Acute kidney injury is associated with subsequent infection in neonates
after the Norwood procedure: a retrospective chart review
Danielle E. Soranno
Sonali S. Patel
Katja M. Gist
Received: 7 December 2017 / Revised: 18 January 2018 / Accepted: 26 January 2018 / Published online: 5 March 2018
Background Acute kidney injury (AKI) and infection are common complications after pediatric cardiac surgery. No pediatric
study has evaluated for an association between postoperative AKI and infection. The objective of this study was to determine if
AKI in neonates after cardiopulmonary bypass was associated with the development of a postoperative infection.
Methods We performed a single center retrospective chart review from January 2009 to December 2015 of neonates (age ≤ 30 days)
undergoing the Norwood procedure. AKI was defined by the modified neonatal Kidney Disease Improving Global outcomes serum
creatinine criteria using (1) measured serum creatinine and (2) creatinine corrected for fluid balance on postoperative days 1–4.
Infection, (culture positive or presumed), must have occurred after a diagnosis of AKI and within 60 days of surgery.
Results Ninety-five patients were included, of which postoperative infection occurred in 42 (44%). AKI occurred in 38 (40%)
and 42 (44%) patients by measured serum creatinine and fluid overload corrected creatinine, respectively, and was most
commonly diagnosed on postoperative day 2. The median time to infection from the time of surgery and AKI was 7 days
(IQR 5–14 days) and 6 days (IQR 3–13 days), respectively. After adjusting for confounders, the odds of a postoperative infection
were 3.64 times greater in patients with fluid corrected AKI (95% CI, 1.36–9.75; p =0.01).
Conclusions Fluid corrected AKI was independently associated with the development of a postoperative infection. These find-
ings support the notion that AKI is an immunosuppressed state that increases the risk of infection.
Keywords Acute kidney injury
Sepsis is the leading cause of death in patients with acute
kidney injury (AKI) [1–4]. Sepsis is also the most common
cause of AKI. Sepsis-induced AKI significantly worsens pa-
tients’ prognosis, when compared to AKI from other causes
[5–13]. Several adult studies have evaluated for the impact of
AKI on subsequent rates of infection or sepsis [14–19]. In
adults after cardiac surgery, infectious complications were
significantly higher among patients with impaired preoper-
ative renal function [15, 20]orpostoperativeAKI[15, 20,
21]. These findings have led to the conclusion that AKI—
like end stage renal disease (ESRD)—is an immunosup-
pressed state [18, 22, 23].
AKI after pediatric cardiac surgery is common, occurring
in 20–50% of patients [24, 25]. The etiology of cardiac sur-
gery associated AKI is multifactorial and is associated with
significant morbidity and mortality, including increased dura-
tion of mechanical ventilation, prolonged intensive care and
hospital length of stay [24, 25], and increased hospital costs
. Although AKI is typically diagnosed by a rise in serum
Electronic supplementary material The online version of this article
(https://doi.org/10.1007/s00467-018-3907-5) contains supplementary
material, which is available to authorized users.
* Katja M. Gist
Department of Pediatrics, Children’s Hospital Colorado, The Heart
Institute, University of Colorado, 13123 E 16th Ave, B100,
Aurora, CO 80045, USA
Renal Division, Department Medicine, University of Colorado,
Aurora, CO, USA
Denver VA Medical Center, Denver, CO, USA
Department of Pediatrics, Children’s Hospital Colorado, The Kidney
Center, University of Colorado, Aurora, CO, USA
Pediatric Nephrology (2018) 33:1235–1242