A study of serum electrolytes and renal parameters among newborns born with birth asphyxia

 

 

Abstract               Background: Acute renal failure (ARF) is a frequent clinical condition in neonatal intensive care units (NICU). The leading cause of neonatal ARF is perinatal asphyxia. ARF carries poor immediate prognosis and may result in permanent renal damage in upto 40% of survivors. Early recognition of acute renal failure is particularly important in asphyxiated neonates with HIE, in whom a stable biochemical mileu is vital, because it facilitates the administration of appropriate fluid and electrolyte replacement. Objective: To study Electrolyte Status and Renal Failure in asphyxiated newborns of different severity in early neonatal period. Methodology: A Prospective study was conducted by the Department of Pediatrics, Gadag Institute of Medical Sciences, Gadag from July 2019 to December 2020. All the newborn term infants which were admitted to the NICU for birth Asphyxia during the study period were included in the study and further followed up till discharge. A total of 42 Newborn term infants which met the inclusion criteria were included in the study. At the time of enrolment an informed written consent was obtained from the parents. Results: In our study renal failure was seen in nearly 26(62%) of the study participants. Among those subjects who had renal failure 12% of them did not had HIE, 15% were HIE Stage I , 50% were Stage II of HIE and 23 % of them were classified into HIE III. Among the 26 study subjects with renal failure nearly 23% of them had Mild, 46% with Moderate and 31% had severe asphyxia. The Mean Serum Sodium Levels was found to be statistically significant with Birth Asphyxia whereas Serum Pottasium and Serum Calcium levels were found to be statistically insignificant with p value more than 0.05.Conclusion: The renal parameters should bemonitored and if possible the renal indices should be calculated to identify pre-renal and intrinsic renal failure as the treatment differs in both entity.

Key Words: Neonate, Birth asphyxia, Acute renal failure, Hypoxic ischemic encepahalopathy.

 

INTRODUCTION

In most term infants, asphyxia occurs in the antepartum and/or intrapartum period as a result of impaired gas exchange across the placenta that leads to inadequate oxygenation and impaired removal of carbon dioxide and hydrogen ions from the fetus. The remainder of the events occur in postpartum period and is usually secondary to pulmonary, cardiovascular or neurologic abnormalities.¹ Perinatal asphyxia is a common neonatal problem and contributes significantly to neonatal mortality and long term morbidity. The incidence of perinatal asphyxia is 1 – 1.5 % in most developed countries and is inversely related to gestational age and birth weight1.^2,3,4 Perinatal asphyxia has been an area of interest for physicians for centuries. Interest in multiorgan involvement in asphyxia began with studies on animal models which analysed circulatory responses to intrauterine asphyxia16-18. In these studies it was found that asphyxia resulted in redistribution of cardiac output with a larger proportion of flow distributed to cerebral, coronary and adrenal circulations with decreased perfusion to kidney, gastrointestinal tract and skin. This led to the concept of “diving reflex”, which consists of shunting of blood from skin and splanchnic circulation to vital organs. In the last 30 years there has been an increasing interest in normal and abnormal renal function in newborns. The pathological changes in renal failure was first described by Johnson in 1951 as low nephron nephrosis in asphyxia neonatorum. Later in 1961, Bernstein and Meyer recognized a consistent association of renal failure with shock caused by perinatal hypoxia.^5,6 Early recognition of renal failure is important in babies with HIE to facilitate appropriate fluid and electrolyte management as a stable electrical milieu is vital. Diagnosis of renal failure is difficult in this group as many clinical and biochemical parameters are unreliable in this age group. Hence this study was done to determine the incidence of acute renal failure in asphyxiated babies and correlate the severity with HIE grading with emphasis on early diagnosis of acute renal failure which may be of particular benefit for asphyxiated newborns at risk of developing renal failure.

 

MATERIALS AND METHODS

 A Prospective study was conducted by the Department of Pediatrics ,Gadag Institute of Medical Sciences, Gadag from July 2019 to December 2019. All the newborn term infants which were admitted to the NICU for birth Asphyxia during the study period were included in the study and further followed up till discharge .

INCLUSION CRITERIA

1. Term, appropriate for gestational age, newborns with history of birth asphyxia.
2. Evidence of neurologic abnormalities suggestive of Hypoxic ischemic encephalopathy

EXCLUSION CRITERIA

1. Congenital abnormalities of kidneys and/or urinary tract.
2. Babies with septicemia, respiratory distress syndrome.
3. Neonates who have received aminoglycoside antibiotics and aminophylline.
4. Pre term babies with birth asphyxia.

