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Abstract RUOG+HDOWK2UJDQL]DWLRQGHILQHVDVSK\[LD
Background $VSK\[LD QHRQDWRUXP PD\ UHVXOW LQ PXOWLRUJDQ as failure to breath spontaneous and
dysfunction including renal involvement. There is no consensus regularly at birth. The incidence of
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making establishment of the diagnosis and its management
EHFRPHV GLIILFXOW 7KH $FXWH .LGQH\ ,QMXU\ 1HWZRUN $.,1
of live birth. ,Q ,QGRQHVLD HVWLPDWHG LQFLGHQFH
UHFRPPHQGV$.,FULWHULDEDVHGRQLQFUHDVHGVHUXPFUHDWLQLQH RIQHRQDWDODVSK\[LDLVRIOLYHELUWK4 A study
level and reduced urine output. performed at the Department of Child Health,
Objectives 7R LGHQWLI\ WKH SUHYDOHQFH RI $., LQ DVSK\[LDWHG 8QLYHUVLW\ RI ,QGRQHVLD 0HGLFDO 6FKRRO&LSWR
QHRQDWHVXVLQJWKH$.,1FULWHULDWRFRPSDUHWKHGLIIHUHQFHRI 0DQJXQNXVXPR +RVSLWDO 56&0 LQ UHSRUWV
$.,VWDJHVDQGWKHJORPHUXODUILOWUDWLRQUDWHV*)5EHWZHHQ
PRGHUDWHDQGVHYHUHDVSK\[LD
QHRQDWDO DVSK\[LD RI DOO ELUWK5 +\SR[LD DQG
Methods 7KLVZDVDFURVVVHFWLRQDODQDO\WLFDOVWXG\FRQGXFWHG DFXWHLVFKHPLDGXHWRDVSK\[LDFDXVHPXOWLRUJDQG\V
EHWZHHQ-XO\DQG-DQXDU\6XEMHFWVZHUHDOODVSK\[LDWHG function including renal dysfunction which reached
QHRQDWHV$SJDUVFRUHDWILIWKPLQXWHZLWKJHVWDWLRQDODJHRI FDVHV7KHRFFXUUHQFHRI$.,LQQHRQDWHVZLWK
>35 weeks delivered and hospitalized in Cipto Mangunkusumo $SJDUVFRUHRQILUVWPLQXWHLVDQGLQDERXW
+RVSLWDO DQG .RMD 'LVWULFW +RVSLWDO -DNDUWD ,QGRQHVLD
Glomerular filtration rate was calculated using the components
RIWKHPWKHNLGQH\LQMXU\FRQWLQXHVXQWLO
RI XULQH FUHDWLQLQH VHUXP FUHDWLQLQH DQG XULQH RXWSXW ZKLOH hours after birth. Until now, no universal definition
$.,VWDJHVZHUHGHWHUPLQHGDFFRUGLQJWR$.,1FULWHULD8ULQDU\ H[LVWVDERXW$.,0RVWVWXGLHVXVHGVHUXPFUHDWLQLQH
output was measured via urethral catheterization. OHYHO RI !PJG/ DV D FXWRII SRLQW RI $., LQ
Results2IVXEMHFWVWKHUHZHUHQHRQDWHVZLWKPRGHUDWH neonates. $FXWH .LGQH\ ,QMXU\ 1HWZRUN $.,1
DQGQHRQDWHVZLWKVHYHUHDVSK\[LDZLWKWKHSUHYDOHQFHRI$.,
ZDV7ZHQW\RQHRXWRIQHRQDWHVZLWKVHYHUHDVSK\[LD
UHFRPPHQGVFULWHULDRI$.,EDVHGRQWKHLQFUHDVHRI
H[SHULHQFHG$.,ZKLOHQHRQDWHVZLWKPRGHUDWHDVSK\[LDZKR VHUXPFUHDWLQLQHOHYHODQGRUGHFUHDVHRIXULQHRXWSXW
H[SHULHQFHG$.,ZDVRXWRIVXEMHFWV7ZRWKLUGRI DQGFODVVLILHV$.,LQWRWKUHHVWDJHVVWDJHPLOG
QHRQDWHVZLWKVHYHUHDVSK\[LDZKRH[SHULHQFHG$.,KDGVWDJH (moderate), and 3 (severe).
RI$.,0RUHVHYHUH$.,VWDJHVDQGORZHUPHGLDQ*)5ZHUH
We aimed to LGHQWLI\WKHSUHYDOHQFHRI$.,RQ
IRXQGLQQHRQDWHVZLWKVHYHUHFRPSDUHGWRPRGHUDWHDVSK\[LD
3 QHRQDWDODVSK\[LDXVLQJ$.,1FULWHULDWRUHFRJQL]H
Conclusion7KHSUHYDOHQFHRI$.,LQQHRQDWDODVSK\[LDLVKLJK
7KHPRUHVHYHUHGHJUHHRIQHRQDWDODVSK\[LDWKHPRUH
VHYHUH$.,VWDJHDQGWKHORZHUPHGLDQ*)5[Paediatr Indones.
