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Renal near-infrared spectroscopy use in the neonate

As bedside monitoring capabilities continue to advance in the neonatal intensive care unit, renal tissue oxygenation monitoring with near-infrared spectroscopy (NIRS) has emerged as a potentially useful tool for clinicians. Renal perfusion and oxygen utilization by the neonatal kidney is impacted by many factors including gestational age, chronological age, hemodynamic status of the infant, fluid balance, and other underlying conditions. Renal tissue oxygen saturation (RrSO 2…

Renal tubular acidosis

Renal acid-base regulation Since birth, the kidney represents the crucial ultimate line of defense against disturbances of acid-base balance, which is performed by the tubular reabsorption of bicarbonate and the excretion of fixed hydrogen ions. The glomerulus contributes to renal acid-base homeostasis by the filtration of urea (the major end-product of protein catabolism) and by providing the filtered load of bicarbonates to the proximal tubule. Up…

Dialysis and kidney transplantation in infancy

Introduction Although the provision of dialysis and the need for a kidney transplant during infancy is rare, medical advancements have led to increased availability and efficacy of these treatments when needed worldwide. Data from the US Renal Data System (USRDS) show that the overall incidence of pediatric end-stage kidney disease (ESKD) requiring dialysis or transplantation has decreased slightly from 12 cases per million people in 2009…

Diagnosis and management of prenatal urinary tract dilatation

Definitions and scope of prenatal urinary tract dilation Abnormal dilation of the fetal urinary tract is a common finding during antenatal screening ultrasound (US) (1%–3% of all pregnancies), second only to cardiac defects. This dilation signifies a spectrum of disease, in some children a transient and physiologic phenomenon and in others an association with significant renal functional impairment. Table 11.1 lists common and impactful causes of…

Effect of preterm birth on renal outcomes

Introduction Preterm birth is estimated to impact 15 million births worldwide annually. Due to advancements in the treatment of preterm infants, survival of these infants has improved, albeit with increased morbidity due to the development of chronic diseases, especially in those born extremely preterm. , The renal consequences of preterm birth are relevant in the short term, during the neonatal intensive care unit (NICU) course, as…

Evidence-based approach to diuretic therapy in the neonate

Introduction Diuretics are commonly used in the neonatal population to treat infants with bronchopulmonary dysplasia (BPD), cardiac disease associated with congestive heart failure, and acute kidney injury (AKI). The relatively high frequency of diuretic use has been documented by several large retrospective cohorts. Laughon et al. utilized the Pediatrix Medical Group data warehouse (1997–2011) to identify that 37% of almost 40,000 infants <32 weeks’ gestation and…

Genetic causes of congenital anomalies of the kidney and urinary tract

Introduction Congenital anomalies of the kidneys and urinary tract (CAKUT) encompass many heterogenous anomalies of the kidney, ureter, bladder, and urethra ( Fig. 8.1 ). CAKUT is the leading cause of kidney disease and of renal failure in children. The prevalence of CAKUT is estimated by population studies to lie between 0.1% and 2%, with higher prevalence in preterm infants. CAKUT has a complex etiology with…

Pathophysiology and management of hyponatremia and hypernatremia in the neonate

Dysnatremias, hyponatremia and hypernatremia, are common in the neonatal intensive care unit. Recent studies indicate that these conditions can result in both short- and long-term morbidity and mortality. This chapter will review the development of renal function with emphasis on the renal handling of water and sodium. We will then discuss the pathophysiology of water and sodium homeostasis that results in hyponatremia and hypernatremia. This will…

Physiological management of fluid and electrolyte therapy in newborns

Introduction Water is critical to the support of all life, and ensuring appropriate balance of fluid and electrolytes is a central aspect of the clinical management of patients. It has been extremely difficult to study and define optimal fluid and electrolyte management in premature infants, despite the fact that this is a population that is essentially completely dependent on what is administered. Study in this area…

Pathophysiology and management of hyperkalemia in the neonate

Potassium (K), the major intracellular (IC) cation (98% of [K] is located inside the cells), is responsible for protein synthesis, cell growth, and regulation of cell volume. Sodium-potassium ATPase (Na-K-ATPase) in cell membranes is responsible for maintaining this gradient, which is critical for excitable cells. Compared with children and adults, neonates have a higher serum potassium concentration ([K]), with very preterm and very low birth weight…