 A total of 42 Newborn term infants which met the inclusion criteria were included in the study. At the time of enrolment an informed written consent was obtained from the parents. Detailed perinatal history was obtained from hospital records. Detailed clinical examination was done. Newborns identified as appropriate for gestational age by applying Ballard’s score and by percentile chart. Diagnosis of birth asphyxia by APGAR score and children with Hypoxic ischemic encephalopathy are staged by SARNAT and SARNAT staging. Gestational age, birth weight, relevant perinatal history, findings on physical examination and systemic examination were recorded on predesigned proforma. Renal function parameters – urine output, urine analysis, urine sodium and creatinine and serum electrolytes with serum calcium were monitored initially within 24hrs of birth. Renal Parametes were monitered regularly till discharge to study the outcome of condition and to asses the renal function . Acute renal failure is defined as serum creatinine of level >1.0 mg/dl on day3 of life and/or urine output of < 1.0ml/kg/hour. On the basis of apgar score at 5 minutes the asphyxiated babies are grouped into mild(score of 6-7), moderate(score of 4-5) and severe asphyxia(score of 3 or less).

Data was entered in Microsoft Excel and analyzed using SPSS version 24.0th. Mean and Standard deviation were calculated for quantitative variables, and proportion calculated for categorical variables.

To assess the association of Serum Electrolytes and Severity of Asphyxia ANOVA test was used and p value of <0.05 was considered statistically significant. Institutional ethical committee approval was taken for given study.

RESULTS

A total of 42 Study subjects were included in the study and analyzed

Table 1: Social Demographic and Clinical Profile of the study subjects

In our study all the study participants were newborn. Nearly 69% of them male and 31% were Female . Nearly 62 % of them were from Urban areas and 38 % were rural areas. In our study 43% of them were suffering from Mild Asphyxia ,36% with moderate asphyxia and 21% with severe asphyxia.Majority of the study subjects were in HIE stage II for 46 %, Stage I and Stage III accounted for 19% and 16% of them did not had HIE.

 

Table 2: Incidence of Renal Failure in Different staging of HIE

 

In our study renal failure was seen in nearly 26(62%) of the study participants. Among those subjects who had renal failure 12% of them did not had HIE, 15% were HIE Stage I, 50% were Stage II of HIE and 23 % of them were classified into HIE III.

Among the 26 study subjects with renal failure nearly 23% of them had Mild, 46% with Moderate and 31% had severe asphyxia .

 

Table 3: Serum Electrolytes level within 24 hours of Birth among subjects

 

From the above table the Mean Serum Electrolytes value were compared with the levels of Asphyxia and it was found that the Mean Serum Sodium Levels was found to be statistically significant with Birth Asphyxia whereas Serum Pottasium and Serum Calcium levels were found to be statistically insignificant with p value more than 0.05.

DISCUSSION

The present cross sectional study was conducted among newborn with asphyxia admitted in NICU.  In our study majority of the study subjects who were admitted with asphyxia were male and similar findings were also seen in the study done by Mac Donald et al. ⁷. The incidence of Renal Failure was found to be 62% in our study which is similar to the study findings of Karlowicz et al. ⁸. Other studies have showed wide variation in the incidence of renal failure among asphyxiated new born varying from 36.5% in the study done by Gharebhagi et al. ⁹, 43.3% in the study done by Jayashree et al. ¹⁰ ,47% in the Gupta et al. ¹¹ study and 72% in the Pammi V Mohan et al. ¹² study. Such wide range of values of renal failure could be due to different hospital set up and even the criteria for deciding renal failure could be different . Even the selection of the study subjects are different in each of studies where few of them including or excluding the subjects with HIE.

The serum Electrolytes levels were measured and was found that serum sodium levels were found to be statistically significant association was seen with birth asphyxia other parameters of serum electrolytes were found to be statistically insignificant. The mean serum sodium levels in our study was 132.75 mEq/L which was found to be similar to the study findings of Gupta et al. ¹¹ (132.83 mEq/L) and Misra et al. ¹³ study(128.28 mEq/L) . The Mean Serum Pottasium levels was found to be 5.21 mEq/Lin our study which is similar to the study findings of Basu P et al. ¹⁴ (5.05 mEq/L). Whereas Gupta et al. ¹¹ (4.5 mEq/L) the value was lesser than our study findings and Misra et al. ¹³ (7.16 mEq/L)was much higher value when compared to our study findings. The overall mean serum calcium levels in our study from all the study subjects was found to be 8.59 mEq/L which is slightly higher when compared to findings of Basu P et al. ¹⁴(6.85 mEq/L).

 

CONCLUSION AND RECOMMENDATION

Perinatal asphyxia is an important cause of neonatal renal failure. Frequent and repeated measurement of Serum Urea and Creatinine levels helps in early diagnosis and even the management of renal failure . Acute renal failure in birth asphyxia shows a strong positive correlation with HIE. ARF in birth asphyxia is predominantly intrinsic renal failure and depends on the seveity of asphyxia. ARF in birth asphyxia is predominantly intrinsic renal failure and depends on the seveity of asphyxia.

 

REFERENCES

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