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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 81-87
Risk factors associated with acute kidney injury in newborns


1 Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Department of Pediatrics, Ministry of Health, Cairo, Egypt

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Date of Web Publication15-Feb-2018
 

   Abstract 

Acute kidney injury (AKI) in the newborn is a common problem in the neonatal intensive care unit with many underlying factors such as asphyxia, respiratory distress syndrome (RDS), and urogenital anomalies. The aim of this study is to highlight possible risk factors and profile of neonates developing AKI in the Neonatal Intensive Care Unit (NICU) of Cairo University Pediatric Hospital. The study was carried out on 90 neonates (30 patients and 60 controls), among neonates admitted to NICU. The study was done over two months, from January 2015 to March 2015. Our study showed that sepsis was detected in 53.3%, prematurity in 46.67%, RDS in 43.3%, congenital heart disease in 20%, and hypoxic-ischemic encephalopathy in 6.67% of patients. Maternal illness and low body temperature were both significant risk factors of AKI in neonates. History of maternal illness, low body temperature, sepsis, prematurity, and respiratory distress can contribute to the development of AKI in neonates.

How to cite this article:
Ghobrial EE, Elhouchi SZ, Eltatawy SS, Beshara LO. Risk factors associated with acute kidney injury in newborns. Saudi J Kidney Dis Transpl 2018;29:81-7

How to cite this URL:
Ghobrial EE, Elhouchi SZ, Eltatawy SS, Beshara LO. Risk factors associated with acute kidney injury in newborns. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Jun 24];29:81-7. Available from: http://www.sjkdt.org/text.asp?2018/29/1/81/225179

   Introduction Top


Acute kidney injury (AKI) in the newborn is a common problem in the neonatal intensive care unit (NICU) with an incidence ranging from 6% to 24%.[1] Neonatal kidney injury can present with mild dysfunction up to complete anuria.[2],[3],[4]

Underlying factors contributing to AKI development include perinatal asphyxia, respiratory distress syndrome (RDS), prematurity, sepsis, umbilical artery catheterization, early drug administration especially aminoglycosides, volume depletion, and urogenital anomalies.[5],[6],[7],[8],[9]

AKI is suspected in newborns who have an elevated or rising serum creatinine and/or anuria/oliguria.[10] Diagnosis is confirmed when the serum creatinine is greater than 1.5 mg/dL (133 μmol/L) or increases by at least 0.2–0.3 mg/dL (17–27 μmol/L) per day. An elevated or rising serum creatinine is an indicator of a reduction in glomerular filtration rate, which is the hallmark of AKI.[11]

The aim of this study was to investigate the risk factors in neonates developing AKI in NICU of Cairo University Pediatric Hospital (CUPH).


   Patients and Methods Top


This retrospective case–control study was carried out on 90 neonates, who were admitted to the tertiary care NICU of CUPH, during a period of two months (from January 2015 to March 2015).

All neonates admitted at NICU for any medical condition were included in the study. Neonates presenting with congenital anomalies of the kidneys and the urinary tract were excluded from the study.

The included neonates were further subdivided into two groups; Group 1 included 30 neonates presenting with AKI and Group 2: control group included 60 neonates not presenting with AKI.

AKI was defined as increased serum creatinine or a reduction in urine output <1 mL/kg/h.[12]

All neonates were subjected to the following:

  • Demographic data including sex, gestational age, and duration of admission, antenatal history including maternal age, maternal illnesses (diabetes, hypertension, rheumatic heart disease, anemia, bronchial asthma, immune thrombocytopenic purpura, toxoplasmosis, autoimmune hepatitis, antepartum hemorrhage, premature rupture of membranes, and urinary tract infection), and maternal drug intake [antibiotics, steraids, low-molecular-weight heparin and treatment of diabetes mellitus (DM), and hypertension], natal history including mode of delivery, whether normal vaginal delivery or cesarean section as well as place of delivery, whether at home or at a hospital, and postnatal history including cyanosis, jaundice, respiratory distress, and perinatal asphyxia
  • All neonates were subjected to general examination including anthropometric measures (weight, length, and head circumference), vital signs (heart rate, respiratory rate, blood pressure, and temperature), skin examination (for pallor, edema, sclerema, and poor perfusion), and urine output. Systemic examination was performed for all neonates including chest examination (for the presence of respiratory distress), cardiovascular examination (for the presence of cardiac failure and poor perfusion), abdominal examination (for the presence abdominal distension, hepatomegaly, full bladder, and fullness of renal angle), and neurological examination (including assessment of the conscious level and neonatal reflexes)
  • Laboratory investigations were done for all neonates including complete blood count with differential [using a hematology coulter (Cell Dyne 3700, Abbott laboratories; North Chicago, USA)], Creactive protein, blood culture, arterial blood gasses, serum creatinine on days 3, 7, 14 of birth, and serum blood urea nitrogen and electrolytes such as sodium, potassium, and calcium on admission (using a multichannel autoanalyzer; Hitachi, Japan), urine analysis (to search other for findings of AKI such as proteinuria, red blood cells, and pus cells in urine), and urine culture and sensitivity.


