1. 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

2. Neonatal AKI: How Do We Define It?

3. 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

4. Neonatal AKI: What Interventions Do We Have?

5. 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

6. 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

7. 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

8. Renal Replacement Therapy for Neonatal AKI

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

10. Neonatal AKI: What About Outcomes?

12. 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 )
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. Koralkar et al. Pediatr Res 2011
3. Carmody et al. CJASN 2014
2. Viswanathan et al. Pediatr Nephrol 2012

13. ECMO and AKI Study Population Results Gadepalli1
All congen DH patients on ECMO from (N=68)
AKI incidence 71%
Those with highest level of AKI:
Lower survival (27% vs 80%; P=0.001)
Longer ECMO ( vs 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

14. 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 )
Stage 3: OR 9.46 (95% CI )
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 )
Longer ICU stay: HR 9.09 (95% CI )
1. Blinder et al. J Thorac Cardiovasc Surg 2012
2. Al Abbas et al. Pediatr Nephrol 2013

15. 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

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

17. ppCRRT Data of Infants < 1 Month: Overall Survival

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

19. 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

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

21. 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

22. 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

23. 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

24. 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!

25. Good-Bye, AKI!

26. Thank You for Your Attention!