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Hypotension: a modifiable risk factor impacting surgical NEC-associated AKI and brain injury in preterm infants

Pediatric Research (2024)Cite this article

Necrotizing enterocolitis (NEC) affects 6–10% of preterm infants with a birth weight of less than 1500 g,1,2 remaining as one of the most common surgical conditions in the neonatal intensive care unit. It also has both high mortality and long-term morbidity from intestinal failure leading to significant financial burden for patients and families as well as high health care system costs.3 Clinically, NEC triggers a systemic inflammatory response causing capillary leak syndrome with resultant intravascular volume depletion, hypotension, and multi-organ dysfunction.4 These adverse hemodynamic changes, combined with surgical stresses, anesthetic agents, and nephrotoxic medications are associated with acute kidney injury (AKI).5

Surgical NEC and its associated inflammation are associated with severe white matter injury (WMI) injury and adverse neurodevelopmental outcomes at two years of age.6,7,8,9,10,11 In our recent MRI study of 69 cases, we detailed clinical and histopathological determinants of WMI in infants with surgical NEC and reported WMI in 52%, gray matter injury in 10%, and cerebellar injury in 30%.12 In addition to WMI, of 202 neonates with medical and surgical NEC, 46.5% had AKI, as defined by worst serum creatinine or urine output staging criteria.13 Stages 2 and 3 AKI (severe) occurred in 66/202 (32.7%). We identified an association of dopamine use at 24 h after NEC onset and AKI [78.5% vs. 47%; p < 0.001], supporting a link between hypotension and severe AKI. Gestational age-based assessment of AKI revealed that infants with gestational age ≤27 weeks had double the prevalence of severe AKI (46.3% vs. 20%).14 On multivariable logistic regression the combination of GA ≤ 27 weeks, surgical NEC, and the presence of an ostomy were associated with higher odds of severe AKI.14

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Acknowledgements

The Mississippi Center for Clinical and Translational Research for supporting NEC research.

Funding

Funding

P.M.G. is partially supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number U54GM115428. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Authors and Affiliations

  1. Department of Pediatrics/Neonatology, Brenner Children’s at Atrium Health Wake Forest Baptist and Wake Forest University School of Medicine, Winston Salem, NC, USA

    Parvesh Mohan Garg

  2. Department of Pediatrics/Nephrology, Brenner Children’s at Atrium Health Wake Forest Baptist and Wake Forest University School of Medicine, Winston Salem, NC, USA

    Andrew M. South

  3. Children Hospital of Orange County, University of California, Irvine, Orange, CA, USA

    Terrie Inder

  4. Department of Pediatrics, Connecticut Children’s and The University of Connecticut School of Medicine, Hartford, CT, USA

    Jeffrey S. Shenberger

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P.M.G., A.M.S., T.I. and J.S.S. had written and approved the manuscript.

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Correspondence to Parvesh Mohan Garg.

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Garg, P.M., South, A.M., Inder, T. et al. Hypotension: a modifiable risk factor impacting surgical NEC-associated AKI and brain injury in preterm infants. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03244-x

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