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Ahn HC, Frymoyer A, Boothroyd DB, Bonifacio S, Sutherland SM, Chock VY. Acute kidney injury in neonates with hypoxic ischemic encephalopathy based on serum creatinine decline compared to KDIGO criteria. Pediatr Nephrol 2024:10.1007/s00467-024-06287-8. [PMID: 38326648 DOI: 10.1007/s00467-024-06287-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Neonates with hypoxic ischemic encephalopathy receiving therapeutic hypothermia (HIE + TH) are at risk for acute kidney injury (AKI). The standardized Kidney Disease Improving Global Outcomes (KDIGO) criteria identifies AKI based on a rise in serum creatinine (SCr) or reduced urine output. This definition is challenging to apply in neonates given the physiologic decline in SCr during the first week of life. Gupta et al. proposed alternative neonatal criteria centered on rate of SCr decline. This study aimed to compare the rate of AKI based on KDIGO and Gupta in neonates with HIE and to examine associations with mortality and morbidity. METHODS A retrospective review was performed of neonates with moderate to severe HIE + TH from 2008 to 2020 at a single center. AKI was assessed in the first 7 days after birth by KDIGO and Gupta criteria. Mortality, brain MRI severity of injury, length of stay, and duration of respiratory support were compared between AKI groups. RESULTS Among 225 neonates, 64 (28%) met KDIGO, 69 (31%) neonates met Gupta but not KDIGO, and 92 (41%) did not meet either definition. Both KDIGO-AKI and GuptaOnly-AKI groups had an increased risk of the composite mortality and/or moderate/severe brain MRI injury along with longer length of stay and prolonged duration of respiratory support compared to those without AKI. CONCLUSIONS AKI in neonates with HIE + TH was common and varied by definition. The Gupta definition based on rate of SCr decline identified additional neonates not captured by KDIGO criteria who are at increased risk for adverse outcomes. Incorporating the rate of SCr decline into the neonatal AKI definition may increase identification of clinically relevant kidney injury in neonates with HIE + TH.
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Affiliation(s)
- Haejun C Ahn
- Division of Pediatric Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA.
- Pediatric Nephrology, Swedish Health, Seattle, WA, USA.
| | - Adam Frymoyer
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Derek B Boothroyd
- Quantitative Sciences Unit, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Sonia Bonifacio
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Scott M Sutherland
- Division of Pediatric Nephrology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Valerie Y Chock
- Division of Neonatal and Developmental Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
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Joshi M, Muneer J, Mbuagbaw L, Goswami I. Analgesia and sedation strategies in neonates undergoing whole-body therapeutic hypothermia: A scoping review. PLoS One 2023; 18:e0291170. [PMID: 38060481 PMCID: PMC10703341 DOI: 10.1371/journal.pone.0291170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/03/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia (TH) is a widely practiced neuroprotective strategy for neonates with hypoxic-ischemic encephalopathy. Induced hypothermia is associated with shivering, cold pain, agitation, and distress. OBJECTIVE This scoping review determines the breadth of research undertaken for pain and stress management in neonates undergoing hypothermia therapy, the pharmacokinetics of analgesic and sedative medications during hypothermia and the effect of such medication on short- and long-term neurological outcomes. METHODS We searched the following online databases namely, (i) MEDLINE, (ii) Web of Science, (iii) Cochrane Library, (iv) Scopus, (v) CINAHL, and (vi) EMBASE to identify published original articles between January 2005 and December 2022. We included only English full-text articles on neonates treated with TH and reported the sedation/analgesia strategy used. We excluded articles that reported TH on transport or extracorporeal membrane oxygenation, did not report the intervention strategies for sedation/analgesia, and reported hypoxic-ischemic encephalopathy in which hypothermia was not applied. RESULTS The eligible publications (n = 97) included cohort studies (n = 72), non-randomized experimental studies (n = 2), pharmacokinetic studies (n = 4), dose escalation feasibility trial (n = 1), cross-sectional surveys (n = 5), and randomized control trials (n = 13). Neonatal Pain, Agitation, and Sedation Scale (NPASS) is the most frequently used pain assessment tool in this cohort. The most frequently used pharmacological agents are opioids (Morphine, Fentanyl), benzodiazepine (Midazolam) and Alpha2 agonists (Dexmedetomidine). The proportion of neonates receiving routine sedation-analgesia during TH is center-specific and varies from 40-100% worldwide. TH alters most drugs' metabolic rate and clearance, except for Midazolam. Dexmedetomidine has additional benefits of thermal tolerance, neuroprotection, faster recovery, and less likelihood of seizures. There is a wide inter-individual variability in serum drug levels due to the impact of temperature, end-organ dysfunction, postnatal age, and body weight on drug metabolism. CONCLUSIONS No multidimensional pain scale has been tested for reliability and construct validity in hypothermic encephalopathic neonates. There is an increasing trend towards using routine sedation/analgesia during TH worldwide. Wide variability in the type of medication used, administration (bolus versus infusion), and dose ranges used emphasizes the urgent need for standardized practice recommendations and guidelines. There is insufficient data on the long-term neurological outcomes of exposure to these medications, adjusted for underlying brain injury and severity of encephalopathy. Future studies will need to develop framework tools to enable precise control of sedation/analgesia drug exposure customized to individual patient needs.
