Nephrotoxic medications and acute kidney injury risk factors in the neonatal intensive care unit: clinical challenges fo
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EDUCATIONAL REVIEW
Nephrotoxic medications and acute kidney injury risk factors in the neonatal intensive care unit: clinical challenges for neonatologists and nephrologists Heidi J. Murphy 1 & Brady Thomas 2 & Brynna Van Wyk 3 & Sarah B. Tierney 4 & David T. Selewski 1 & Jennifer G. Jetton 3 Received: 18 March 2019 / Revised: 21 August 2019 / Accepted: 2 September 2019 # IPNA 2019
Abstract Neonatal acute kidney injury (AKI) is common. Critically ill neonates are at risk for AKI for many reasons including the severity of their underlying illnesses, prematurity, and nephrotoxic medications. In this educational review, we highlight four clinical scenarios in which both the illness itself and the medications indicated for their treatment are risk factors for AKI: sepsis, perinatal asphyxia, patent ductus arteriosus, and necrotizing enterocolitis. We review the available evidence regarding medications commonly used in the neonatal period with known nephrotoxic potential, including gentamicin, acyclovir, indomethacin, vancomycin, piperacillin–tazobactam, and amphotericin. We aim to illustrate the complexity of decision-making involved for both neonatologists and pediatric nephrologists when managing infants with these conditions and advocate for ongoing multidisciplinary collaboration in the development of better AKI surveillance protocols and AKI mitigation strategies to improve care for these vulnerable patients. Keywords Nonsteroidal anti-inflammatory drugs . Antibiotics . Hypoxic ischemic encephalopathy . Patent ductus arteriosus . Neonatal sepsis . Necrotizing enterocolitis
Introduction Critically ill neonates represent a high-risk population with morbidity and mortality resulting from a number of underlying conditions such as prematurity, sepsis, perinatal asphyxia, patent ductus arteriosus (PDA), and necrotizing enterocolitis (NEC). Unfortunately, acute kidney injury (AKI) also occurs commonly in these patients, increasing their morbidity and mortality [1–5]. Many of the medications commonly used to * Jennifer G. Jetton [email protected] 1
Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
2
Stead Family Department of Pediatrics, Division of Neonatology, University of Iowa, Iowa City, IA, USA
3
Stead Family Department of Pediatrics, Division of Nephrology, Dialysis, and Transplantation, University of Iowa, 200 Hawkins Drive, 2027 BT, Iowa City, IA 52241, USA
4
Department of Pharmaceutical Care, University of Iowa Stead Family Children’s Hospital, Iowa City, IA, USA
treat these underlying conditions have nephrotoxic potential. Two recent studies have shown that > 80% of premature infants receive at least one nephrotoxic medication during their hospital stay [6, 7]. Whether or not risk of AKI is related to the underlying condition itself, nephrotoxic medications, or a combination of both, is unclear; how to balance the risks and benefits of nephrotoxic medications and non-nephrotoxic alternatives continues to be a significant challenge for the teams caring for the
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