The impact of fluid balance on outcomes in premature neonates: a report from the AWAKEN study group.
Selewski DT, Gist KM, Nathan AT, Goldstein SL, Boohaker LJ, Akcan-Arikan A, Bonachea EM, Hanna M, Joseph C, Mahan JD, Mammen C, Nada A, Reidy K, Staples A, Wintermark P, Griffin R, Askenazi DJ, Guillet R; Neonatal Kidney Collaborative. Pediatr Res. 2019 Sep 19.
One hundred and forty-nine (14.8%) were on MV at postnatal day 7. The median peak FB was 0% (IQR: −2.9, 2) and occurred on postnatal day 2 (IQR: 1,5). Multivariable models showed that the peak FB (aOR 1.14, 95% CI 1.10–1.19), lowest FB in first postnatal week (aOR 1.12, 95% CI 1.07–1.16), and FB on postnatal day 7 (aOR 1.10, 95% CI 1.06–1.13) were independently associated with MV on postnatal day 7. In a similar analysis, a negative FB at postnatal day 7 protected against the need for MV at postnatal day 7 (aOR 0.21, 95% CI 0.12–0.35).
The Association of Intraventricular Hemorrhage and Acute Kidney Injury in Premature Infants from the Assessment of the Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) Study.
Stoops C., Boohaker L., Sims B., Griffin R., Selewski D.T., Askenazi D., on behalf of the National Kidney Collaborative (NKC). Neonatology. 2019 Aug 28:1-10.
AKI was documented in 22.2% (183/825) of infants and IVH in 14.3% (118/825). Infants with AKI (n = 183) were more likely to have IVH (26.8%, 49/183) than those without AKI (n= 642) who had IVH (10.7%, 69/642, p < 0.0001). After controlling for 5-min Apgar score, vasopressor support within the first week of age, and gestational age, infants with AKI had 1.6 times higher adjusted odds to develop any grade IVH (95% CI 1.04–2.56). Furthermore, infants of gestational age of 22–28 weeks had 1.9 times higher adjusted odds to develop IVH (OR 1.87, 95% CI 1.08–3.23).
Incidence and Risk Factors of Early Onset Neonatal AKI
Jennifer R. Charlton, Louis Boohaker, David Askenazi, Patrick D. Brophy, Carl D’Angio, Mamta Fuloria, Jason Gien, Russell Griffin, Sangeeta Hingorani, Susan Ingraham, Ayesa Mian, Robin K. Ohls, Shantanu Rastogi, Christopher J. Rhee, Mary Revenis, Subrata Sarkar, Alexandra Smith, Michelle Starr, Alison L. Kent and on behalf of the Neonatal Kidney Collaborative. CJASN February 2019
In over 2,000 patients, early AKI (≤7 days) occurred in 21% of neonates. Infants with early AKI had higher risk of death (aOR 2.8, 95% CI 1.7 to 4.7) and longer length of stay (7.3 days, 95% CI 4.7 to 10). Risk factors for early AKI are: outborn delivery; resuscitation with epinephrine; admission diagnosis of hyperbilirubinemia, inborn errors of metabolism, or surgical need; frequent kidney function surveillance; and admission to a children’s hospital. Protective factors were: multiple gestations, cesarean section, and exposures to antimicrobials, methylxanthines, diuretics, and vasopressors.
Neonatal Acute Kidney Injury: A Survey of Neonatologists' and Nephrologists' Perceptions and Practice Management.
Kent AL, Charlton JR, Guillet R, Gist KM, Hanna M5 El Samra A, Fletcher J, Selewski DT, Mammen C. Am J Perinatol. Jan 2018
Many knowledge gaps among neonatologists, and to a lesser extent, pediatric nephrologists were identified. Neonatologists were less likely to use categorical definitions of neonatal AKI (p <0.00001) or diagnose stage 1 AKI (p < 0.00001) than pediatric nephrologists. Guidelines for creatinine monitoring for nephrotoxic medications were reported by 34% (aminoglycosides) and 62% (indomethacin) of respondents. Nephrologists were more likely to consider follow-up after AKI than neonatologists (p < 0.00001). Also, 92 and 86% of neonatologists and nephrologists, respectively, reported no standardization or infrastructure for long-term renal follow-up.
Of 675 preterm infants ≤ 33 weeks, AKI occurred less frequently in neonates who received caffeine than those who did not (50 of 447 (11.2%) vs. 72 of 228 (31.6%), P<0.01). After multivariable adjustment, the number needed to treat to prevent one case of AKI was 4.3 and those receiving caffeine were less likely to develop high grade AKI (stage 2 or 3, OR 0.20, 95% CI 0.12-0.34).