2013;53:232-8.]. )URPWKH'HSDUWPHQWRI&KLOG+HDOWK8QLYHUVLW\RI,QGRQHVLD0HGLFDO
6FKRRO&LSWR0DQJXQNXVXPR+RVSLWDO-DNDUWD,QGRQHVLD
Keywords: acute kidney injury, asphyxiated neonates, Reprint request to: Roy Amardiyanto, Department of Child Health,
serum creatinine, urine output 8QLYHUVLW\ RI ,QGRQHVLD 0HGLFDO 6FKRRO &LSWR 0DQJXQNXVXPR
+RVSLWDO -O 'LSRQHJRUR -DNDUWD 7HO (PDLO
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Table 1#-+0ETKVGTKC9
Stage Serum creatinine Urine output
1 Increase >0.3 mg/dL or <0.5 mL/kg/hour over 6 hours
increase >150-200% baseline
2 Increase >200-300% baseline <0.5 mL/kg/hour over 12 hours
3 Increase >300% baseline or <0.3 mL/kg/hour over 24 hours
> 4.0mg/dL with acute increase or no urine for 12 hours
> 0.5mg/dL
7KH $., ZDV GHWHUPLQHG EDVHG RQ $.,1 FULWHULD Table 2. Characteristics of subjects
DQG$.,VWDJHZDVFKRVHQEDVHGRQWKHZRUVWVWDJH Characteristics n=94
of serum creatinine level increase or urine output Mean birth weight (SD), gram 2.737 (581)
Median birth length (range), cm 48 (41-53)
decrease (Table 1).
Sex, n (%)
0RWKHUVVHUXPFUHDWLQLQHOHYHOSHUIRUPHGEHIR
Male 57 (61)
UHGHOLYHU\RUKRXUVDIWHUGHOLYHU\FRQVLGHUHGDVWKH Female 37 (39)
baseline serum creatinine level of the neonates. The Median gestational age (range), weeks 38 (35-43)
QRUPDO FXWRII SRLQW IRU PRWKHUV VHUXP FUHDWLQLQH Degree of asphyxia, n (%)
OHYHO ZDV PJG/ 7KH PHDQ QRUPDO *)5 RQ Moderate 70 (75)
QHRQDWHV ZLWK JHVWDWLRQDO DJH ZHHNV DW DJH Severe 24 (25)
Delivery type, n (%)
DQGGD\VZHUH6'DQG6'P/
Spontaneous 40 (43)
PLQP, consecutively. Vacuum extraction 8 (9)
This study had approval from Ethical Committee Forceps extraction 1 (1)
RI8QLYHUVLW\RI,QGRQHVLD0HGLFDO6FKRRO$OOSDUHQWV Caesarian surgery 46 (47)
gave consents for the study. /GFKCPTUVOKEVWTKVKQPCIG
TCPIGJQWTU 7 (1-36)
7KHGLIIHUHQFHEHWZHHQPRGHUDWHDQGVHYHUH$.,
ZHUH DQDO\]HG E\ XVLQJ &KLVTXDUH RU .ROPRJRURY but 3 neonates were of incomplete data, therefore
6PLUQRYZKHUH&KLVTXDUHZDVQRWDEOHWREHDSSOLHG WKH\H[SHOOHGIURPWKHDQDO\VLV7KHUHZHUHDWRWDO
0DQQ:KLWQH\WHVWZDVXVHGIRUDQDO\]LQJQXPHULFDO RI DVSK\[LDWHG QHRQDWHV UHFUXLWHG LQ WKLV VWXG\
GDWD7KHVLJQLILFDQFHLQWKLVVWXG\ZDV3 FRQVLVWHG RI QHRQDWHV ZLWK PRGHUDWH DVSK\[LD
DQGQHRQDWHVZLWKVHYHUHDVSK\[LD%LUWKZHLJKW
ELUWKOHQJWKVH[JHVWDWLRQDODJHGHJUHHRIDVSK\[LD
Results type of delivery, and age of first micturition are listed
on Table 2. Mean and median of mothers serum
'XULQJWKHVWXG\SHULRGWKHUHZHUHOLYHELUWK FUHDWLQLQH OHYHO ZHUH 6' PJG/ DQG
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Table 3. Prevalences and stages of acute kidney injury in all asphyxiated neonates
Variables Numbers
n=94
$CUGFQP#-+0ETKVGTKCP
#-+ 59 (63)
5VCIGUQH#-+
Stage 3 18 (31)
Stage 2 18 (31)
Stage 1 23 (38)
0Q#-+ 35 (37)
Based on serum creatinine level, n (%)
#-+ 44 (47)
5VCIGUQH#-+
Stage 3 9 (21)
Stage 2 12 (27)
Stage 1 23 (52)
0Q#-+ 50 (53)
$CUGFQPJQWTUWTKPGQWVRWVEQNNGEVGFCHVGTTUVOKEVWTKVKQPP
#-+ 39 (42)
5VCIGUQH#-+
Stage 3 13 (33)
Stage 2 15 (39)
Stage 1 11 (28)
0Q#-+ 55 (58)
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criteria was assessed based on the increase of serum micturition are shown in Table 4.
