Neonatal Acute Kidney Injury: A Case Based Approach

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

Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study

Background: Single-center studies suggest that neonatal acute kidney injury (AKI) is associated with poor outcomes. However, inferences regarding the association between AKI, mortality, and hospital length of stay are limited due to the small sample size of those studies. In order to determine whether neonatal AKI is independently associated with increased mortality and longer hospital stay, we analyzed the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) database. Methods: All neonates admitted to 24 participating neonatal intensive care units from four countries (Australia, Canada, India, United States) between January 1 and March 31, 2014, were screened. Of 4273 neonates screened, 2022 (47·3%) met study criteria. Exclusion criteria included: no intravenous fluids ≥48 hours, admission ≥14 days of life, congenital heart disease requiring surgical repair at <7 days of life, lethal chromosomal anomaly, death within 48 hours, inability to determine AKI status or severe congenital kidney abnormalities. AKI was defined using a standardized definition -i.e., serum creatinine rise of ≥0.3 mg/dL (26.5 mcmol/L) or ≥50% from previous lowest value, and/or if urine output was <1 mL/kg/h on postnatal days 2 to 7. Findings: Incidence of AKI was 605/2022 (29·9%). Rates varied by gestational age groups (i.e., ≥22 to <29 weeks =47·9%; ≥29 to <36 weeks =18·3%; and ≥36 weeks =36·7%). Even after adjusting for multiple potential confounding factors, infants with AKI had higher mortality compared to those without AKI [(59/605 (9·7%) vs. 20/1417 (1·4%); p< 0.001; adjusted OR=4·6 (95% CI=2·5-8·3); p=<0·0001], and longer hospital stay [adjusted parameter estimate 8·8 days (95% CI=6·1-11·5); p<0·0001]. Interpretation: Neonatal AKI is a common and independent risk factor for mortality and longer hospital stay. These data suggest that neonates may be impacted by AKI in a manner similar to pediatric and adult patients

Does protein intake correlate with tubular function in very preterm neonates?

Background High protein intake in very preterm neonates (VPN) is important for growth. However, preterm kidneys have fewer functional nephrons and many of the ones present may be immature. Studies have shown that high protein intake induces nephron hypertrophy, proteinuria, and glomerular sclerosis, which lead to tubular injury. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a biomarker that is released during proximal tubular cell injury. The uNGAL to creatinine (uNGAL/Cr) ratio is commonly performed for normalization. Objective To assess for a possible association between protein intake and uNGAL/Cr ratio in VPN. Methods A prospective cohort study was conducted in two NICUs in Jakarta. Subjects’ urine specimens were collected at 0-48 hours, 72 hours, and 21 days after birth to determine uNGAL/Cr ratio as a biomarker of tubular injury. Protein was administered according to study sites NICU guidelines. Protein intake was recorded daily from 14-21 days of age for formula and measured twice with a human milk analyzer for breast milk. ELISA was used to measure uNGAL concentration. Low protein intake was defined as <3g/kg/day and high protein intake was defined as ?3g/kg/day. Maternal and perinatal variables were recorded from medical records. Results Fifty-nine VPN were recruited, of whom 39 completed the study. Median uNGAL/Cr ratio ranged from 0.32-104.11 ng/mg. The uNGAL/Cr ratio was not correlated with protein intake but was inversely correlated with gestational age and birth weight [r = -0.320, P=0.019 for the 72-hr (T2) urinary collection]. Higher uNGAL/Cr levels were associated with maternal infection [14.4 (range 4.4-104.1) vs 7.2 (range 0.5–32.4) ng/mg, P=0.004 at the 0-48-hr (T1)], maternal anemia [6.9 (range 1.2–66.6) vs 1.7 (range 0.3–89.2) ng/mg, P=0.001 at the 21-day (T3)] and nephrotoxic medication [15.9 (range 1.3–63.8) vs 1.0 (range 0.4–8.6) ng/mg, P=0.026 at the 72-hr]. Conclusion Protein intake according to current nutritional guidelines does not correlate with tubular injury in VPN, as measured by uNGAL/Cr ratio. Maternal infection, maternal anemia, lower birth weight, and nephrotoxic medication, were associated with higher uNGAL/Cr levels in VPN

Selected Lectures of the XXIV National Congress of the Italian Society of Neonatology (Società Italiana di Neonatologia, SIN); Rome (Italy); September 26-29, 2018

Selected Lectures of the XXIV National Congress of the Italian Society of Neonatology (Società Italiana di Neonatologia, SIN); Rome (Italy); September 26-29, 2018 Guest Editor: Mauro Stronati LECT 1. FEEDING INTOLERANCE IN PRETERM INFANTS • A. Aceti LECT 2. PREBIOTICS ARE ALL THE SAME • M. Agosti LECT 3. NURSE AND PAIN MANAGEMENT IN NEWBORN: THEORETICAL AND PRACTICAL ASPECTS • A. Allegro, I. Arenga, S. Lazzari LECT 4. THE “THINKING” NURSE: A RESOURCE OR A TROUBLESOME FIGURE? HOW TO INTERACT WITHIN A MULTIDISCIPLINARY TEAM • M. Altafini, D. Bolognini, P. Coscia LECT 5. COMPARISON OF PAIN MEASUREMENT PERFORMED BY NURSES AND PARENTS • G. Ancora, N. Simeone, E. Baudassi, T. Pesaresi, S. Grandi, F. Fabbri, S. Lazzari LECT 6. RED REFLEX AT BIRTH: AIM, EXECUTION AND IMPLEMENTATION • G. Araimo, S. Aversa, A. Baldascino, S. Frezza LECT 7. ERRORS IN THERAPY ADMINISTRATION IN THE NEONATAL INTENSIVE CARE UNIT: WHICH IS