Incidence of neonatal hypertension from a large multicenter study [Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates – AWAKEN]
Emily J. Kraut, Louis J. Boohaker, David J. Askenazi, Jeffery Fletcher, Alison L. Kent & on behalf of the Neonatal Kidney Collaborative (NKC). Pediatric Research. May 2018
Of over 2,000 infants, hypertension was documented in 1.8% and an additional 3.7% were defined as having undiagnosed hypertension. Hypertension was associated with a diagnosis of AKI and other risk factors for HTN were hyperbilirubinemia, Caucasian race, outborn, vaginal delivery and congenital heart disease. Protective factors were SGA, multiple gestation and maternal betamethasone.
Acute kidney injury in neonatal encephalopathy: an evaluation of the AWAKEN database.
Megan J. Kirkley, Louis Boohaker, Russell Griffin,Danielle E. Soranno, Jason Gien, David Askenazi, Katja M. Gist, On behalf of the Neonatal Kidney Collaborative (NKC). Pediatric Nephrology, August 2018.
Of 113 patients with neonatal encephalopathy, 41.6% developed AKI. Risk factors for AKI were outborn, IUGR and presence of meconium at delivery. AKI resulted in longer hospital stays (8.5 days, 95% CI 0.79-16.2).
The impact of fluid balance on outcomes in critically ill near term/term neonates: a report from the AWAKEN study group.
David T. Selewski, Ayse Akcan-Arikan, Elizabeth M. Bonachea, Katja M. Gist, Stuart L. Goldstein, Mina Hanna, Catherine Joseph, John D. Mahan, Arwa Nada, Amy T. Nathan, Kimberly Reidy, Amy Staples, Pia Wintermark, Louis J. Boohaker, Russell Griffin, David J. Askenazi, Ronnie Guillet & on behalf of the Neonatal Kidney Collaborative. Pediatric Research, September 2018.
The median peak fluid balance was 1.0% and occurred on post-natal day 3. Multivariable models showed the peak fluid balance, lowest fluid balance in 1st postnatal week and fluid balance on postnatal day 7 were independently associated with need for mechanical ventilation on postnatal day 7.
Optimizing the AKI definition during the first postnatal week using Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) cohort.
David Askenazi, Carolyn Abitbol, Louis Boohaker, Russell Griffin, Rupesh Raina, Joshua Dower, T. Keefe Davis, Patricio E. Ray, Sofia Perazzo, Marissa DeFreitas, Lawrence Milner, Namasivayam Ambalavanan, F. Sessions Cole, Erin Rademacher, Michael Zappitelli, Maroun Mhanna & for the Neonatal Kidney Collaborative. Pediatric Research, December 2018
The absolute rise in serum creatinine of 0.3 mg/dL outperformed a ≥50% rise in serum creatinine during the first week of life for predicting mortality. The optimal serum creatinine thresholds to predict AUC and specificity were ≥0.3 and ≥0.6 mg/dL for ≤29 weeks gestational age and ≥0.1 and ≥0.3 mg/dL for > 29 week gestational age. The maximum serum creatinine value provides great specificity.
Late onset neonatal acute kidney injury: results from the AWAKEN study.
Jennifer R. Charlton, Louis Boohaker, David Askenazi, Patrick D. Brophy, Mamta Fuloria, Jason Gien, Russell Griffin, Sangeeta Hingorani, Susan Ingraham, Ayesa Mian, Robin K. Ohls, Shantanu Rastogi, Christopher J. Rhee, Mary Revenis, Subrata Sarkar, Michelle Starr, Alison L. Kent & on behalf of the Neonatal Kidney Collaborative (NKC). Pediatric Research, December 2018
In over 2,000 patients, late AKI (> 7 days after birth) occurred in 9% of neonates. Infants with late AKI had increased risk of death (aOR 2.1, p=0.02) and longer length of stay (21.9, p<0.001). Risk factors for late AKI are: intubation, oligo- and polyhydramnios, mild-moderate renal anomalies, admission diagnoses of congenital heart disease, necrotizing enterocolitis, surgical need, exposure to diuretics, vasopressors, and NSAIDs, discharge diagnoses of patent ductus arteriosus, necrotizing enterocolitis, sepsis, and urinary tract infection.
In over 2,000 infants admitted to the NICU on IVF for at least 48 hours, 30% developed AKI based on the neonatal KDIGO definition. AKI varies by gestational age at birth: 48% for those born 22-29 weeks, 18% for 29-35 weeks and 37% for babies ≥ 36 weeks. Babies with AKI have higher mortality (OR 4.6, 95% CI 2.5-8.3) and longer length of hospital stay (8.8 days, 95% CI 6.1-11.5) after adjusting for multiple confounding factors.
Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates: Design of a Retrospective Cohort Study.
Jennifer G. Jetton, Ronnie Guillet, David J. Askenazi, Lynn Dill, Judd Jacobs, Alison L. Kent, David T. Selewski, Carolyn L. Abitbol, Fredrick J. Kaskel, Maroun J. Mhanna, Namasivayam Ambalavanan, Jennifer R. Charlton and the Neonatal Kidney Collaborative. Frontiers in Pediatrics. July 2016
Describes the formation of the NKC and establishment of the AWAKEN cohort and database – the largest most inclusive neonatal AKI study to date.