FUHDWLQLQH OHYHO DQGRU GHFUHDVH RI KRXUV XULQH Table 5 shows that neonates with severe
output collected after first micturition. Based on those DVSK\[LD KDG D KLJKHU PHGLDQ UDQJH RI VHUXP
WZRLQGLFDWRUVWKHSUHYDOHQFHRI$.,ZDVVXEMHFWV creatinine level and a lower median (range) of GFR
7KHUHZHUHQHRQDWHVZLWK$.,VWDJH FRPSDUHG WR WKH PRGHUDWH DVSK\[LD 3
1HRQDWHV ZLWK $., EDVHG RQ LQFUHDVH RI VHUXP 3UHVSHFWLYHO\
FUHDWLQLQHOHYHORQO\ZHUHWKLVZDVFRPSULVH
RIQHRQDWHVZLWKVWDJH$.,7KHQHRQDWHV
ZLWK$.,EDVHGRQGHFUHDVHRIKRXUVXULQHRXWSXW Discussion
DIWHUILUVWPLFWXULWLRQZDVDPRQJVWWKHP
QHRQDWHVKDGVWDJHRI$.,Table 3). The numbers of neonates with moderate and severe
7KHFRPSDULVRQRISUHYDOHQFHDQGVWDJHRI$., DVSK\[LDZHUHDQGFRQVHFXWLYHO\
LQ PRGHUDWH DQG VHYHUH DVSK\[LD EDVHG RQ $.,1 7KLVLVDOPRVWVLPLODUZLWKRWKHUVWXGLHVZKLFKUHSRU
criteria, increase of serum creatinine level, and WHGWKHQXPEHUVRIPRGHUDWHDQGVHYHUHDVSK\[LDZHUH
Table 42TGXCNGPEGUCPFUVCIGUQH#-+DCUGFQPUGXGTKV[QHCURJ[ZKC
Variables Severe asphyxia group Moderate asphyxia group P value
(n=24) (n=70)
$CUGFQP#-+0ETKVGTKCP
Yes 21 38 0.003#
No 3 32
Stages
Stage 3 14 4 <0.001#
Stage 2 5 14
Stage 1 2 22
Based on serum creatinine increasing level, n (%)
Yes 16 28 0.025#
No 8 42
Stages
Stage 3 6 3 0.458*
Stage 2 4 8
Stage 1 6 17
$CUGFQPWTKPGQWVRWVJQWTUCHVGTTUVOKEVWTKVKQPP
Yes 20 19 <0.001#
No 4 51
Stages
Stage 3 12 1 <0.001#
Stage 2 6 9
Stage 1 2 9
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Table 55GTWOETGCVKPKPGNGXGNUCPFINQOGTWNCTNVTCVKQPTCVGUQPOQFGTCVGCPFUGXGTGCURJ[ZKC
P
48-72 hours
Moderate asphyxia (n=74) Severe asphyxia (n=24) P value
Median (range) Median (range)
Serum creatinine level (mg/dL) 0.62 (0.42-1.88) 0.84 (0.40-3.32) 0.005*
GFR based on eCCl (mL/min/1.73m2) 29.59 (9.46-115.53) 11.21 (2.11-43.8) <0.001*
* Mann-Whitney test
DQG Almost all neonates with serum creatinine level compared to this study.
