 and 2013. Analysis of the data indicated that there was no significant difference between the accuracy of the PDA diameter and the PDAM score as markers of either a hemodynamically significant PDA or a very hemodynamically significant PDA that needed ligation. These data did show that the PDAM score provided slightly higher sensitivity (93.3%) and specificity (75.6%) than the PDA diameter to identify a PDA that needed ligation at the specified cutoff level of PDAM = 5.1. Consequently, clinicians may be more confident using the PDAM score, rather than the PDA diameter alone, when selecting PDA cases for surgical intervention.

Bedside surgery to treat patent ductus arteriosus in low-birth-weight premature infants

BACKGROUND

Patent ductus arteriosus (PDA) is commonly seen in premature infants with low birth weights (LBW). It is a condition that has high mortality and morbidity rates. Early closure of the ductus arteriosus may require surgery or medical treatment. However, the decision of first medical approach for symptomatic PDA closure is still debated. In this study, we compared the surgical and medical treatments for the closure of PDA in premature LBW infants.

METHODS

This study included 27 premature infants whose birth weights were lower than 1500 g, who were born in the period between 2011 and 2013 and had symptomatic PDA. Patients were separated into two groups: groups A and B. Group A included patients whose PDAs were closed with medical treatment (n = 16), and group B included patients who had undergone surgical operations for PDA closure (n = 11).

RESULTS

There were no statistically significant differences between groups A and B when the groups were compared in terms of birth weight, gestational age, respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), sepsis, intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP), and pneumothorax. Although the mortality rate was determined to be lower in group B (2 out of 11, 18.1%) than in group A (7 out of 16, 43.7%), no statistically significant difference was found between the two groups. A statistically significant increase was determined in the incidence of kidney function loss in patient group that received Ibuprofen, a medical treatment, in comparison to the patients who had surgery.

CONCLUSION

In conclusion, surgery is a safe method to repair PDA in premature LBW infants. Although there is no remarkable difference between surgery and medical treatment, we suggest that a surgical approach may be used as a first choice to repair PDA considering the lower rate of mortality and morbidity and higher rate of closure compared to medical treatment.

[Left vocal cord paralysis after patent ductus arteriosus surgery]

INTRODUCTION

Patent ductus arteriosus (PDA) is a common problem in preterm newborns. Left vocal cord paralysis (LVCP) can complicate surgical closure if the recurrent nerve is damaged.

MATERIALS AND METHODS

A retrospective case series study was conducted on preterm babies diagnosed with PDA in our unit from 1999 to 2013. Their clinical features and treatment complications were reviewed. In those patients that received surgical treatment a telephone questionnaire on the symptoms of LVCP symptoms was completed, and laryncoscopy examination offered.

RESULTS

A total of 88 subjects diagnosed with PDA were found, of whom 13.64% (12/88) needed surgery. These patients had a lower gestational age and birth weight. They required mechanical ventilation more frequently, and they had more complications such as, diaphragmatic paralysis, bronchopulmonary dysplasia and intraventricular hemorrhage. One third (3/9) of the surgically treated patients had LVCP, and all of them had dysphonia (100% vs. 16.7%, p=.05).

DISCUSSION

LVCP is a common complication of PDA surgery. Further studies are needed to determine its risk factors and its short and long-term consequences.

Patent ductus arteriosus, low platelets, cyclooxygenase inhibitors, and intraventricular hemorrhage in very low birth weight preterm infants

OBJECTIVE

To assess the risk for intraventricular hemorrhage (IVH) in very low birth weight preterm infants with patent ductus arteriosus (PDA) and low platelet count with treatment with cyclooxygenase (COX) inhibitors.

STUDY DESIGN

Diagnosis and treatment of PDA, as well as risk factors for IVH, were assessed using prospectively collected data of all infants born at a gestational age <32 weeks and with a birth weight ≤ 1500 g at Innsbruck University Hospital (January 2003-December 2009). Infants with severe thrombocytopenia (<50 × 10(9)/L) were excluded from analysis.

RESULTS

Sixty-five (20%) of the 325 infants had IVH, and 149 (45.9%) of the 325 were treated with COX inhibitors. Treatment of PDA with COX inhibitors was not an independent risk predictor for IVH in preterm infants with platelets ≥ 100 × 10(9)/L. However, COX inhibitors amplified the risk of bleeding in the presence of moderately decreased platelets (50-99 × 10(9)/L) on days of life 2-7. Multivariable OR for IVH were 0.89 [95% CI 0.43-1.87] for patients with platelets ≥ 100 × 10(9)/L and treatment with COX inhibitors, 3.40 [95% CI 1.13-10.29] for those with moderately decreased platelets without treatment, and 53.3 [95% CI 5.9-484] for patients with both moderately decreased platelets and COX inhibitor treatment compared with those with platelets ≥ 100 × 10(9)/L and no treatment (reference group) (P < .001).

CONCLUSION

In very low birth weight infants with moderate thrombocytopenia treatment with COX inhibitors increased the risk for intracerebral bleeding. Any benefits of this therapy should be carefully balanced against this potential hazard.