THE BEST STRATEGY TO PREVENT THEM? • M.C. Ariotti, F. Vignali, F. Logrippo, F. De Matteis, M. Luciano, A. Coscia, F. Cresi, E. Bertino LECT 8. KANGAROO MOTHER CARE AT THE HEART OF INDIVIDUALIZED FAMILY-CENTERED CARE: IMPLICATIONS FOR THE DEVELOPMENT OF PRETERM INFANTS • C. Artese, G. Calciolari LECT 9. KANGAROO MOTHER CARE IN ITALY: 2017 SURVEY • C. Artese, G. Paterlini; Neonatal Care Study Group LECT 10. NEWBORN OF MOTHERS AFFECTED BY THYROID DISEASE • G. Barera, M.C. Vigone, G. Vincenzi LECT 11. NURSING RECOMMENDATIONS ON THE SKIN MANAGEMENT OF TERM AND PRETERM INFANT • E. Bernabei, P. Coscia, M. Di Giuseppe, L. Guarinoni, S. Tuccio, V. Vanzi LECT 12. INTRAUTERINE GROWTH RESTRICTION: SHORT AND LONG TERM OUTCOME • E. Bertino, A. Coscia, E. Spada, M. Baricco, S. Sottemano, P. Di Nicola LECT 13. INTERSOCIETY POLICY STATEMENT ON THE USE OF WHOLE-EXOME SEQUENCING IN THE CRITICALLY ILL NEWBORN INFANT • A. Borghesi, M.A. Mencarelli, L. Memo, G.B. Ferrero, A. Bartuli, M. Genuardi, M. Stronati, A. Villani, A. Renieri, G. Corsello, on behalf of their respective Scientific Societies LECT 14. LET’S SHED SOME LIGHT ON DISCHARGE INSTRUCTIONS FOR NEWBORNS • K. Bressan, P. Paolillo LECT 15. STOP-IVH PROTOCOL IN VERY LOW BIRTH WEIGHT INFANTS: A QUALITY IMPROVEMENT APPROACH • L. Brombin, A. Galderisi, E. Baraldi, E. Lolli, D. Trevisanuto LECT 16. MINDFULNESS IN HELP FOR THE OPERATORS IN NICU: AN EXPERIMENTAL TRAINING PATH AT THE S. ANNA TURIN HOSPITAL • G. Cacciato, L. Ostacoli, M. Montanari LECT 17. KANGAROO MOTHER CARE: ITS BIRTH, WORLDWIDE DIFFUSION, SCIENTIFIC EVIDENCE • G. Calciolari LECT 18. USE OF BUNDLES TO PREVENT CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTION IN NEONATAL INTENSIVE CARE UNITS • A. Capasso, D. Celentano, R. Mastroianni, N. Pozzi LECT 19. NEONATE OF MOTHER WITH AUTOIMMUNE DISEASE • L. Capasso, M. Palma, C. Coppola, C. Gagliardo, C. Parrella, S. Cioffi, C. Colinet, F. Raimondi LECT 20. RETINOPATHY OR PREMATURITY: DIAGNOSIS AND THERAPEUTIC APPROACHES BY THE OPHTHALMOLOGIST • S. Capobianco LECT 21. STRATEGIES FOR HUMAN MILK FORTIFICATION • M. Carta, G. Corsello LECT 22. NEONATAL ACUTE KIDNEY INJURY: DIAGNOSIS AND TREATMENT CHALLENGE • D. Cattarelli LECT 23. ROLE OF MILRINONE IN THE MANAGEMENT OF RIGHT VENTRICULAR DYSFUNCTION • R.M. Cerbo LECT 24. MULTIDISCIPLINARY EXPERIENCE WITH A CASE OF OMPHALOPAGUS TWINS • M. Cheli, A. Barletta, M. Colledan, B.G. Locatelli, P. Betalli, L. Migliazza, M. Colusso LECT 25. NEONATAL CRANIAL ULTRASOUND: HOW TO OPTIMIZE ITS PERFORMANCE • A. Chiara LECT 26. A CLINICAL AND DIAGNOSTIC APPROACH TO A NEWBORN WITH MULTIPLE CONGENITAL MALFORMATIONS • P. Cianci, A. D’Ambra, L. Memo LECT 27. BASIC ECHOCARDIOGRAPHY COURSE FOR THE NEONATOLOGIST • I. Corsini, S. Fiocchi, K. Rossi, S. Salvadori, F. Schena, M. Savoia LECT 28. MANAGEMENT OF SHORT BOWEL SYNDROME IN THE NEONATAL POPULATION • L. Corvaglia, S. Martini LECT 29. STRATEGIES OF NUTRITION AND FORTIFICATION IN PRETERM SMALL-FOR-GESTATIONAL AGE OR GROWTH-RESTRICTED NEWBORNS • A. Coscia, M. Baricco LECT 30. THE MUCOPOLYSACCHARIDOSES • S. Costa, C. Cocca, G. Vento LECT 31. FEEDING INTOLERANCE AND GASTROESOPHAGEAL REFLUX • F. Cresi, E. Maggiora LECT 32. FAMILY-CENTERED CARE IN ITALIAN NEONATAL INTENSIVE CARE UNITS: PARENT EXPERIENCE AND SATISFACTION, A SYNTHESIS OF A MULTICENTER STUDY AND PRELIMINARY RESULTS • I. Dall’Oglio, A. Portanova, R. Mascolo, E. Tiozzo, A. Ragni, P. Amadio, O. Gawronski, M. Fiori, A. Dotta, C. Offidani, S. Piga, G. Rocco, R. Alvaro, J.M. Latour; the Italian NICUs Family-Centered Care Study Group LECT 33. RESPIRATORY SUPPORT AND PHARMACOLOGICAL TREATMENT OF BRONCHOPULMONARY DYSPLASIA: TOWARDS INDIVIDUALIZED CARE • C. Dani LECT 34. DECREASING THE POLLUTION OF HUMAN MILK, WHILE DEFENDING THE GOOD REPUTATION OF BREASTFEEDING • R. Davanzo, C. Di Lucca, A. Derosa, C. Mastrorilli, F. Forte, M. Delvecchio, P. Appio, V. Targiani, C. Figliuolo, T. Faillace LECT 35. CAN BLOOD GAS ANALYSIS BY UMBILICAL CORD ARTERY PREDICT CLINICAL OUTCOME IN NEWBORNS WITH APGAR SCORE ≥ 7 AT 5 MINUTES FROM BIRTH? • G. De Bernardo, R. Ippolito, M. Giordano, F. Beccagutti, D. Sordino, P. Villani LECT 36. ULTRASOUND FINDINGS IN NEONATAL MENINGITIS • A. Di Comite LECT 37. CONTAMINANTS IN INFANTS’ FOODS • S. Di Fabio, V. Nardi LECT 38. LEFT VENTRICULAR DYSFUNCTION: COULD BE FENOLDOPAM USEFUL? • D. Doni LECT 39. THE NEONATAL NETWORK OF THE ITALIAN SOCIETY OF NEONATOLOGY • A. Fabiano, D. Di Lallo, F. Franco, P. Paolillo LECT 40. VISUAL FUNCTION DEFICIT IN PRETERM NEWBORNS • E. Fazzi, L. Malerba, M. Gnesi, A. Rossi LECT 41. CASE REPORT: SEVERE ACUTE BRONCHIOLITIS • T. Fedeli, F. Cattaneo LECT 42. ACUTE KIDNEY INJURY: DEFINITION AND CLASSIFICATION • R. Galiano, P. Novellino LECT 43. HEALTH-RELATED QUALITY OF LIFE OF FORMERLY PRETERM INFANTS FROM CHILDHOOD TO ADULTHOOD • F. Gallini, D.U. De Rose, H. Hindocha, K. Del Vecchio, M. Coppola, L. Maggio LECT 44. COMPUTERIZED MANAGEMENT OF THE EMERGENCY: FROM THE REQUEST TO THE APPROPRIATE HOSPITALIZATION • M. Gente, F. Franco, D. Di Lallo LECT 45. SEX-RELATED DIFFERENCES IN THE OUTCOME OF PRETERM INFANTS: A REVIEW • P. Ghirri, M. Ciantelli LECT 46. GROWTH ASSESSMENT AND NUTRITION • M.L. Gianni, P. Roggero, F. Mosca LECT 47. BREASTFEEDING GUIDED BY NEWBORN • A. Giustardi, M. Stablum, A. Semjonova LECT 48. TEAMWORK AND ON THE JOB TRAINING IN NEONATAL INTENSIVE CARE UNIT • L. Guarinoni, E. Dioni LECT 49. THE ROLE OF THE NURSE IN THE PROMOTION OF THE KANGAROO