Pulmonary hypoplasia in the fetus with oligohydramnios: Causes, treatment, and prevention

Introduction Normal amniotic fluid production and volume are essential for normal fetal development. Oligohydramnios, or low amniotic fluid volume, when severe can impact normal lung development. As the fetal kidneys are the major source of amniotic fluid in the second half of pregnancy, anomalies associated with poor fetal kidney function lead to oligohydramnios, particularly in the second and third trimesters of pregnancy in humans. Congenital anomalies…

Diagnosis and management of neonatal acute kidney injury

Introduction Acute kidney injury (AKI) is defined as a decrease in overall kidney function, resulting in reduction of glomerular filtration rate (GFR) and subsequent retention of waste products such as urea. As a result, there is a loss of established electrolyte, acid-base, and fluid balance regulation. AKI is a serious, underrecognized yet common complication that occurs in neonates who receive intensive medical care, and there is…

Assessment of neonatal kidney function

Background Two thirds of drugs are eliminated by the kidneys, and their function levels must be taken into account for diagnostic and treatment plans. Kidney function level identifies acute kidney injury (AKI), or chronic kidney disease (CKD) but it cannot be measured directly, so clinicians have to calculate the clearance of a marker (for instance, inulin) over a given time period. A comprehensive review on measuring…

Assessment of renal function in fetuses with lower urinary tract obstruction

Introduction Fetal lower urinary tract obstruction (LUTO) or congenital bladder outlet obstruction has an incidence of 2.2/10,000 pregnancies and is usually diagnosed in late first or early second trimester of pregnancy with the characteristic findings of dilated fetal bladder, dilated proximal ureter, and renal hydronephrosis. LUTO represents a spectrum of congenital anomalies with the principal etiology differing according to fetal sex and additional structural anomalies. If…

Skin Disorders inNewborn Infants

KEY POINTS 1. Neonatal skin matures with gestational age with increasing thickness, less permeability, and higher density of sweat and sebaceous glands. Keratinization begins at 24 weeks and matures near term. 2. Cold stress is an important risk to preterm infants. Lower skin thickness, less subcutaneous fat, and immaturity of the nervous system predisposes to heat loss. 3. Several minor congenital anomalies may predominantly involve the…

Leadership and OrganizationalCulture in Healthcare

KEY POINTS 1. All organizations, be it in healthcare or in any other sector(s) of society, strive for effective, potentially transformational leadership. 2. In any health-care system, infants receiving care in neonatal intensive care units are often the most vulnerable patients, with very high severity levels of illness. 3. The first step in analyzing the impact of leadership in any organization is to observe the interactions…

Organization of Neonatal Intensive Care

KEY POINTS 1. Neonatal intensive care units (NICUs) are organized for the clinical care of premature and critically ill newborn infants. 2. Healthcare centers require a well-considered structure to enable collaborative decision-making to provide family-centered, high-value care to the mother-infant dyad. 3. In most parts of the world, NICUs are designated per the infrastructural levels and the severity of illness of infants receiving care in the units.…

Designing Clinical Trials in Neonatology—International Trials

KEY POINTS 1. Assessing therapeutic safety and efficacy of a drug/device or technology requires carefully designed trials that are sufficiently powered to detect differences in outcomes. 2. International trials can help reduce the time required for the study and improve generalizability of the findings. 3. Variations in regulations for clinical trials between jurisdictions can significantly prolong the time required to conduct the trial. 4. Anticipating challenges…

Neonatal Randomized Controlled Trials

KEY POINTS 1. Neonates and infants often are treated with medicines that have not been approved by regulatory authorities for use in this age group. 2. The inclusion of infants in drug development studies and clinical trials is limited by difficulties in enrollment, concerns for adverse effects due to developmental limitations, and the lack of universally accepted response variables in many conditions. 3. Neonatal randomized controlled…

Quality Improvement in Neonatal Care

KEY POINTS 1. The quality of clinical care and improvement is typically measured in six areas: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equality. 2. Healthcare administered during pregnancy, labor, and childbirth continues to show considerable center-to-center variability and needs careful study both for improving outcomes and also to reduce the possibility of harm. 3. The care of premature and critically ill infants in neonatal intensive care…