Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study

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Abstract

Background

Single-center studies suggest that neonatal acute kidney injury (AKI) is associated with poor outcomes. However, inferences regarding the association between AKI, mortality, and hospital length of stay are limited due to the small sample size of those studies. In order to determine whether neonatal AKI is independently associated with increased mortality and longer hospital stay, we analyzed the Assessment of Worldwide Acute Kidney Epidemiology in Neonates (AWAKEN) database.

Methods

All neonates admitted to 24 participating neonatal intensive care units from four countries (Australia, Canada, India, United States) between January 1 and March 31, 2014, were screened. Of 4273 neonates screened, 2022 (47·3%) met study criteria. Exclusion criteria included: no intravenous fluids ≥48 hours, admission ≥14 days of life, congenital heart disease requiring surgical repair at <7 days of life, lethal chromosomal anomaly, death within 48 hours, inability to determine AKI status or severe congenital kidney abnormalities. AKI was defined using a standardized definition —i.e., serum creatinine rise of ≥0.3 mg/dL (26.5 mcmol/L) or ≥50% from previous lowest value, and/or if urine output was <1 mL/kg/h on postnatal days 2 to 7.

Findings

Incidence of AKI was 605/2022 (29·9%). Rates varied by gestational age groups (i.e., ≥22 to <29 weeks =47·9%; ≥29 to <36 weeks =18·3%; and ≥36 weeks =36·7%). Even after adjusting for multiple potential confounding factors, infants with AKI had higher mortality compared to those without AKI [(59/605 (9·7%) vs. 20/1417 (1·4%); p< 0.001; adjusted OR=4·6 (95% CI=2·5–8·3); p=<0·0001], and longer hospital stay [adjusted parameter estimate 8·8 days (95% CI=6·1–11·5); p<0·0001].

Interpretation

Neonatal AKI is a common and independent risk factor for mortality and longer hospital stay. These data suggest that neonates may be impacted by AKI in a manner similar to pediatric and adult patients.

Funding

US National Institutes of Health, University of Alabama at Birmingham, Cincinnati Children’s, University of New Mexico.

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Most cited references 25

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CRIB II: an update of the clinical risk index for babies score.

William Tarnow-Mordi, Janet Tucker, Gareth Parry (2003)

The clinical risk index for babies (CRIB) score is a risk-adjustment instrument widely used in neonatal intensive care. Its appropriateness with contemporary data has been questioned. We have examined these questions, developed a new five-item CRIB II score with data from a UK-wide sample of infants admitted to neonatal intensive care in 1998-99, and shown how mortality after neonatal intensive care has fallen in the past 12 years. CRIB II provides a recalibrated and simplified scoring system that avoids the potential problems of early treatment bias. A valid and simple method of risk-adjustment for neonatal intensive care is important to ensure accurate assessment of quality of care. Such assessments should be done in tandem with national audit systems for neonatal intensive care, incorporating measures of morbidity as well as mortality.

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Acute kidney injury reduces survival in very low birth weight infants.

David J. Askenazi, Emily Levitan, Stuart Goldstein … (2011)

Acute kidney injury (AKI) independently predicts mortality in children and adults. Our understanding of the epidemiology of AKI in very LBW (VLBW) infants is limited to retrospective studies. After adjustment for demographics, comorbidities, and interventions, infants with AKI have decreased survival compared with those without AKI. The study was conducted in regional quaternary care NICU of the University of Alabama at Birmingham. VLBW infants were followed prospectively and were classified into a serum creatinine (SCr)-based classification for AKI. Forty-one of 229 (18%) VLBW infants developed AKI. Those with AKI were more likely to have umbilical artery catheters, assisted ventilation, blood pressure medications, and lower 1-and 5-min Apgar scores. Of the infants with AKI, 17 of 41 (42%) died compared with 9 of 188 (5%) of those without AKI (p < 0.001). AKI was associated with mortality with a crude hazard ratio (HR) of 9.3 (95% CI, 4.1-21.0). After adjusting for potential confounders, those with AKI had higher chance of death as the adjusted HR was 2.4 (95% CI 0.95-6.04). AKI is associated with mortality in VLBW infants. Efforts to prevent and ameliorate the impact of AKI may improve the outcomes in this vulnerable population.

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Recognition and reporting of AKI in very low birth weight infants.

J Bryan Carmody, Jonathan R Swanson, Erika T Rhone … (2014)

AKI is associated with both increased short-term morbidity and mortality and greater long-term risk for CKD. This study determined the prevalence of AKI among very low birth weight infants using a modern study definition, evaluated the frequency of AKI diagnosis reporting in the discharge summary, and determined whether infants were referred to a pediatric nephrologist for AKI follow-up.

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Author and article information

Journal

Journal ID (nlm-journal-id): 101712925

Journal ID (pubmed-jr-id): 46885

Journal ID (nlm-ta): Lancet Child Adolesc Health

Journal ID (iso-abbrev): Lancet Child Adolesc Health

Title: The lancet child & adolescent health

ISSN (Electronic): 2352-4642

Publication date Nihms-submitted: 23 September 2017

Publication date (Print): November 2017

Publication date PMC-release: 01 November 2018

Volume: 1

Issue: 3

Pages: 184-194

Affiliations

[1 ]Department of Pediatrics — Division of Nephrology, Dialysis and Transplantation, University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa, USA

[2 ]Department of Pediatrics — Pediatric Nephrology, University of Alabama at Birmingham