MOTHER CARE IN THE NEONATAL INTENSIVE CARE UNIT • G. Ierardi, G. Cuomo, N. Bertoncelli, L. Lucaccioni, E. Garetti, L. Bedetti, F. Ferrari LECT 50. BREASTFEEDING PROMOTION IN NEONATAL INTENSIVE CARE UNIT • L. Ilardi LECT 51. PERINATAL PALLIATIVE CARE IN 2018: A NATIONAL SURVEY • P. Lago, M.E. Cavicchiolo, F. Benini LECT 52. METABOLIC ACIDOSIS IN CONGENITAL HEART DISEASES • S. La Placa LECT 53. RECENT ADVANCES IN BREASTFEEDING • S. Longo, M. Stronati LECT 54. CONJOINED TWINS: NEONATAL MANAGEMENT • G. Mangili, M. D’Angiò, C. Gilardi, M. Giozani, D. Martinelli LECT 55. INTRACAVITARY ECG FOR CENTRAL CATHETER’S TIP LOCATION IN INFANTS • R. Mastroianni, A. Capasso, N. Pozzi, D. Celentano LECT 56. RESPIRATORY VIRUS INFECTIONS IN CHILDREN: PREVENTION AND TREATMENT • P. Mastromarino, E. Schiavi LECT 57. COMMUNICATION, MEDIA, AND MASS-MEDIA: HOW CAN WE GET READY TO DEAL WITH ALL OF THIS? • A. Mattiola, B. Gigantesco, M. Del Pistoia, F. Lorenzoni, P. Ghirri, E. Sigali, S. Bardelli, S. Tognarelli, M. Ciantelli, R. Scaramuzzo, A. Cuttano LECT 58. GENETIC ASSOCIATION WITH CONGENITAL HEART DISEASE • I. Mauro LECT 59. EARLY STRESS AND EPIGENETIC EFFECTS IN PRETERM INFANTS • R. Montirosso, L. Provenzi LECT 60. FOLLOWING UP THE RESPIRATORY CONSEQUENCES OF PRETERM BIRTH • L. Moschino, M.E. Cavicchiolo, E. Baraldi LECT 61. NEONATAL BLEEDING DISORDERS AND PLASMA TRANSFUSION • M. Motta, B. Guaragni, G. Chirico LECT 62. ASSESSMENT OF NURSING SKILLS: THE EXPERIENCE OF A NEONATAL INTENSIVE CARE UNIT • S. Muscolo, L. Plevani LECT 63. EMERGING BIOMARKERS AND METABOLOMICS FOR MANAGING NEONATAL SEPSIS • M. Mussap, V. Fanos LECT 64. ENTERAL FEEDING IN PRETERM INFANTS: NOT AS TRIVIAL AS IT IS SUPPOSED TO BE • A. Orsi, L. Ilardi, A. Coscia, G. Salvatori, F. Cresi LECT 65. KANGAROO MOTHER CARE AND PROMOTION OF BREASTFEEDING: THE BREASTFEEDING WHEEL • S. Perugi LECT 66. NEUROLOGICAL COMPLICATIONS DURING RESPIRATORY SYNCYTIAL VIRUS INFECTION • S. Picone, F. Di Palma, D. Roma, P. Paolillo LECT 67. SEDATION FOR NEUROIMAGING IN INFANTS • A. Pirelli, B. Garetti, G. Cristofori, I. Arenga, L. Iantorno, P. Lago LECT 68. PERINATAL STROKE: CLINICAL CLUES AND DIAGNOSIS • E. Piro, I.A.M. Schierz, I. Greco, V. Vanella, G. Corsello LECT 69. ULTRASOUND GUIDED CENTRAL VENOUS ACCESS IN CRITICALLY ILL NEONATES AND INFANT BABIES • N. Pozzi, D. Celentano, R. Mastroianni, A. Capasso LECT 70. NATIONAL NETWORK OF THE ITALIAN SOCIETY OF NEONATOLOGY: DATA SOURCE FOR SCIENTIFIC PAPERS • C. Protano, F. Franco, D. Di Lallo, M. De Curtis LECT 71. ANTIBIOTIC PROPHYLAXIS IN THE NEONATE? • L. Pugni, I. Bottino, A. Ronchi, C. Pietrasanta, B. Ghirardi, F. Mosca LECT 72. ETHICAL ISSUES AND NEONATAL RESUSCITATION • C. Romagnoli LECT 73. NUTRITIONAL PROBLEMS