Therapeutic Options for Neonatal Acute Kidney Injury (AKI)

Abstract

Acute kidney injury (AKI) occurs commonly in neonates and is associated with increased mortality. Recent advances in neonatal intensive care have resulted in improved patient survival, but this had not been paralleled by improved outcomes for neonates with AKI. Management of AKI remains supportive with no effective pharmacologic therapy to hasten the recovery process. Emphasis is placed on the prevention and minimization of further renal insults once AKI is established. Routine, regular assessments of renal function with identification of high risk patients and those with incipient AKI are essential so prevention strategies can be promptly initiated. Effective prevention strategies include prompt restoration/preservation of organ perfusion with fluid resuscitation to ensure an adequate effective circulating volume and inotropic support as needed to maintain hemodynamic stability while also avoiding/minimizing nephrotoxin exposure. In established AKI, efforts are focused on maintaining organ perfusion while closely monitoring cumulative fluid balance from admission and remaining cognizant of the need to minimize the degree of fluid overload as this has also been associated with poor outcomes. Continuous renal replacement therapy (CRRT) has become the preferred therapy for managing fluid overload and metabolic disturbances in critically ill children and adults but is still considered by many to be a heroic intervention for neonates due in large part to numerous technical challenges. The recent development of two miniaturized machines specifically designed to deliver CRRT and hemodialysis (HD) to neonates will hopefully change this paradigm making it easier for nephrologists and intensivists to safely offer and provide this therapy to neonates. Prospective studies are needed to assess whether early initiation of RRT with correction of fluid imbalance results in improved patient survival and renal recovery.