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Role of environmental factors in non asphyxial renal failure in NICU.

INTRODUCTION: In the last decade, published data on neonatal renal failure has increased and various studies show an incidence of acute renal failure (ARF) in Neonatal Intensive Care units ranging from 1-8%. (1-5) This is attributed to the following factors:

1. Prolonged survival of seriously ill new borns with improved resuscitation and ventilatory support.

2. Increased awareness of renal failure and importance of monitoring urine output and serial measurements of blood urea and serum creatinine in neonates.

3. Antenatal diagnosis of renal anomalies by ultrasonography, many of which lead to renal failure in neonates.

4. Use of nephrotoxic drugs and increased incidence of gram negative sepsis.

5. Increased survival of premature neonates at a higher risk of renal failure due to physiological immaturity of renal function, sudden adaptation to extra uterine life and exogenous stress factors which break down the homeostasis of body function regulated by the placenta in fetal life.

These are the various causes of acute renal failure in neonates. In addition to these causes; dehydration plays a major role in causing acute renal failure in neonates.

Published data on neonatal renal failure in India is scanty, also there are no studies showing the relation between environmental factors and acute renal failure in neonates. Hence this study was undertaken to study the role of environmental factors in ARF.

OBJECTIVE: To study the role of environmental factors in non asphyxial acute renal failure during summer months (April, May 2013) in neonates admitted to NICU.

METHODS: The study was conducted in our NICU. 35 neonates out of 240, with fever, poor sucking and decreased urine output was admitted to the nursery from April to May 2013 were evaluated for presence of ARF (cases). Sepsis was diagnosed on the basis of either a positive sepsis screen (Immature: total (I: T) (6) neutrophil ratio > 0. 2, [mu] -ESR > age in days + 2 mm or >15 mm, CRP> 6mg/dl, TLC<5000 cells/[mm.sup.3]; 2 or more positive) or a positive blood culture in symptomatic neonates. ARF was defined as blood urea nitrogen (BUN) >20mg/dl (7) on two separate occasions at least 24 hours apart or a serum creatinine level more than 1. 5gm/dl for at least 24-48 hours, if mothers renal function is normal. Oliguria was defined as urine output <1ml/Kg/hr. (8)

OBSERVATION AND RESULTS: INCIDENCE OF ACUTE RENAL FAILURE IN NICU:

Total no of admissions to NICU of both the hospitals-240.

Total no of acute renal failure cases-35.

Incidence-14. 5 %.

INCIDENCE OF ACUTE RENAL FAILURE AMONG INTRAMURAL CASES:

Total no of deliveries of both the hospitals-600.

Intramural acute renal failure cases-20.

Incidence-3. 3%.

Out of 35 cases of acute renal failure, 25 were males and 10 were females.

Out of the 35 babies admitted with acute renal failure, 33 were term n only 2 were preterm.

Out of the 35 cases, 20 babies were born in our hospital and 15 from other hospitals in Gulbarga.

Out of 35 ARF cases, lactation was established in only 15 babies.

TEMPERATURE IN GULBARGA

This graph shows that highest temperature in Gulbarga is in the month of April and May.

Out of the 35 acute renal failure cases, only 5 babies had late onset sepsis and 3 out of them had culture positive.

Oliguric renal failure was seen in only 7 babies (20%) when compared to 28 babies who presented with non oliguric renal failure.

Out of the 35 babies, 65. 7% were born by LSCS and 34. 2 by normal vaginal delivery.

Out of the 35 cases of acute renal failure, 27 babies were born to primi mothers and the rest 8 were born to multigravida mothers.

Out of the 35 cases, all required intravenous fluids and diuretics as the treatment modality. Only 7 babies required peritoneal dialysis as an intervention.

Out of the 35 acute renal failure cases admitted, 32 babies improved and were discharged. Only 2 succumbed to the disease and 1 was referred to higher centre.

