Prognostic Factors in Neonatal Acute Renal Failure

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1984;74;265-272PediatricsRobert L. Chevalier, Fern Campbell and A. Norman A. G. Brenbridge

Prognostic Factors in Neonatal Acute Renal Failure

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Online ISSN: 1098-4275.Copyright 1984 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.

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PED IATR ICS Vo l. 74 N o . 2 A ugus t 1 984 265

P rognos tic F ac to rs in N eona ta l A cu te R ena lFai lureRobert L . Cheva lie r , M D , Fe rn C am pbell, R N FNP , andA . N orm an A . G . B renb r idge , M D

F rom the D epa rtm en ts o f P ed ia tr ics and R ad io logy , U n ive rs ity o f V irg in ia S choo l o fM e dic in e, C h ar lo tt es vil le

ABSTRACT . Six teen in fan ts , 2 to 35 days o f ag e, h adacu te rena l fa ilu re , a d iag nos is ba sed on serum crea tin ineconcen t ra t i ons >1 .5 m g/dL fo r a t lea st 24 hou rs. E igh tin fan ts were o lig u ric (u rine flow 1 .5 m g /dL fo r a t lea s t 2 4 hours ,b u t u rine o u tp u t rem a ined > 1 .0 m L /k g /h .

Serum and u rin e c rea tin ine co ncen tra tion s an dBUN w ere m easured b y m eans of an au tom ated

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266 ACUTE RENAL FAILURE

analyzer sy stem (A stra 8, Ful l erton, CA ). The coef -f i ci ent of variati on for determ ination of creatininestandards in our laboratory w as 5.8% . Fracti onalsodium excreti on (FENa) w as calculated f rom ini ti aluri ne obtained f rom most patients in both ol i gunicand nonol iguni c groups. A l l inf ants underw ent ab-dom inal stati c and real -time ul trasonognaphy , andrenal length was compared w i th publ i shed normal

12 , 13Fol low ing ul trasonography , each inf ant under-

w ent renal nuclear scint igraphy w i th techneti um -99m glucoheptonate, 2.2 to 2.4 mCi , or iodine-131-orthoiodohippurate (H ippuran), 25 to 42 Ci in-f used intravenously . I n inf ants w i th poor v isual i za-ti on w i thin the f i rst 30 m inutes, delayed imageswere obtained up to 24 hours af ter injecti on ofnuclide.

Patients w i th obstructi v e nephropathy w eretreated by decompression or di v ersion of the un-nary tract. Pati ents w i th congesti ve heart f ai lurewere treated w i th digox in, f unosemide, and surgicalcorrection of the def ect w hen possible. A l l i nf antsw ith suspected septi cem ia w ere gi ven ampici l l i n,100 mg/kg/d, and gentam icin, 2.5 mg/kg per dose,for three to 14 days. The interval betw een genta-micin doses was vari ed betw een eight and 36 hoursdepending on glomerulan f i l trati on rate to maintainpeak and trough serum concentrati on 4 to 8 sg/mLand


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A R T I C L E S 267

F ig 1 . Parasagittal sonogram of right kidney of infant w ith renal vein thrombosis.Papillae are somew hat prominent; these are echo-free triangles seen within kidney. R enalcortex is more echogenic than normal for neonate. L eft kidney has similar appearance.

by scintigraphy in one (case 5). T his infant, w ithbilateral renal vein thrombosis, received penitonealdialysis for 16 days and w as found to have bilateralpatchy renal infarction diagnosed by renal biopsy.I n the remaining three patients, scintigraphy re-vealed renal uptake and excretion of nuclide intot h e bladder.

G ro u p IIA ll infants w ith nonoliguric A RF survived. U rine

flow ranged from 1.0 to 2.7 mL /kg/h and FEN a w asnot different from that in group I , averaging 4.7% 3.0%. I nitial serum creatinine concentration didnot differ f rom that in group I but peak serumcreatinine concentration w as low er than in oligunicpatients. Peak serum creatinine concentrationtended to be higher in patients w ho were dying(group I A ) than in those recovering (groups lB andI I ), but the difference was not significant. T herewas no difference in follow-up serum cneatininevalues betw een groups lB and I I . I nitial BU N valuefor group I I w as 21 6 mg/dL , w hich was lowerthan in group I . Peak BU N value was 32 12 mgIdL , and it did not differ signif icantly from group 1.

Renal sonography revealed normal kidneys in f ivepatients and show ed congenital renal anomalies inthe other three. N uclear scintignaphy revealed de-tectable renal perfusion in all nonoligunic patients,although renal blood f low w as qualitatively reducedin each case (Fig 2). T hus, all 11 infants w ithdetectable renal nuclide uptake recovered renalfunction adequate for grow th w hereas 4/5 patientsw ithout renal visualization subsequently died.

DISCUSS IONT o provide optimal care for the neonate with

A RF, it is desirable to predict which infants willrecover adequate renal function for survival, and todetermine those with irreversible renal failure. R e-covery from A RF in the neonate w as unrelated tononrenal factors such as age at diagnosis, birthweight, A pgar scores, on requirement of ventilatonysupport. Our finding that chronic respiratory dis-orders did not appear to influence recovery fromA RF is not surprising in view of the lack of influ-,ence of respiratory status on renal development ofotherw ise normal premature infants. 5 Guignard etal showed a transient reduction in the glomerular

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Prognostic Factors in Neonatal Acute Renal Failure

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