[3 ]Kidney and Urology Institute. Medanta The Medicity, Gurgaon, India

[4 ]Neonatology, Cloudnine Hospital, Gurgaon, Haryana, India

[5 ]Medanta, The Medicity, Gurgaon, Haryana, India

[6 ]Department of Pediatrics — Pediatric Nephrology. University of Colorado and Children’s Hospital of Colorado, Aurora, Colorado, USA

[7 ]Department of Pediatrics, University of Kentucky, Lexington, Kentucky, USA

[8 ]Department of Pediatrics — Pediatric Nephrology. Stony Brook School of Medicine, Stony Brook, NY, USA

[9 ]Department of Pediatrics — Division of Nephrology, University of British Columbia

[10 ]Department of Pediatrics — Division of Neonatology, University of Virginia Children’s Hospital, Charlottesville, Virginia, USA

[11 ]Department of Pediatrics — Neonatology. Stony Brook School of Medicine, Stony Brook, NY, USA

[12 ]Department of Pediatrics — Division of Nephrology, University of New Mexico, Albuquerque, New Mexico, USA

[13 ]Department of Pediatrics — Pediatric Nephrology, Maimonides Medical Center, Albert Einstein College of Medicine, Brooklyn, New York, USA

[14 ]Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA

[15 ]Department of Pediatrics — Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, USA

Author notes

[* ]Corresponding Author: David J Askenazi, MD, MsPH, Department of Pediatrics — Division of Pediatric Nephrology, University of Alabama at Birmingham, daskenazi@ 123456peds.uab.edu , Phone: +1–205–638–9781, Fax: +1–205–996–7590, Postal address: ACC 516, 1600 7 ^TH Avenue South, Birmingham, AL 35233, USA

[**]

NKC Contributors

The following individuals served as collaborators and site investigators for the AWAKEN study. They collaborated in protocol development and review, local IRB submission, data collection, and participated in drafting or review of the manuscript:

David T. Selewski, MD, Subrata Sarkar, MD — C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, Michigan, USA.

Alison Kent, MD, Jeffery Fletcher, PhD — Centenary Hospital for Women and Children, Canberra Hospital, Australian National University Medical School, Canberra, Australia.

Carolyn L Abitbol, MD, Marissa DeFreitas, MD, Shahnaz Duara, MD — Holtz Children’s Hospital, University of Miami, Miami, Florida, USA.

Jennifer R. Charlton, MD — University of Virginia Children’s Hospital, Charlottesville, Virginia, USA.

Ronnie Guillet, MD, Carl D’Angio, MD, Ayesa Mian, MD, Erin Rademacher, MD — Golisano Children’s Hospital, University of Rochester, Rochester, New York, USA.

Maroun J. Mhanna, MD, Rupesh Raina, MD, Deepak Kumar, MD — MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Namasivayam Ambalavanan, MD — Children’s of Alabama, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Ayse Akcan Arikan, MD, Christopher J. Rhee, MD — Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas, USA.

Stuart L. Goldstein, MD, Amy T. Nathan, MD — Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA.

Alok Bhutada, MD, Shantanu Rastogi, MD — Maimonides Medical Center, Brooklyn, New York, USA.

Elizabeth Bonachea, MD, Susan Ingraham, MD, John Mahan, MD; Arwa Nada, MBBCH — Nationwide Children’s Hospital, Columbus, Ohio, USA.

Patrick D. Brophy, MD, Tarah T. Colaizy, MD, Jonathan M. Klein, MD — University of Iowa Children’s Hospital, Iowa City, Iowa, USA.

F. Sessions Cole, MD, T. Keefe Davis, MD — Washington University, St. Louis, Missouri, USA. Joshua Dower, BS, Lawrence Milner, MD, Alexandra Smith, MD — Tufts University School of Medicine, Boston, Massachusetts, USA.

Mamta Fuloria, MD, Kimberly Reidy, MD, Frederick J. Kaskel, MD — The Children’s Hospital at Montefiore, Bronx, New York, USA

Jason Gien, MD, Katja M. Gist, DO — University of Colorado, Children’s Hospital Colorado, Aurora, Colorado, USA.

Mina H. Hanna, MD — University of Kentucky, Lexington, Kentucky, USA.

Sangeeta Hingorani, MD, Michelle Starr, MD — University of Washington, Seattle Children’s Hospital, Seattle, Washington, USA.

Catherine Joseph, MD, Tara DuPont, MD, Robin Ohls, MD, Amy Staples, MD — University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA.

Surender Khokhar, MD — Apollo Cradle, Gurgaon, Haryana, India.

Sofia Perazzo, MD, Patricio E. Ray, Mary Revenis, MD — Children’s National Medical Center, George Washington University School of Medicine and the Health Sciences, Washington DC, USA.

Anne Synnes, MDCM — British Columbia Children’s Hospital, Vancouver, British Columbia, Canada.

Pia Wintermark, MD, Michael Zappitelli, MD — Montreal Children’s Hospital, McGill University Health Centre, Montreal, Quebec, Canada

Article

Manuscript ID: NIHMS905688

DOI: 10.1016/S2352-4642(17)30069-X

PMC ID: 5933049

PubMed ID: 29732396

SO-VID: 47718a3f-eb61-4820-b7f0-9a1dc13365c5

License:

This manuscript version is made available under the CC BY-NC-ND 4.0 license.

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Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study

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Abstract

Background

Methods

Findings

Interpretation

Funding

Related collections

Pediatric Pulse: Advancing Neonatal and Child Health

Most cited references 25

CRIB II: an update of the clinical risk index for babies score.

Acute kidney injury reduces survival in very low birth weight infants.

Recognition and reporting of AKI in very low birth weight infants.

Author and article information

Journal

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Article

History

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Cited by 189

Most referenced authors 360