Abdominal ultrasound was done as possible to search for renal findings such as increased echogenicity of kidneys.

Intravenous fluids, medications, and oxygen administration given to the patients were also recorded.

The first line of antibiotics in our study was combination of cefotaxime and gentamicin or amikacin in most of cases. The dose of amikacin in our study was 15 mg/kg/day intravenously every 12 h, the dose of gentamicin was 4 mg/kg/dose once daily, and the dose of cefotaxime was 100 mg/kg/day.


   Statistical Analysis Top


Data were analyzed by the Statistical Package for the Social Sciences program (SPSS) for Windows version 17.0 (SPSS Inc., Chicago, IL, USA). Excel computer program was used to tabulate the results and represent it graphically. Quantitative variables were expressed as mean and standard error. Qualitative variables were expressed as count and percent.

One-way ANOVA was used to declare the significant difference between groups at P <0.05. Duncan’s multiple comparison test at P <0.05 was used to declare the significant between each two groups. Chi-square test used to declare the significant difference in the distribution between groups at P<0.05.[13]


   Results Top


There were no statistically significant differences between study group and controls regarding maternal age (27.9 ± 5.6 vs. 28.7 ± 28 years, P = 0.516), gestational age (35.1 ± 3.3 vs. 35.1 ± 3.6 weeks, P = 0.983), and duration of admission (24.6 ± 13.3 vs. 25 ± 17.4 days, P = 0.84).

Maternal illness was associated with an increased risk of neonatal kidney injury with P = 0.011, as shown in [Table 1]. Details of the illnesses are shown in [Table 2].
Table 1: Perinatal and natal history and maternal history of the studied neonates.

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Table 2: Maternal illness and drug intake of the studied neonates.

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Sepsis, prematurity, RDS, congenital heart disease, persistent pulmonary hypertension, and intrauterine growth retardation were more common in cases than controls. All possible risk factors of AKI are shown in [Table 3].
Table 3: Risk factors among the studied neonates.

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[Table 4] shows average vital signs, urine output, and duration of admission of the studied neonates. There is a highly significant statistical difference between study group and control group as regarding temperature and urine output while showing no significant difference regarding other vital signs.
Table 4: Average vital signs, urine output, and duration of admission of the studied neonates.

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There is significant statistical difference between study group and controls regarding pH (P = 0.030) and potassium level (P = 0.005). There is also a highly significant statistical difference between cases and controls regarding blood urea nitrogen (BUN) and creatinine on days 3 and 7 (P <0.001, <0.001, <0.001, respectively), but there is no significant difference regarding creatinine on day 14 [Table 5]. None of the patients with AKI needed dialysis or continuous renal replacement therapy.
Table 5: Laboratory findings of the studied neonates.

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There was no statistically significant difference between cases and controls as regard to interventions and medications, as shown in [Table 6]. Nephrotoxic antibiotics were used for a short duration (< 1 week) in our study group and controls.
Table 6: Interventions and medications of the studied neonates.

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   Discussion Top


Pregnancy-induced hypertension (PIH), preterm prolonged rupture of membranes, administration of antenatal corticosteroid, umbilical vein catheterization, mechanical ventilation, and ibuprofen therapy for patent ductus arteriosus closure were found to be associated with AKI.[14]

Our study showed that male:female ratio was 1:1 while Mortazavi et al from Tabriz, Iran,[15] reported male predominance. Other studies revealed female predominance as high as 87.8% from a group from Tuzla, Bosnia and Herzegovina, Evlijana and Devleta (2015).[16]

The mean duration of hospitalization for each newborn was 24.6 ± 13.3 days. It should be noted that our hospital is a referral tertiary care center with more complex diagnoses, late presentation of cases, and high incidence of sepsis, which may explain the long duration of hospitalization of our patients.

Sepsis, perinatal asphyxia, and respiratory distress are predisposing factors of AKI.[15],[16],[17],[18],[19] In this study, sepsis was a predisposing factor in 53.3% of cases; RDS was the admission diagnosis of 43.3% of cases; and perinatal asphyxia occurred in 6.6% of the cases. This high incidence of sepsis in our study may be due to overcrowding, low nurses to patients’ ratio, and improper application to infection control measures. Therefore, infection control measures pre-, intra-, and postnatal are of utmost importance to overcome this high rate of neonatal sepsis with its high incidence of morbidity and mortality.

Sixteen out of 90 patients (17.7%) included in the study suffered from congenital heart disease (CHD). This may be due to the late presentation of cases as we are tertiary care center and many patients with CHD are referred to us. Neonates with CHD who undergo cardiac surgery are vulnerable to AKI.