IN SURGICAL INFANTS: WHICH IS THE GOAL? • G. Salvatori, S. Foligno LECT 74. SYSTEMIC THROMBOEMBOLISM AND CEREBRAL SINOVENOUS THROMBOSIS IN NEONATAL AGE • P. Saracco, A. Viano, R. Bagna, S. Viola, M. Magarotto LECT 75. USE OF SUCROSE IN MINOR INVASIVE PROCEDURE: WHAT’S NEW? • P. Savant Levet LECT 76. CARDIOVASCULAR ABNORMALITIES IN BRONCHOPULMONARY DYSPLASIA (BPD). BPD IS NOT A MATTER OF PULMONARY HYPERTENSION ONLY • M. Savoia LECT 77. NEUROPROTECTION IN ADDITION TO HYPOTHERMIA • A. Scoppa LECT 78. STRATEGIES FOR STIMULATION OF ORAL FEEDING CAPACITY IN PRETERM • E. Stimoli, A. Maini, P. Servi LECT 79. EARLY, PROTECTED AND ASSISTED NEONATAL HOSPITAL DISCHARGE • I. Stolfi, L. Bristot, R. Pedicino, C. Fassi, G. Terrin LECT 80. NEONATAL PAROXYSMAL MOTOR PHENOMENA: FROM SEMIOLOGY TO CLINICAL DIAGNOSIS • A. Suppiej LECT 81. REIKI AND HEALTH: THE MEETING BETWEEN AN ANCIENT ORIENTAL DISCIPLINE AND SCIENCE • A. Tallone LECT 82. PREDICTIVE ROLE OF URINARY METABOLIC PROFILE FOR ABNORMAL MAGNETIC RESONANCE IMAGING SCORE IN PRETERM NEONATES • M.L. Tataranno, S. Perrone, M. Longini, C. Coviello, M. Tassini, A. Vivi, M. Calderisi, L. deVries, F. Groenendaal, G. Buonocore, M. Benders LECT 83. PARENTERAL NUTRITION IN PRETERM NEONATE • G. Terrin, V. Bozzetti, O. Amato, M. Di Chiara LECT 84. CARE IN LOW-INCOME COUNTRIES • B. Tomasini, S. Zani, M.J. Caldes, M. Usuelli LECT 85. MIGRANTS AND EMERGING INFECTIOUS DISEASES • C. Tzialla LECT 86. EVALUATION OF EFFICACY OF GLUCOSE GEL VS. GLUCOSE SOLUTION USED FOR PAIN RELIEF IN NEWBORN BABIES. A RANDOMIZED BLIND CLINICAL TRIAL • P.L. Vasarri, M. Dalla Ragione, S. Fligor LECT 87. PERSISTENT PULMONARY HYPERTENSION OF THE NEWBORN NOT RESPONSIVE TO NITRIC OXIDE THERAPY; TWO CASES REPORT AND REVIEW OF LITERATURE • G. Vellani, G. Morandi, F.P. Fusco, I. Lombardo, E. Agazzani, M. Zanzucchi, G. Calzetti, S. Boccacci, V. Fasolato LECT 88. RESPIRATORY PHENOTYPES IN NEONATAL CHRONIC LUNG DISEASE: WHAT IS BEHIND THE OXYGEN REQUIREMENT? • M.L. Ventura, C. Rigotti LECT 90. PHARMACOKINETICS IN THE NEONATAL PERIOD • M. Regazzi LECT 91. ORAL FEEDING: A TEAMWORK FOR THE PRETERM • A. Orsi, N. Liotto, P. Piemontese, P. Roggero, F. Mosca LECT 92. RESVERATROL PLUS CARBOXYMETHYL-β-GLUCAN IN INFANTS WITH COMMON COLD: A RANDOMIZED DOUBLE-BLIND TRIAL • M.E. Baldassarre, A. Di Mauro, M. Fanelli, G. Labellarte, C. Pignatelli, N. Laforgia LECT 93. PROPHYLAXIS AND TREATMENT OF ACUTE BRONCHIOLITIS: STATE OF THE ART • P. Biban, A. Serra, F. Sacco, L. Andaloro, G. Pagano, S. Spaggiari, P. Bonetti, M. Gaffuri, R. Frassoldati, P. Santuz LECT 94. NEONATES OF DIABETIC MOTHER: METABOLOMICS • A. Dessì, R. Pintus, M. Puddu, G. Ottonello, V. Fano

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