Management of Acute Kidney Injury in Extremely Low Birth Weight Infants

Abstract

Acute kidney injury (AKI) is a common problem in the neonatal intensive care unit (NICU). Neonates born at <1,000 g (extremely low birth weight, ELBW) are at an increased risk of secondary associated comorbidities such as intrauterine growth restriction, prematurity, volume restriction, ischaemic injury, among others. Studies estimate up to 50% ELBW infants experience at least one episode of AKI during their NICU stay. Although no curative treatment for AKI currently exists, recognition is vital to reduce potential ongoing injury and mitigate long-term consequences of AKI. However, the definition of AKI is imperfect in this population and presents clinical challenges to correct identification, thus contributing to under recognition and reporting. Additionally, the absence of guidelines for the management of AKI in ELBW infants has led to variations in practice. This review summarizes AKI in the ELBW infant and includes suggestions such as close observation of daily fluid balance, review of medications to reduce nephrotoxic exposure, management of electrolytes, maximizing nutrition, and the use of diuretics and/or dialysis when appropriate.

Pharmacovigilance of nephrotoxic drugs in neonates: the Pottel method for renal signal detection in ELBW neonates

“…Medication stewardship during nephrotoxic drug exposure, frequent in ELBW neonates, was shown to signi cantly reduce the AKI rates in NICUs by improving medication adjustments, altering nephrotoxic medication pharmacologic monitoring or discontinuation where appropriate. [7,8,21]. Furthermore, in preterm neonates exposure was also associated with elevated markers of kidney dysfunction at a median age of 5 years, irrespective of the development of AKI according to the classical de nitions, and thus suggesting subclinical kidney damage [23].…”

“…These de nitions all rely on de ned changes in urine output (UOP) or Scr assuming a steady-state situation and needing at least 2 observations. Their use is therefore limited in preterm neonates due to their time-dependent Scr physiology as well as challenges in accurately measuring UOP [11,14,21]. ELBW neonates exhibit a postnatal Scr rise from the day of birth (day 1) to approximately day 3 with a subsequent decline, more delayed with increasing immaturity [12].…”

Acute Kidney Injury in Very Low Birth Weight Infants: A Major Morbidity and Mortality Risk Factor

“…The often-unavoidable drugs include aminoglycosides such as gentamicin and amikacin, which are used as empirical treatment, and later vancomycin, and antifungal medications. While using these drugs in preterm infants, both serum levels of antibiotics, and serum creatinine are crucial for careful dose adjustment [45].…”

An Interesting Case of Neonatal AKI: What Is the Time to Consider Anuria Irreversible?

“…Data on PD in ELBW infants in the literature are limited, but PD is currently considered as the only rescue therapy for ELBW newborns affected by AKI, because there are no data regarding the efficacy of hemodialysis (HD) in this population [ 8 ]. Moreover, hemodialysis is extremely difficult perform in ELBW, because there is no small vascular catheter for HD for these children, and data regarding HD machines that can efficiently handle such low-exchange blood volumes are still extremely meager [ 4 , 9 ].…”