How to manage Acute Kidney Injury (AKI) in a neonate?

Management of Acute Kidney Injury in Neonates

A single dose of theophylline should be administered to neonates with severe perinatal asphyxia who are at high risk of AKI, while fluid management with isotonic crystalloids and early intervention for fluid overload are cornerstones of neonatal AKI management. 1

Initial Assessment and Management

• Use isotonic crystalloids rather than colloids (albumin or starches) for initial management of intravascular volume expansion in neonates at risk for or with AKI, unless there is hemorrhagic shock 1
• Implement vasopressors in conjunction with fluids in neonates with vasomotor shock who have or are at risk for AKI 1
• Utilize protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of AKI in high-risk neonates 1
• Monitor fluid balance meticulously, as fluid overload >30% at CRRT initiation is associated with higher mortality in neonates 2, 3

Specific Interventions

• Administer a single dose of theophylline to neonates with severe perinatal asphyxia who are at high risk of AKI - this improves fluid control and GFR in the first week of life 1
• Avoid using diuretics to prevent AKI, but they may be used for management of volume overload in established AKI 1
• Do not use low-dose dopamine, fenoldopam, or atrial natriuretic peptide (ANP) to prevent or treat neonatal AKI 1
• Avoid recombinant human IGF-1 for prevention or treatment of neonatal AKI 1

Nutritional Support

• Provide nutrition preferentially via the enteral route when possible 1
• Ensure adequate protein intake: 2-3 g/kg/d for infants aged 0-2 years with AKI 1
• Do not restrict protein intake with the aim of preventing or delaying initiation of renal replacement therapy 1
• Target total energy intake of 20-30 kcal/kg/d in neonates with any stage of AKI 1

Medication Management

• Avoid aminoglycosides for treatment of infections unless no suitable, less nephrotoxic alternatives are available 1
• If aminoglycosides must be used, administer as a single daily dose rather than multiple-dose daily regimens 1
• Monitor aminoglycoside drug levels when treatment with multiple daily dosing is used for more than 24 hours, or when single-daily dosing is used for more than 48 hours 1
• Use topical or local applications of aminoglycosides rather than intravenous administration when feasible 1
• Use lipid formulations of amphotericin B rather than conventional formulations if antifungal therapy is required 1

Renal Replacement Therapy (RRT)

• Consider early initiation of RRT before the development of severe fluid overload (>30%) or severe azotemia, as this may improve outcomes 2, 4
• Peritoneal dialysis is often the modality of choice for neonates with AKI after cardiac surgery or with multiorgan dysfunction 5, 4
• Continuous renal replacement therapy (CRRT) is increasingly used to manage fluid overload in critically ill neonates, particularly those on extracorporeal membrane oxygenation (ECMO) 6
• The decision to initiate RRT should consider the neonate's fluid balance, electrolyte status, acid-base balance, and nutritional needs 5

Monitoring and Follow-up

• Monitor serum creatinine daily in high-risk neonates during the first days of life 3
• Carefully track fluid balance, with special attention to percent weight accumulation, as this correlates with outcomes 3
• Maintain vigilant monitoring of electrolytes, acid-base status, and nutritional parameters 5
• Recognize that neonates who have experienced AKI are at risk for late development of renal failure and require long-term follow-up 5

Common Pitfalls and Caveats

• Avoid overzealous fluid resuscitation in certain conditions as it may worsen outcomes 1
• Be cautious with hyperchloremic solutions (normal saline) as they can induce metabolic acidosis; consider balanced electrolyte solutions when appropriate 1
• Remember that while theophylline may improve renal function in asphyxiated neonates, it does not affect mortality outcomes 1
• Recognize that AKI in neonates as part of multisystem failure carries a much higher mortality rate than AKI from intrinsic renal disease 5