Velazquez Danitza M, Reidy Kimberly J, Sharma Madhu, Kim Mimi, Vega Melissa, Havranek Tomas
a Division of Neonatal-Perinatal Medicine , Bristol-Myers Squibb Children's Hospital, Robert Wood Johnson Medical School , New Brunswick , NJ , USA.
b Division of Pediatric Nephrology , The Children's Hospital at Montefiore, Albert Einstein College of Medicine , Bronx , NY , USA.
J Matern Fetal Neonatal Med. 2019 Oct;32(19):3209-3214. doi: 10.1080/14767058.2018.1460349. Epub 2018 Apr 12.
Acute kidney injury (AKI) in preterm neonates is becoming an increasingly recognized morbidity in the neonatal intensive care unit neonatal intensive care unit (NICU), yet its epidemiology, delineation and relation to numerous toxic exposures and common morbidities such as systemic hypertension is just evolving. With a frequency of the patent ductus arteriosus (PDA) as high as 70% in preterm infants born before 28-week gestation, the role of the hemodynamically significant PDA (hs-PDA) remains unclear. To determine if AKI and systemic hypertension is more common in extremely low gestational age newborns (ELGAN) with hs PDA compared to ELGAN with no or non-hs PDA using modified AKIN and Neonatal Risk, Injury, Failure, Loss of Kidney Function, and End-stage (N-RIFLE) scoring systems. This was a retrospective cohort study of infants ≤28 weeks gestational age born between 2010 and 2016 who had echocardiographic PDA evaluation completed for hemodynamical significance as well as serial serum creatinine and urine output measurement documented, needed for the two AKI scoring systems: modified AKIN (based on serial serum creatinine) and N-RIFLE (using urine output data). Blood pressure measurements and therapy were evaluated during the hospitalization and on the day of NICU discharge. Baseline characteristics and outcome variables were compared between the hs-PDA and no or non-hs PDA using unpaired -tests for continuous variables and chi square tests for categorical data. One hundred fifty-one infants were eligible of which 110 had hs-PDA. Infants with hs-PDA were smaller (777 versus 867 g, = .026), less mature (25.8 versus 26.4 weeks, = .023) and had greater exposure to nephrotoxic drugs (14 versus 9.4 days, = .001). Other clinical and demographic variables were similar between the two groups. The overall incidence of AKI was not different between the hs-PDA and no PDA or non-hs PDA groups when evaluated by the acute kidney injury network (AKIN) or N-RIFLE staging; however, preterm newborns with hs-PDA demonstrated a trend towards increased risk of AKI injury (12.7 versus 0.02%, = .06). The N-RIFLE and AKIN scoring systems demonstrated very poor degree of agreement (kappa = 0.00853) in our study. There was no difference in the rates of hypertension during the hospitalization as well as on the day of NICU discharge. Preterm neonates with hs-PDA had similar rates of AKI and hypertension as neonates with no or non-hs PDA.
早产新生儿急性肾损伤（AKI）在新生儿重症监护病房（NICU）中越来越被认为是一种发病率较高的疾病，但其流行病学、定义以及与多种毒性暴露和常见疾病（如系统性高血压）的关系仍在不断演变。在妊娠28周前出生的早产儿中，动脉导管未闭（PDA）的发生率高达70%，具有血流动力学意义的PDA（hs-PDA）的作用仍不明确。本研究旨在使用改良的急性肾损伤网络（AKIN）和新生儿风险、损伤、衰竭、肾功能丧失及终末期（N-RIFLE）评分系统，确定与无hs-PDA或非hs-PDA的超低出生体重新生儿（ELGAN）相比，有hs-PDA的ELGAN中AKI和系统性高血压是否更常见。
这是一项回顾性队列研究，研究对象为2010年至2016年间出生的孕周≤28周的婴儿，这些婴儿均完成了评估血流动力学意义的超声心动图PDA检查，并有连续血清肌酐和尿量测量记录，这是两种AKI评分系统（改良AKIN（基于连续血清肌酐）和N-RIFLE（使用尿量数据））所需要的。在住院期间和NICU出院当天评估血压测量和治疗情况。使用连续变量的非配对t检验和分类数据的卡方检验比较hs-PDA组与无hs-PDA或非hs-PDA组之间的基线特征和结局变量。
151名婴儿符合条件，其中110名有hs-PDA。有hs-PDA的婴儿体重较小（777克对867克，P = 0.026），成熟度较低（25.8周对26.4周，P = 0.023），接触肾毒性药物的时间更长（14天对9.4天，P = 0.001）。两组之间的其他临床和人口统计学变量相似。当通过急性肾损伤网络（AKIN）或N-RIFLE分期评估时，hs-PDA组与无PDA或非hs-PDA组之间AKI的总体发生率没有差异；然而，有hs-PDA的早产新生儿显示出AKI损伤风险增加的趋势（12.7%对0.02%，P = 0.06）。在我们的研究中，N-RIFLE和AKIN评分系统的一致性程度非常低（kappa = 0.00853）。住院期间以及NICU出院当天的高血压发生率没有差异。有hs-PDA的早产新生儿与无hs-PDA或非hs-PDA的新生儿的AKI和高血压发生率相似。