DISCUSSION: The neonatal kidney is particularly vulnerable to the effects of hypo perfusion since the renal vascular resistance and plasma renin activity are high. Consequently, renal blood flow is proportionately more reduced in neonates.

Dehydration can operate through a variety of mechanisms in producing renal failure. It can cause renal failure by shock, DIC, hemorrhage, cardiac failure and through ATN. Dehydration can be caused due to adverse climatic conditions (increased temperature and humidity) or poor feeding techniques or lactation.

While dehydration has been said to be one of the important predisposing causes of ARF, the actual incidence of renal failure in all dehydration cases is not documented. In this present study, of the 35 cases of ARF, 30 had pure dehydration with no other predisposing factor for ARF.

The present study has analyzed ARF in relation to dehydration due to the adverse climatic condition. The mean temperature in Gulbarga was 39-40[degrees]C. To the best of our knowledge, no such study focusing on ARF in dehydration has been published till date.

The general incidence of acute renal failure in NICU attached to Basaveshwara teaching and general hospital and Sangameshwar General Hospital is 14.5%, which is higher than the national standards of 1-8%.1-5 Incidence of ARF among intramural cases of both the hospitals is 3. 3%.

In the present study out of 35 cases, 25 (71%) were males and 10 (29%) were females.

According to the gestational age-33 were term babies and only 2 were preterm.

Out of 35 cases, 20 babies (57.14%) were intramural and 15 babies (42.8%) were extramural.

The present study contradicts the general perception that ARF in neonates is commonly oliguric. Only 20 % was oliguric whereas 80% of the majority was non oliguric. Previous studies done by Jayashree et al (6) on birth asphyxia patients found 69. 2% of ARF to be oliguric. In a study by Pereira et al (7) on 20 cases of ARF (out of which 18 had sepsis), the incidence of oliguria was 80%.

Mode of delivery and parity played a role in this present study. 23 (65%) babies were born by LSCS and 27 babies (77%) were born to primi mothers. This can be explained by poor lactation post c section and also poor feeding techniques in primi mothers.

All the cases were treated with boluses and furosemide injections. Only 7 babies (20%) required peritoneal dialysis in addition to the above treatment, and only 2 out of 35 cases succumbed to ARF.

CONCLUSION:

* General incidence of ARF in our study was high in the months of April and May (14. 5%), 2013 when compared to other studies (1-8%) and also when compared to 0 cases in the month of November and December. This shows that seasonal variation like temperature and humidity has got an influence on ARF.

* Non-oliguric ARF was commoner than oliguric ARF.

* Aggressive management is needed for better outcome.

RECOMMENDATIONS:

WHAT WE KNOW ALREADY?

* ARF is common in summer months with adverse climatic conditions (temperature and humidity.

* No proven data available regarding the same. WHAT TO DO?

* Early interventions to reduce incidence of ARF during peak summer months has to be initiated.

* Interventions can be in the form of formula feeds/intra venous fluids along with exclusive breast feeding.

* Frequent breast feeding and improved breast feeding counseling to be advised during summer months.

* Further studies with intervention as above need to be done.

DOI: 10.14260/jemds/2015/595

BIBLIOGRAPHY:

(1.) Stapleton F, Jones D, Green R. Acute renal failure in neonates: incidence, etiology and outcome. Pediatr Nephrol 1987; 1: 314-320.

(2.) Norman ME, Asadi FK. A prospective study of acute renal failure in the newborn infant. Pediatrics 1979; 63: 475-479.

(3.) Modi N. Treatment of renal failure in neonates. Arch Dis Child 1989, 64: 630-631.

(4.) Meeks ACG, Sims DG. Treatment of acute renal failure in neonates. Arch Dis Child 1988, 63: 1372-1376.

(5.) Anand SK. Acute renal failure in neonates Pediatr Clin North Am 1982, 29: 791-800.

(6.) Pereira S, Pereira BJG, Bhakoo ON, Narang A, Sakhuja VS, Chugh KS. Peritoneal dialysis in neonates with acute renal failure. Ind J Pediatr 1988, 58: 973-978.

