Frequency of Acute Kidney Injury and Association With Mortality Among Extremely Preterm Infants

IMPORTANCE: Neonatal acute kidney injury (AKI) is common and associated with morbidity and mortality. The temporal relationship between AKI and critical illness, as well as the frequency of AKI definition components (urine output and serum creatinine [sCr] concentration change), are unknown in extremely low-birth-weight (ELBW) (<1000 g), extremely preterm (<29 weeks’ completed gestational age [GA]) infants. OBJECTIVE: To measure the frequency of AKI from birth to death or discharge with attention to the definition components as well as the temporal relationship of AKI to critical illness and death. DESIGN, SETTING, AND PARTICIPANTS: A single-center, multiyear, retrospective cohort study was conducted at an academic level IV neonatal intensive care unit between January 1, 2012, and January 1, 2020. Participants included inborn ELBW and infants at 22 to 28 weeks’ completed GA with confirmed congenital anomalies who survived 12 hours or more. EXPOSURES: Extremely preterm birth and ELBW. MAIN OUTCOMES AND MEASURES: The primary outcome was AKI frequency. The timing, severity, and criteria for AKI were measured. The temporal relationship between AKI, organ dysfunction, and outcomes were quantified using odds ratios (ORs), logistic regression, and Shapley Additive Explanations. Acute kidney injury recognition, imaging, pediatric nephrology consultation, and follow-up were determined. RESULTS: A total of 436 infants (52% male; 44% Black) met the inclusion criteria (median BW, 725 g; median GA, 25.7 wk). Acute kidney injury was common in the first week of life (44%), primarily based on the change in the sCr concentration criterion (88%), and negatively associated with GA (OR, 0.69; 95% CI, 0.60-0.78), but positively associated with antecedent critical illness (OR, 1.17; 95% CI, 1.12-1.23), severe intraventricular hemorrhage (OR, 1.86; 95% CI, 1.12-3.08), late-onset sepsis (OR, 1.03; 95% CI, 1.02-1.03), and mortality (OR, 2.77; 95% CI, 1.63-4.72). Acute kidney injury had negligible clinical contribution to death within the model (Shapley Additive Explanation, <0.5% change to outcome) relative to antecedent patient-concentration organ dysfunction (6%-15% change). Among infants with severe AKI, recognition (32%), nephrology inpatient consultation (16%), and outpatient follow-up (9%) were not common. CONCLUSIONS AND RELEVANCE: In this cohort study of ELBW infants, AKI was common in the first week of life, inversely associated with GA, and followed organ (primarily cardiovascular) dysfunction. Acute kidney injury considered as the primary pathway to mortality was rare, and amelioration of AKI to modify death was not well supported.