DVSK\[LDKDGILUVWPLFWXULWLRQLQKRXUVDIWHUELUWK ,QWKLVVWXG\QHRQDWHVKDG$.,EDVHG
7KHUHZDVQHRQDWHZLWKVHYHUHDVSK\[LDKDGLWVILUVW RQDGHFUHDVHRIKRXUVXULQHRXWSXWFROOHFWHGDIWHU
PLFWXULWLRQDWKRXUV0DQRHet al reported 3 out of first micturition. Perlman et alUHSRUWHGWKDWRXWRI
QHRQDWHVZLWKDVSK\[LDKDGWKHLUILUVWPLFWXULWLRQ QHRQDWHVZLWKDVSK\[LDKDGROLJXULD Mohan et al
LQKRXUVDIWHUELUWK,QQHRQDWHVZLWKDVSK\[LD UHSRUWHGWKDWRXWRIQHRQDWHVZLWKDVSK\[LDKDG
DSDUDO\VLVRIEODGGHUPLJKWWHPSRUDULO\H[LVWZKLFK oliguria. Vasoconstriction of afferent arterioles which
may cause urine tardiness. The low prevalence of RFFXUUHDWWKHWLPHRIK\SR[HPLDOHDGVWRDGHFUHDVH
QHRQDWHV ZLWK DVSK\[LD ZLWK ILUVW PLFWXULWLRQ ! in urine output due to a decrease of blood flow to the
hours in this study might be because of the use of kidneys. Perlmans report was similar to this study,
urinary catheter which ensure urine output, although probably because of relatively similar subject criteria
there might be temporary bladder paralysis. although they added the parameters of pH and pCO
,QWKLVVWXG\QHRQDWHVZLWKDVSK\[LDKDG RIXPELOLFDOFRUGDUWHU\LQGLDJQRVLQJDVSK\[LDThe
$.,EDVHGRQLQFUHDVHRIVHUXPFUHDWLQLQHOHYHODQGRU high incidence of oliguria in Mohans report might be
decrease of urine output. The result is similar to a report because of kidney injury occurred more severe than
from Aggarwal et al and Karlowicz et al who reported those in our study. Mohan used tighter criteria for
DQGQHRQDWHVZLWKDVSK\[LDKDGDFXWHUHQDO QHRQDWDODVSK\[LDWKRVHZHUHORZHU$SJDUVFRUHDQG
failure, consecutively. Askenazi et alUHSRUWHG WKH RFFXUUHQFH RI K\SR[LF LVFKHPLF HQFHSKDORSDWK\
QHRQDWHVZLWKDVSK\[LDKDG$.,DQG6HOHZHVNLet al +,(+\SR[LFLVFKHPLFHQFHSKDORSDWK\LQGLFDWHV
UHSRUWHGQHRQDWHVZLWKDVSK\[LDZKRZHUHWUHDWHG WKH VHYHULW\ RI K\SR[LD LQ WKH ERG\ ZKLFK LQGXFHV
ZLWKK\SRWKHUPLFPHWKRGKDG$.,DFFRUGLQJWR$.,1 organs, including kidney, to have worse disruptions
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of the kidney. This in turn caused a disturbance in the DVSK\[LDEDVHGRQWKHLQFUHDVHRIVHUXPFUHDWLQLQH
nephrons which will increase the serum creatinine level OHYHODQGRUWKHGHFUHDVHRIXULQHRXWSXWZDV
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in the study by Askenazi et al might be due to subject SUHYDOHQFH EHWZHHQ PRGHUDWH DQG VHYHUH DVSK\[LD
analysis was only performed on neonates with moderate ZDV 5DGLW\R et al reported the difference of
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et alUHSRUWHGWKDWRXWRIQHRQDWHVZLWK lead to more increase of serum creatinine level and
ILIWKPLQXWH$SJDUVFRUHKDGDQLQFUHDVHRIVHUXP GHFUHDVH RI XULQH RXWSXW WKDQ PRGHUDWH DVSK\[LD
creatinine level. The assault of the nephrons due to 7KH ILQGLQJV WKDW PRUH $., ZDV IRXQG LQ VHYHUH
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creatinine clearance which in turn will increase serum are similar to other previous studies.
creatinine level. 7KH SUREOHP RI GLDJQRVLV RI $., This study also indicates that neonates with
based on serum creatinine level only in neonates is that VHYHUHDVSK\[LDDUHPRUHOLNHO\WRKDYHPRUHVHYHUH
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hours with mothers serum creatinine level. The low WHVZLWKVHYHUHDVSK\[LDZDVKLJKHUWKDQPRGHUDWH
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analysis for the difference of GFR in severe and SHUVSHFWLYH3HGLDWULFV
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consecutively. We found a larger difference between
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Limitations of this study were the criteria for 34.
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has superiority, where urinary output was monitored Warnock DG, et al. Acute kidney injury network: Report of
carefully using urinary catheter therefore we could an initiative to improve outcome in acute kidney injury. Crit
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References 3HGLDWU1HSKURO
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a practical guide. Geneva: World Health Organization. WKHUDSHXWLFK\SRWKHUPLD-3HGLDWU
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3HUOPDQ -0 5HQDO LQMXU\ LQ WKH DVSK\[LDWHG QHZERUQ
infant: relationship to neurologic outcome. J Pediatr. 8PERK$+XEXQJDQDVILNVLDQHRQDWRUXPGHQJDQJDQJJXDQ
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