(7.) Brion LP, Bernstein J, Spitzer A. Kidney and urinary tract. In Neonatal- perinatal medicine: Diseases of the Fetus and Infant, Fanaroff AA, Martin RJ eds. St. Louis, Mosby-Year Book Inc., 1997, pp 1586.

(8.) Pereira S, Pereira BJG, Bhakoo ON, Narang A, Sakhuja VS, Chugh KS. Peritoneal dialysis in neonates with acute renal failure. Ind J Pediatr 1988, 58: 973-978.

Sandeep V. H [1], Savita S. T [2], Simi Mathew [3]

AUTHORS:

[1.] Sandeep V. H.

[2.] Savita S. T.

[3.] Simi Mathew

PARTICULARS OF CONTRIBUTORS:

[1.] Assistant Professor, Department of Paediatrics, M. R. Medical College, Gulbarga.

[2.] Assistant Professor, Department of obstetrics & Gynaecology, KBN Institute of Medical Sciences, Gulbarga.

[3.] Junior Resident, Department of Paediatrics, M. R. Medical College, Gulbarga.

FINANCIAL OR OTHER COMPETING INTERESTS: None

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Sandeep V. H, Department of Paediatrics, M. R. Medical College, Gulbarga.

E-mail: vhsandeep@gmail.com.

Date of Submission: 13/13/2015.

Date of Peer Review: 14/03/2015.

Date of Acceptance: 16/03/2015.

Date of Publishing: 20/03/2015.

Table 1: Sex Distribution

              APRIL, MAY 2013         NOV, DEC 2013

          ARF   NON ARF   TOTAL   ARF   NON ARF   TOTAL

Male      25      135      160     0      123      123
Female    10      70       80      0      104      104
          35      205      240     0      227      227

Table 2: Gestational Age

                 APRIL, MAY 2013         NOV, DEC 2013

           ARF   NON ARF   TOTAL   ARF   NON ARF   TOTAL

Term       33      163      196     0      150      150
Preterm     2      42       44      0      77       77
           35      205      240     0      227      227

Table 3: Place of Birth

                APRIL, MAY 2013           NOV, DEC 2013

              ARF   NON ARF   TOTAL   ARF   NON ARF   TOTAL

Intramural    20      92       112     0      137      137
Extramural    15      113      128     0      90       90
              35      205      240     0      227      227

Table 4: Lactation

                  Number

Established         15
Not established     20
                    35

Table 5: SEPSIS

          APRIL, MAY 2013            NOV, DEC 2013

          Number   NON ARF   TOTAL   ARF   NON ARF   TOTAL

Present     5        103      108     0      120      120
Absent      30       102      132     0      87       87
            35       205      240     0      227      227

Table 6: URINE OUTPUT

                NUMBER    %

Oliguria          7      20
non oliguria      28     80
                  35     100

Table 7: Maternal history

                                   NOV, DEC 2013

        Number   NON ARF   TOTAL   ARF   NON ARF   TOTAL

LSCS      23       53       76      0      74       74
NVD       12       152      164     0      153      153
          35       205      240     0      227      227

Table 8

                                          NOV, DEC 2013

               Number   NON ARF   TOTAL   ARF   NON ARF   TOTAL

Primigravida     27       167      194     0      177      177
Multigravida     8        38       46      0      50       50
                 35       205      240     0      227      227

Table 9: TREATMENT

                       Number   % age

BOLUSES                  35      100
DIURETICS                35      100
PERITONEAL DIALYSIS      7       20

Table 10: OUTCOME

                           Number   NON ARF   TOTAL

Improved and discharged      32       179      211
Referred                     1         2        3
Death                        2        24       26
                             35       205      240
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Title Annotation:ORIGINAL ARTICLE
Author:Sandeep, V.H.; Savita, S.T.; Mathew, Simi
Publication:Journal of Evolution of Medical and Dental Sciences
Date:Mar 23, 2015
Words:1812
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