Neonatal acute kidney injury: Evaluation, management, and prognosis
- Tej K Mattoo, MD, DCH, FRCP
Tej K Mattoo, MD, DCH, FRCP
- Section Editor — Pediatric Nephrology
- Professor of Pediatrics
- Wayne State University School of Medicine
- Section Editors
- Richard Martin, MD
Richard Martin, MD
- Section Editor — Neonatology
- Professor, Pediatrics, Reproductive Biology, and Physiology & Biophysics
- Case Western Reserve University School of Medicine
- F Bruder Stapleton, MD
F Bruder Stapleton, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Nephrology
- Professor and Chair, Department of Pediatrics
- University of Washington School of Medicine
Acute kidney injury (AKI), formerly referred to as acute renal failure (ARF), is defined as an acute reduction in kidney function due to a decline in glomerular filtration rate (GFR) leading to retention of urea and other nitrogenous waste products, and loss of fluid, electrolyte, and acid-base regulation. AKI is an important contributing factor to the morbidity and mortality of critically ill neonates.
The diagnostic evaluation, management, and prognosis of neonatal AKI are presented in this topic review. The pathogenesis, etiology, presentation, and diagnosis of neonatal AKI are presented separately. (See "Acute kidney injury in children: Clinical features, etiology, evaluation, and diagnosis".)
IDENTIFYING THE UNDERLYING CAUSE
Overview — Once the diagnosis of neonatal AKI is made, further evaluation is focused towards identifying the underlying etiology so that management can be directed towards reversing the underlying cause if possible (table 1).
The evaluation consists of a directed history and physical examination, renal imaging, and the use of a fluid challenge as a diagnostic and therapeutic measure. Laboratory tests such as serum potassium, bicarbonate, and phosphorus are not as useful in neonates compared with older patients because of the variable range of values due to functional and developmental immaturity of the neonatal kidney, which is affected by gestational and postnatal age. (See "Neonatal acute kidney injury: Pathogenesis, etiology, clinical presentation, and diagnosis", section on 'Normal neonatal renal function'.)
Our general approach to the diagnostic evaluation encompasses the following (algorithm 1):
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- IDENTIFYING THE UNDERLYING CAUSE
- Physical examination
- Renal ultrasound
- - Prenatal ultrasound
- - Postnatal imaging
- Fluid challenge
- Laboratory evaluation
- - Urine tests
- - Serum/plasma sodium
- - FENa
- Unproven measures
- - Dopamine
- - Theophylline and perinatal asphyxia
- Directed therapy based on etiology
- Fluid management
- - Furosemide
- Electrolyte and acid-base management
- - Hyperkalemia
- - Metabolic acidosis
- - Hypocalcemia
- - Hyperphosphatemia
- - Hyponatremia
- Renal replacement therapy
- SUMMARY AND RECOMMENDATIONS