Acute Kidney Injury in Premature Children With Hemodynamically Significant Open Arterial Duct

Abstract

Introduction. Hemodynamically significant patent ductus arteriosus (HSPDA) leads to the “steal” phenomenon of the systemic circulation and renal hypoperfusion, which can contribute to the development of acute kidney injury (AKI).
 Aim of the study. To assess the frequency and severity of AKI according to the criteria of neonatal modification of KDIGO in premature infants with HSPDA.
 Material and research methods. We examined 74 premature infants (gestational age 29-36 weeks) who were treated in the department of anesthesiology and intensive care of newborns. The duration of observation was ten days from the first day of life. The patients were divided into three groups depending on the presence of patent ductus arteriosus (PDA) and its hemodynamic significance: group I - 40 children with HSPDA, group II - 17 children with PDA without hemodynamic disorders, group III - 17 children with closed arterial duct. Clinical examination and treatment of premature infants was carried out according to the generally accepted methods. In HSPDA, ibuprofen was used to close the ductus arteriosus for 32 premature babies, and restrictive infusion therapy for 8 ones.
 Doppler echocardiography was performed at 5-11 hours of life and then daily to determine the PDA, its size and hemodynamic significance. Diagnosis and stratification of the severity of acute kidney injury were carried out according to the criteria of neonatal modification KDIGO, for which the concentration of serum creatinine was studied on the first, third, fifth, seventh, tenth days and the level of urine output every 6-12 hours.
 Research results. AKI on the third day of life was diagnosed in 52.5% of children with HSPDA, which is 2.2 times more often than in children with PDA without hemodynamic significance (p <0.05) and 4.4 times more often than with closed arterial duct (p<0.007). On the fifth day of life, AKI was detected in two more children and their total number increased to 57.5%. On the seventh and tenth days of life, AKI in children with HSPDA was more common than in children with a closed duct (50.0% versus 11.8%, p<0.008, and 29.4% versus 0%, p<0.02, respectively).
 Analysis of the severity of acute kidney injury showed the effect of HSPDA on this parameter. The presence of HSPDA was a factor that led to the development of stage II AKI on the third and fifth days of life. In addition, with HSPDA, the frequency of stage III AKI increased 2.7 times within four days, while the percentage of stages I-II AKI decreased by 1.5 times.
 The frequency and severity of AKI in children with HSPDA depended on the size of the ductus arteriosus. With PDA up to 2 mm in diameter, on the third and fifth days of life, AKI was diagnosed in every fifth patient of stage I only, and on the tenth day of life - only in one patient. Meanwhile, in the majority of children with a PDA diameter of more than 2 mm, AKI was diagnosed on the third, fifth and seventh days; only on the tenth day of life, the number of such patients decreased 1.3 times. But the proportion of severe acute kidney injury practically did not change - acute kidney injury of stages II-III was observed on the first day in every second child with a large PDA diameter.
 The serum creatinine level on the third and tenth days directly depended on the size of the PDA on the first day (ρ = 0.493, p˂0.001 and ρ = 0.432, p˂0.002, respectively). With HSPDA, this dependence was more pronounced (ρ = 0.732, p˂0.001 and ρ = 0.731, p˂0.001, respectively) than in the group with PDA without hemodynamic significance (ρ = 0.285, p<0.05 and ρ = 0.324, p>0.05, respectively). The serum creatinine concentration directly correlated with the closure time of the PDA. Analysis of the connection between the rate of closure of the PDA and the presence of AKI in the HSPDA group showed that in the case of late closure of the ductus arteriosus (at 3-5 days of life), 16 (94.1%) premature infants suffered from kidney damage versus 1 (5.9%) case among children, in which the duct closed in the first two days (OR = 36.57; CI: 4.02-332.34 p<0.001). A close correlation was also established between the rate of closure of the PDA and the maximum stage of the AKI (ρ = 0.700, p˂0.001).
 Conclusions. HSPDA contributes to the development of AKI in premature infants. The diameter and rate of closure of the ductus arteriosus determine the frequency and severity of AKI in premature infants with HSPDA. Additional research is needed to diagnose acute kidney injury in premature babies with HSPDA earlier.