Outcomes of Acute Kidney Injury in Neonates

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Presentation transcript:

Outcomes of Acute Kidney Injury in Neonates 9th International pCRRT Conference on Pediatric Continuous Renal Replacement Therapy August 31-September 2, 2017 Outcomes of Acute Kidney Injury in Neonates Jordan M. Symons, MD University of Washington School of Medicine Seattle Children’s Hospital Seattle, WA

Neonatal AKI: How Do We Define It?

Neonatal AKI: Challenging to Define Often non-oliguric Unclear baseline Not steady state Less frequent labs Suboptimal markers Documentation issues Jetton & Askenazi, Clin Perinatol 2014

Neonatal AKI: What Interventions Do We Have?

Management of Established AKI: Pharmacotherapy Attempted Therapies Definitive Therapies Diuretics Mannitol Dopamine Fenoldopam Glucocorticoids Atrial natriuretic peptide N-acetylcysteine (other than contrast-induced AKI Hmmmm . . . . .

Prophylaxis of Neonatal AKI Theophylline may protect asphyxiated infants against AKI: However: Insufficient information on long-term renal or neurodevelopmental outcome Different doses between trials Toxicity remains unclear Unsure of interaction/benefit with hypothermia Al-Wassia et al. J Perinatol 2013

Conservative Management of Established AKI: Traditional Approach Limit fluid intake Limit input of retained substances Augment losses (diuretics) Try not to mess up Wait and Hope

Renal Replacement Therapy for Neonatal AKI

Renal Replacement Therapy for Neonatal AKI A New Era in Neonatal CRRT

Neonatal AKI: What About Outcomes?

Low Birthweight and AKI Study Population Results Koralkar1 VLBW (N=229) AKI incidence 18% Mortality 42% vs. 5% without AKI HR for death 9.3 (95% CI 4.1-21.0) Viswanathan2 ELBW (N=472; 46 AKI, 46 matched controls) AKI incidence 12.5% overall (59/472) Case mortality rate 70% in cases vs. 22% in controls Carmody3 VLBW (N=455) AKI incidence 39.8% More common in sicker infants (CRIB score <10) More common in most premature (gest age <28w) OR for death 4.0 (95% CI 1.4-11.5) 1. Koralkar et al. Pediatr Res 2011 3. Carmody et al. CJASN 2014 2. Viswanathan et al. Pediatr Nephrol 2012

ECMO and AKI Study Population Results Gadepalli1 All congen DH patients on ECMO from 1999-2009 (N=68) AKI incidence 71% Those with highest level of AKI: Lower survival (27% vs 80%; P=0.001) Longer ECMO (314 + 145 vs 197 + 115 hr; P=0.001) Fewer vent-free days in first 60 days of illness Zwiers2 All neonates over 14 year period placed on ECMO (N=242) Overall survival 74% AKI incidence 64% Lower survival to ICU discharge (35%) compared to milder AKI or no AKI (76-82% survival) 1. Gadepalli et al. J Pediatr Surg 2011 2. Zwiers et al. Crit Care 2013

Heart Surgery and AKI Study Population Results Blinder1 Infants <90d old undergoing surgery for CHD (N=430) AKI incidence 52% More severe AKI associated with mortality Stage 2: OR 5.1 (95% CI 1.7-15.2) Stage 3: OR 9.46 (95% CI 2.91-30.7) AKI also associated with longer ICU stay Al Abbas2 Infants <28d old undergoing surgery for CHD (N=122) AKI incidence 62% Stage 3 AKI associated with: Mortality: OR 6.7 (95% CI 1.08-41.50) Longer ICU stay: HR 9.09 (95% CI 1.35-60.95) 1. Blinder et al. J Thorac Cardiovasc Surg 2012 2. Al Abbas et al. Pediatr Nephrol 2013

Neonatal AKI in a PICU Population <28d old Gest age 38w AKI 35%; more common with Younger infant Bacteremia Higher serum sodium Kriplani et al. PCCM 2016

ppCRRT Data of Infants <10kg: Survival by Weight Group Askenazi et al. J Ped 2013

ppCRRT Data of Infants < 1 Month: Overall Survival

ppCRRT Data of Infants < 1 Month: Survival by Disease Category 73% 25% 33% 100% Totals: N=35 Survivors=15

Therapeutic Hypothermia: Protective Against AKI? Hypothermia standard of care for term infants with perinatal asphyxia RCT of 120 term infants (N=60 each) AKI AKI No AKI No AKI Tanigasalam et al. J Matern-Fetal Neo Med 2016

Neonatal AKI: What’s the Long-Term Outlook?

Risk for CKD After AKI Growing recognition of risk Mammen et al. (AJKD 2012) Up to 3-year follow-up for survivors of pediatric AKI in the ICU Markers of CKD Albuminuria; GFR; blood pressure

Risk for CKD After AKI CKD (low GFR or albuminuria) ~10% Risk of CKD (GFR 60-90; HTN; hyperfiltration) ~47% Mammen et al. AJKD 2012

Likelihood of Renal Recovery in Very Small Infants with AKI Retrospective review of 20 infants ELBW, AKI (mean Cr 2.9), up to 18-yr F/U Compared those with later CKD to normals 9/20 patients went on to develop CKD: Risk factors for progression: Urine Pr/Cr >0.6 at 1 yr Cr >0.6 mg/dL at 1 yr BMI >85th percentile Abitbol et al, Pediatr Nephrol 18:887, 2003

Acute Kidney Injury in Neonates: Summary Neonates are at special risk for AKI Unique physiology Clinical risks Nature of our interventions Like older children and adults, AKI is a significant problem for the newborn Morbidity and mortality Management remains a challenge Meeting the challenge is why we are here!

Good-Bye, AKI!

Thank You for Your Attention!