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Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure Kidney Int 2002;62(6):2223–9 106 Fivez T, Kerklaan D, Mesotten D, et al Early versus late parenteral nutrition in critically ill children N Engl J Med 2016;374(12):1111–22 Neonatal Acute Kidney Injury 44 Cherry Mammen and David Askenazi Introduction Critically ill neonates admitted to neonatal and cardiac intensive care units are at high risk for acute kidney injury (AKI) In theory, the potential benefits to providing renal replacement therapy (RRT) for neonates with severe AKI are similar to larger pediatric and adult populations Performing peritoneal dialysis is possible even in the smallest of infants The use of extracorporeal therapies to provide RRT has been limited as the devices that are commonly used are not designed for small infants and carry added risks to the patient Fortunately, several novel machines with smaller extracorporeal volumes have been introduced into clinical practice in select centers around the world In this chapter, we will describe a case of a critically ill neonate admitted to the neonatal intensive care unit to illustrate the diagnosis of neonatal AKI, delineate consequences and medical management of AKI, discuss indications for RRT, compare and contrast options for care, and provide specifics of RRT in neonates Chapter contents directly relevant to the case are C Mammen (*) Department of Pediatrics, Division of Nephrology, BC Children’s Hospital, Vancouver, BC, Canada e-mail: cmammen@cw.bc.ca D Askenazi Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA provided in italics We conclude by reporting on the novel devices which promise to change the approach to the care of neonates who can benefit from RRT Case Presentation A term male infant is born via spontaneous vaginal delivery at 37 weeks gestational age to a 31-year-old G1P0 mother with history of maternal fever and prolonged rupture of membranes The infant is assessed in the nursery on the first day of life (DOL) with poor latching, shallow respirations, and lethargy With concerns of sepsis, he is transferred to the Neonatal Intensive Care Unit (NICU) Vital signs reveal elevated heart rate of 180 beats/minute, increased respiratory rate of 64 breaths/minute, increased temperature of 38.5 degrees Celsius, and low blood pressure (BP) of 42/20 mmHg (mean arterial pressure 30) Physical exam reveals poor peripheral pulses and prolonged capillary refill Initial labs include neutropenia (1.0 × 109/L) and lactic acidosis (HCO3 17 mmol/L, lactate 5.0 mmol/L) Chest X-ray shows normal heart size and lung fields Umbilical venous and arterial catheters are placed Boluses of 20 cc/kg of normal saline (NS) are administered with no improvement in blood pressure and no documented urine output Broad- spectrum intravenous antibiotics are started (ampicillin 50 mg/kg/dose q8h and gentamycin 2.5 mg/kg/dose q12h) With ongoing hypotension, © Springer Nature Switzerland AG 2021 B A Warady et al (eds.), Pediatric Dialysis, https://doi.org/10.1007/978-3-030-66861-7_44 861 C Mammen and D Askenazi 862 dopamine is started at mcg/kg/min, and 20 cc/ kg of NS was administered again to optimize perfusion Blood pressure stabilized at this point with a mean arterial pressure maintained above 40 mmHg Over the next 12 hours, dopamine is stopped due to stable BP. Blood cultures are positive for Group B Streptococcus (GBS) at 36 hours Infant is kept NPO, and standard total parenteral nutrition was commenced with an ongoing total fluid intake of 80 cc/kg/day and protein intake of 2.5 g/kg/day Gentamycin trough level before the third dose is elevated at 5.0 mg/L, and antibiotics are switched to IV penicillin (sensitive to GBS) A Foley catheter is inserted due to ongoing oliguria Renal ultrasound showed two normal-sized echogenic kidneys On the third DOL, severe body wall edema and ascites are noted, and the infant develops worsening respiratory distress requiring intubation and ventilation Chest X-ray is consistent with pulmonary edema and a slightly large cardiac silhouette Intravenous furosemide (1 mg/kg dose) is attempted with no increase in urine output Chemistry on DOL #3 reveals sodium (Na+) 127 mmol/L, potassium (K+) 6.4 mmol/L, bicarbonate (HCO3) 15 mmol/L (lactate normal), phosphate (PO4) 9.1 mg/dL (2.94 mmol/L), ionized calcium (Ca++) 1.0 mmol/L, uric acid 12 mg/dL (713 umol/L), and serum albumin of 1.8 g/dL. Pediatric nephrology is consulted for further management of acute kidney injury Table 44.1 provides trends of renal function (blood urea nitrogen, and serum creatinine), weight, and urine output from birth till DOL Table 44.1 Renal function, weight, and urine output trends from case example Day of life BUN in mg/dL (urea in mmol/L) SCr in mg/dL (umol/L) Weight (kg) Urine output (ml/kg/hour) N/A N/A 3.4 22 (7.9) 0.7 (62) 3.7 0.2 42 (15) 1.1 (97) 4.0 0.3 70 (25) 2.1 (186) 4.3 0.3 BUN blood urea nitrogen, SCr serum creatinine, N/A not available Defining Neonatal AKI Acute kidney injury (AKI) has replaced the previous term “acute renal failure” in order to represent the entire spectrum of injury severity ranging from mild increases in serum creatinine (SCr) to severe oligoanuria requiring renal replacement therapy (RRT) Consequently, there has been a steady evolution of severity graded AKI definitions based on changes in serum creatinine (SCr) and/or urine output including RIFLE (Risk, Injury, Failure, Loss, and End Stage Renal Disease), AKIN (Acute Kidney Injury Network), and most recently the KDIGO (Kidney Disease: Improving Global Outcomes) definition in 2013 [1–3] These staged definitions were first validated for older pediatric and adult cohorts and more recently have been applied empirically to single- and multi-center neonatal studies Beyond the traditional challenges to using SCr to define AKI, there is added complexity in the first perinatal weeks due to the complex physiology surrounding adaptation and transition into the extrauterine environment Neonatal SCr around birth represents maternal creatinine and achieves a steady-state value over several days as the innate renal function equilibrates Preterm infants of approximately 30 weeks gestational age (GA) have a GFR