Anuria in neonatal intensive care: Answers
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CLINICAL QUIZ
Anuria in neonatal intensive care: Answers Özgür Özdemir-Şimşek 1 & Seçil Arslansoyu-Çamlar 1 & Hüseyin Üstün 2 & İrem Nur Nur İngenç 3 & Gökçen Erfidan 1 & Eren Soyaltın 1 & Melek Akar 2 & Demet Alaygut 1 & Fatma Mutlubaş 1 & Defne Engür 2 & Mehmet Yekta Öncel 2,4 & Belde Kasap-Demir 1,5
# IPNA 2020
Keywords Preterm . Neonate . Neonatal intensive care . Anuria . Acute kidney injury . Hypertension . Enalapril
Answers 1. How can we define stages of acute kidney injury (AKI) in this patient? Acute kidney injury is defined as rising serum creatinine (SCr) or decreased urine output. Before 2008, most neonatal AKI studies used definitions of AKI when SCr was ≥ 1.5 mg/ dL. In order to standardize AKI research, the Acute Dialysis Quality Initiative Group put forth the RIFLE criteria: risk, injury, failure, loss of function, and end-stage kidney disease [1]. It classified AKI into three categories (risk, injury, and failure) according to the status of SCr and urine output (UO). Problems in the diagnosis of AKI in neonatal intensive care units (NICUs) substantially include relatively low number of creatinine tests, unclear normal thresholds for normal neonatal creatinine levels (generally secondary to maternal creatinine This refers to the article that can be found at https://doi.org/10.1007/ s00467-020-04580-w * Seçil Arslansoyu-Çamlar [email protected]
influence), glomerular filtration rate (GFR) and “immature” kidney function variability, and thus unavailability of baseline/reference thresholds. For this reason, serum creatinine is not used in the neonatal RIFLE classification, but only urine output. Urine output classification in the neonatal RIFLE criteria are risk UO < 1.5 ml/kg/h for 24 h, injury UO < 1.0 ml/kg/h for 24 h, and failure UO < 0.7 ml/kg/h for 24 h or anuric for 12 h [2]. Most newborns are non-oliguric, and various classifications have been made to identify AKI in the early stages. Therefore, the nRIFLE criteria are insufficient in the classification of non-oliguric patients. The categorical staging model as mild, moderate, and severe was preserved in the AKI definition of Kidney Diseases Improving Global Outcomes (KDIGO) published in 2013. A classification was created that shows urine output and the patient’s creatinine. Jetton and Askenazi modified the neonatal modified KDIGO criteria and described a standard AKI definition. It should be used in children of < 120 days and classifies AKI stages depending upon a significant increase from a baseline lowest SCr [3]. Our patient had anuria lasting more than 12 h, and so was in the “Failure” group according to nRIFLE and stage III in the KDIGO classification.
1
University of Health Sciences, Tepecik Training and Research Hospital, Department of Pediatrics, Division of Nephrology, Izmir, Turkey
2. What would be the underlying causes of AKI in this patient?
2
University of Health Sciences, Tepecik Training and Research Hospital, Department of Pediatrics, Division of Neonatology, Izmir, Turkey
Neonates have low GFR, high renal vascular
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