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Affiliation(s)
- Mahima Joshi
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Javed Muneer
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
| | - Lawrence Mbuagbaw
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ipsita Goswami
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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3
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Giesinger RE, El-Khuffash AF, McNamara PJ. Arterial pressure is not reflective of right ventricular function in neonates with hypoxic ischemic encephalopathy treated with therapeutic hypothermia. J Perinatol 2023; 43:162-167. [PMID: 36460796 DOI: 10.1038/s41372-022-01567-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 10/29/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Abstract
AIM to evaluate the correlation of recovery of arterial pressure with physiological recovery among patients with hypoxic ischemic encephalopathy undergoing therapeutic hypothermia. METHODS At 24 h postnatal age, we compared 53 neonates of whom 22 (41%) were inotrope-treated to those untreated with cardiovascular medications. RESULTS Inotrope-treated patients had persistent severe right ventricular (RV) dysfunction and evidence of abnormal brain tissue oxygen delivery, despite recovered arterial pressure. CONCLUSION Arterial pressure is not reflective of RV function and the need for inotropic agents may be reflective of abnormal brain tissue oxygen delivery.
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Affiliation(s)
- R E Giesinger
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA.,The Hospital for Sick Children, Toronto, ON, Canada
| | - A F El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - P J McNamara
- Department of Pediatrics, University of Iowa, Iowa City, IA, USA. .,The Hospital for Sick Children, Toronto, ON, Canada. .,Department of Internal Medicine, University of Iowa, Iowa City, IA, USA.
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Jung P, Ha E, Zhang M, Fall C, Hwang M, Taylor E, Stetkevich S, Bhanot A, Wilson CG, Figueroa JD, Obenaus A, Bragg S, Tone B, Eliamani S, Holshouser B, Blood AB, Liu T. Neuroprotective role of nitric oxide inhalation and nitrite in a Neonatal Rat Model of Hypoxic-Ischemic Injury. PLoS One 2022; 17:e0268282. [PMID: 35544542 PMCID: PMC9094545 DOI: 10.1371/journal.pone.0268282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/26/2022] [Indexed: 12/01/2022] Open
Abstract
Background There is evidence from various models of hypoxic-ischemic injury (HII) that nitric oxide (NO) is protective. We hypothesized that either inhaled NO (iNO) or nitrite would alleviate brain injury in neonatal HII via modulation of mitochondrial function. Methods We tested the effects of iNO and nitrite on the Rice-Vannucci model of HII in 7-day-old rats. Brain mitochondria were isolated for flow cytometry, aconitase activity, electron paramagnetic resonance, and Seahorse assays. Results Pretreatment of pups with iNO decreased survival in the Rice-Vannucci model of HII, while iNO administered post-insult did not. MRI analysis demonstrated that pre-HII iNO at 40 ppm and post-HII iNO at 20 ppm decreased the brain lesion sizes from 6.3±1.3% to 1.0±0.4% and 1.8±0.8%, respectively. Intraperitoneal nitrite at 0.165 μg/g improved neurobehavioral performance but was harmful at higher doses and had no effect on brain infarct size. NO reacted with complex IV at the heme a3 site, decreased the oxidative stress of mitochondria challenged with anoxia and reoxygenation, and suppressed mitochondrial oxygen respiration. Conclusions This study suggests that iNO administered following neonatal HII may be neuroprotective, possibly via its modulation of mitochondrial function.
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Affiliation(s)
- Peter Jung
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Euntaik Ha
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Meijuan Zhang
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Carolyn Fall
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Mindy Hwang
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Emily Taylor
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Samuel Stetkevich
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Aditi Bhanot
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Christopher G. Wilson
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
- Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Johnny D. Figueroa
- Center for Health Disparities and Molecular Medicine, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Andre Obenaus
- Department of Pediatrics, School of Medicine, University of California, Irvine, CA, United States of America
| | - Shannon Bragg
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Beatriz Tone
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Saburi Eliamani
- Center for Imaging Research, Department of Radiology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Barbara Holshouser
- Center for Imaging Research, Department of Radiology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Arlin B. Blood
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
- Center for Perinatal Biology, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
| | - Taiming Liu
- Division of Neonatology, Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, United States of America
- * E-mail:
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Chen A, Chen X, Deng J, Zheng X. Research advances in the role of endogenous neurogenesis on neonatal hypoxic-ischemic brain damage. Front Pediatr 2022; 10:986452. [PMID: 36299701 PMCID: PMC9589272 DOI: 10.3389/fped.2022.986452] [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: 07/05/2022] [Accepted: 09/20/2022] [Indexed: 11/13/2022] Open
Abstract
Hypoxic-ischemic brain damage (HIBD) is the main cause of perinatal mortality and neurologic complications in neonates, but it remains difficult to cure due to scarce treatments and complex molecular mechanisms remaining incompletely explained. Recent, mounting evidence shows that endogenous neurogenesis can improve neonatal neurological dysfunction post-HIBD. However, the capacity for spontaneous endogenous neurogenesis is limited and insufficient for replacing neurons lost to brain damage. Therefore, it is of great clinical value and social significance to seek therapeutic techniques that promote endogenous neurogenesis, to reduce neonatal neurological dysfunction from HIBD. This review summarizes the known neuroprotective effects of, and treatments targeting, endogenous neurogenesis following neonatal HIBD, to provide available targets and directions and a theoretical basis for the treatment of neonatal neurological dysfunction from HIBD.
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Affiliation(s)
- Andi Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Xiaohui Chen
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Jianhui Deng
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China
| | - Xiaochun Zheng
- Department of Anesthesiology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, China.,Fujian Emergency Medical Center, Fujian Provincial Key Laboratory of Emergency Medicine, Fujian Provincial Key Laboratory of Critical Care Medicine, Fujian Provincial Co-Constructed Laboratory of "Belt and Road", Fuzhou, China
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