It is to be noted that our study showed that low body temperature was one of the most significant risk factors of AKI in neonates (P <0.001). Our study showed that the mean urine output (UOP) was 1.9 ± 0.6, which, although normal, is significantly lower in cases than in controls (2.3 ± 0.8), (P = 0.043). This revealed that most of our AKI patients were nonoliguric, where oliguria is defined as UOP <1 mL/kg/h.[12]

Our study showed that certain maternal illnesses such as maternal hypertension were the most important significant risk factors of AKI in neonates (50%), which are significantly higher in cases than in controls (P = 0.011).

Our study showed that 33.33% of patients with AKI were exposed to maternal drug intake during pregnancy such as antibiotics, steroids, and treatment of DM, hypertension, and idiopathic thrombocytopenic purpura.

The mean level of BUN was significantly higher in the study group than in controls (P <0.001), and the mean level of creatinine on D3 and on D7 and almost 14 days was significantly higher in cases than in controls. Kidney affection is associated with an increase in the mean serum potassium level, and the mean potassium (K+) level was significantly higher in the study group than in controls (P = 0.005).

In our study, 33% of patients were treated by cefotaxime, 36.70% by vancomycin, 26.70% by amikacin, and 46.70% by gentamicin. Furthermore, other medications were also used in our patients, where 16.7 % were treated by diuretics, 50% by inotropes, 33.3% by benzodiazepines, and 33.3% by xanthines. Although the literature reports that nephrotoxic medications have a role in AKI in neonates, the values are not significant in our study.

The major limitation of this study was the lack of follow-up of patients after discharge.


   Conclusion Top


AKI in the newborn is a common problem in the neonatal intensive care unit. The study concluded that history of maternal illness and low body temperature were the most important risk factors of AKI in neonates. Sepsis, prematurity, and respiratory distress were also considered as contributing factors. Normalization of kidney functions takes 7–14 days.

Acknowledgment

We thank all nurses and employee in NICU who helped us to collect the data of the patients from their files.

Conflict of interest

The authors have no conflicts of interest relevant to this article.

This study was approved by the ethical scientific committee in the Cairo University hospital and was conducted in accordance with the University bylaws for human research. All caretakers have given their informed consent.

 
   References Top

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Itabashi K, Ohno T, Nishida H. Indomethacin responsiveness of patent ductus arteriosus and renal abnormalities in preterm infants treated with indomethacin. J Pediatr 2003;143:203-7.  Back to cited text no. 8
    
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Boer DP, de Rijke YB, Hop WC, Cransberg K, Dorresteijn EM. Reference values for serum creatinine in children younger than 1 year of age. Pediatr Nephrol 2010;25:2107-13.  Back to cited text no. 11
    
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Srisawat N, Hoste EE, Kellum JA. Modern classification of acute kidney injury. Blood Purif 2010;29:300-7.  Back to cited text no. 12
    
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Bolton S, Bon C. Pharmaceutical Statistics: Practical and Clinical Applications. 5th ed. Broken Sound Parkway, NW: Taylor and Francis; 2009.  Back to cited text no. 13
    
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Bolat F, Comert S, Bolat G, et al. Acute kidney injury in a single neonatal Intensive Care Unit in Turkey. World J Pediatr 2013;9:323-9.  Back to cited text no. 14
    
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Mortazavi F, Hosseinpour Sakha S, Nejati N. Acute kidney failure in neonatal period. Iran J Kidney Dis 2009;3:136-40.  Back to cited text no. 15
    
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Evlijana Z, Devleta H. Acute renal failure in the newborns hospitalized at the Intensive Care Unit university clinical centre Tuzla. J Clin Neonatal 2015;10:47-50.  Back to cited text no. 16
    
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Youssef D, Abd-Elrahman H, Shehab MM, Abd-Elrheem M. Incidence of acute kidney injury in the neonatal Intensive Care Unit. Saudi J Kidney Dis Transpl 2015;26:67-72.  Back to cited text no. 17
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Subramanian S, Agarwal R, Deorari AK, Paul VK, Bagga A. Acute renal failure in neonates. Indian J Pediatr 2008;75:385-91.  Back to cited text no. 18
    
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Cuzzolin L, Fanos V, Pinna B, et al. Postnatal renal function in preterm newborns: A role of diseases, drugs and therapeutic interventions. Pediatr Nephrol 2006;21:931-8.  Back to cited text no. 19
    

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Correspondence Address:
Dr. Emad E Ghobrial
Department of Pediatrics, Faculty of Medicine, Cairo University, Cairo
Egypt
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DOI: 10.4103/1319-2442.225179

PMID: 29456211

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    Abstract
   Introduction
   Patients and Methods
   Statistical Analysis
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