Prevalence of Acute Kidney Injury in Neonates with Congenital Diaphragmatic Hernia

Abstract

<b><i>Background:</i></b> Congenital diaphragmatic hernia (CDH) often presents with severe cardio-respiratory impairment in the neonatal period. Affected infants may be exposed to multiple nephrotoxic insults, predisposing them to acute kidney injury (AKI). The prevalence of AKI in a CDH cohort has not previously been described. <b><i>Objectives:</i></b> The primary aim of this study was to quantify the prevalence of AKI in patients with CDH treated in a single national centre. Secondarily, we investigated the association between AKI, select neonatal outcomes, and recognised AKI risk factors. <b><i>Methods:</i></b> This was a retrospective analysis of all patients with CDH treated at our regional neonatal surgical centre between September 2011 and December 2017. Data was collected on demographics, CDH Study Group stage (size), laboratory and physiological parameters, medications, mortality, and duration of hospitalisation. AKI severity was stratified using the modified paediatric RIFLE criteria, determined by comparing the percentage increase in serum creatinine from baseline. Statistical analysis was performed using Fisher’s exact and Pearson’s χ<sup>2</sup> tests for parametric analysis and Mann-Whitney U testing for non-parametric analysis. <b><i>Results:</i></b> Fifty-four CDH patients met the inclusion criteria, 37% of whom developed AKI. The development of AKI was significantly associated with larger CDH defect (type C/D; <i>p</i> = 0.014), extracorporeal membranous oxygenation support (<i>p</i> = 0.003), patch repair (<i>p</i> = 0.004), and exposure to vancomycin, corticosteroids and diuretics (<i>p</i> = 0.004, <i>p</i> = 0.007, and <i>p</i> ≤ 0.001, respectively). There was no statistical association between AKI and gentamicin administration, umbilical arterial catheter insertion, or significant infection. Prolonged hospitalisation and patient mortality were significantly associated with AKI (<i>p</i> = 0.01 and <i>p</i> = 0.001, respectively). <b><i>Conclusions:</i></b> AKI is common in CDH cases treated in our centre and is associated with adverse outcomes. Potentially modifiable risk factors include nephrotoxic medication exposure. Prevention and early recognition of contributory factors for AKI may improve outcomes in CDH.

Acute Kidney Injury, Fluid Overload, and Renal Replacement Therapy Differ by Underlying Diagnosis in Neonatal Extracorporeal Support and Impact Mortality Disparately

“…AKI also occurred in nearly 40% of infants with CDH adding to a small body of literature about AKI in neonates with CDH. Our AKI rates are lower than those reported by Gadepalli et al [9, 27] (71%) but similar to rates reported in a more recent study (63%). AKI in our subjects was most often stage 1.…”

“…Accordingly, the incidence of AKI in all diagnostic groups, including CDH, may be underestimated in our cohort. Furthermore, variables known to be associated with development of AKI, including CDH defect size and need for patch repair, were not examined here but may contribute to the differences in AKI rates [27].…”

Risk factors for acute kidney injury in neonates with congenital diaphragmatic hernia

“…The incidence of AKI in our study (38%) was comparable to that reported by Ryan et al (37%) in a similar cohort, but it was higher than the AWAKEN study (30%), which represented a more general neonatal population [ 14 , 15 ]. Within our cohort, infants requiring ECLS had an AKI incidence of 81%, which is higher than that reported by Gadepalli et al (71%) in a similar cohort of CDH ECLS infants [ 4 ] and higher than the general ECLS neonatal population (63–66%) [ 23 , 24 ].…”

“…AKI has been studied in specific neonatal populations. Ryan et al reported an AKI incidence of 37% in a cohort of 54 infants with CDH [ 15 ], and Gadepalli et al reported an incidence of 71% in those with severe CDH requiring ECLS [ 4 ]. Renal failure was associated with decreased ventilator-free days in the first 60 days of life and increased ECLS duration [ 4 ].…”

Risk Factors and Outcomes of Acute Kidney Injury in Neonates with Persistent Pulmonary Hypertension of the Newborn

“…Although causes of PPHN did not differ significantly between infants with and without AKI, CHD, and HIE accounted for majority (73.9%) of AKI cases and both of them have high risks for AKI. Ryan et al 16 reported that…”