Does treatment of patent ductus arteriosus with cyclooxygenase inhibitors affect neonatal regional tissue oxygenation?

The effect of patent ductus arteriosus (PDA) treatment with cyclooxygenase (COX) inhibitors (indomethacin [INDO] and ibuprofen [IBU]) on regional oxygenation requires further clarification. The authors hypothesized that both INDO and IBU reduce regional tissue oxygenation in preterm neonates with PDA but that the risk is not uniform for different tissues and other factors may contribute. Regional cerebral (rSO(2-C)), renal (rSO(2-R)), and mesenteric (rSO(2-M)) tissue oxygenation measured by near-infrared spectroscopy and peripheral arterial oxygen saturation measured by pulse oximetry were recorded simultaneously before, during, and after treatment with the first dose of INDO or IBU in very preterm-born infants with PDA. Tissue-specific fractional oxygen extraction (FOE) was calculated using the rSO(2-C), rSO(2-R), rSO(2-M), and corresponding SpO(2) measurements. The findings showed a significant reduction in rSO(2-C), rSO(2-R), and rSO(2-M) and an increase in regional FOE after treatment with COX inhibitors in approximately one third of the 38 enrolled infants, which were associated with increased baseline regional tissue oxygen saturation (p < 0.01). However, the infants with posttreatment reduction of tissue oxygenation had significantly lower baseline rSO(2-C) (66.7 ± 8.1 vs 69.7 ± 8.1 %), rSO(2-R) (55.2 ± 10.8 vs 62.7 ± 11.8 %) and especially rSO(2-M) (37.8 ± 11.4 vs 46.7 ± 16.0 %) than the neonates with unchanged or increased tissue oxygenation. The two groups did not differ in terms of the risk for posttreatment reduction in regional tissue oxygenation with respect to either INDO or IBU treatment and their respective blood levels. Treatment of PDA with either INDO or IBU is associated with a 30-40 % risk for a reduction in regional tissue oxygenation, which is more pronounced in mesenteric tissue than in cerebral or renal tissue. Despite the inconsistency, reduction of regional tissue oxygenation in preterm infants with PDA is more likely associated with the administration of INDO than with the administration of IBU.

Treatment of patent ductus arteriosus (PDA) using ibuprofen: renal side-effects in VLBW and ELBW newborns

OBJECTIVES

This study aims to determine whether or not treatment of preterm neonates with PDA using IV ibuprofen can impair renal function and in what range of birth weights and gestational ages the risk of major renal side-effects due to ibuprofen is highest.

METHODS

134 preterm newborns with PDA were enrolled and randomized to receive either placebo or a 3-day-course (10, 5 and 5 mg/kg) of IV ibuprofen. 67 newborns (mGA: 27(+3) w and mBW: 989 g) with PDA received ibuprofen.

RESULTS

Subdividing the infants according to BW and to GA, the values of creatinine and BUN were only significantly higher than initial values at the end of the therapy in newborns with a BW ≤1000 g and/or GA ≤26 weeks. Renal impairment is greater the lower the weight and gestational age of the infant at birth.

CONCLUSIONS

Ibuprofen significantly impairs renal function in preterm infants with a GA ≤26 weeks and/or in ELBW neonates, while it may be considered safe for infants with a BW >1000 g and/or GA >26 weeks. Thus, before starting therapy with IV ibuprofen, it is essential to take into account the BW and GA of newborns and the effective need for treatment from the point of view of the ratio of risks to benefits, due to its substantial renal side-effects.

Early NT-proBNP is able to predict spontaneous closure of patent ductus arteriosus in preterm neonates, but not the need of its treatment

The objective of this study was to establish the potential utility of N-terminal pro-brain natriuretic peptide (NT-proBNP) in the management of patent ductus arteriosus (PDA). This was a monocentric prospective blind study that was conducted in a referral neonatal intensive care unit. The patients were very low-birth-weight/gestational-age neonates. Babies with cardiac congenital anomaly other than PDA, life-threatening congenital malformation, severe asphyxia at birth, persistent pulmonary hypertension, and death within the first week of life were excluded. Plasma NT-proBNP concentrations were determined on days 2, 4, and 7 of life. Echocardiography was performed on days 4 and 7. Results were blinded to clinicians. Only echographic results were available upon request. Thirty-one infants were included. NT-proBNP levels were significantly correlated to ductal size and to left atrial-to-aortic diameter ratio. The median NT-proBNP on both days 2 and 4 was significantly higher in neonates with later treated or persistent PDA. A level above 10.000 pg/mL at 48 h of age yielded a 100% positive and a 87% negative predictive value to exclude spontaneous ductal closure. However, no NT-proBNP threshold could predict which PDA would be judged necessary to treat. It was concluded that early low NT-proBNP values can be used as a reliable independent marker to predict spontaneous ductal closure in preterm neonates. Yet, high NT-proBNP levels should not be used to guide the decision to treat PDA, the risk being of treating many bystanding PDAs.