Severe acute kidney injury in neonates with necrotizing enterocolitis: risk factors and outcomes



To study the risk factors and outcomes of severe acute kidney injury (AKI) in neonates with necrotizing enterocolitis.


Retrospective chart review of 202 neonates with necrotizing enterocolitis (NEC) (Bell stage >IIa) from 2013 to 2018. AKI was defined as per-modified neonatal Kidney Disease: Improving Global Outcomes criteria. Demographic, clinical, and outcome data were compared between neonates without severe AKI (stage 0 and 1 AKI) and those with severe AKI (stage 2 and 3 AKI).


Severe AKI occurred in 66/202 (32.6%) of neonates after NEC diagnosis and after 61/104 (58.7%) of surgical NEC diagnoses. On adjusted model, surgical NEC [adjusted odds ratio (aOR) = 30.6; 95% confidence interval (CI) = 8.9, 130.6], outborn [aOR = 3.9; 95% CI = 1.54, 11.0], exposure to antenatal steroids [aOR = 3.0; 95% CI = 1.1, 8.9], and positive blood culture sepsis [aOR = 3.5; 95% CI = 1.3, 10.0] had increased odds for severe AKI. Those with severe AKI required longer hospitalization [124 days (interquartile range (IQR) 88–187) vs. 82 days (IQR 42–126), p < 0.001].


Severe AKI is common in neonates with NEC who require surgical intervention, are outborn, have positive blood culture sepsis, and receive antenatal steroids. Severe AKI is associated with a significantly longer length of hospitalization.


  • Neonates with NEC, who are transferred from outside hospitals, require surgical NEC management, and/or have a positive blood culture at NEC onset are at the highest odds for severe (stages 2 and 3) AKI.

  • Assessment of urine output is important for patients with NEC. Without it, 11% of those with severe AKI would have been misdiagnosed using serum creatinine alone.

  • Kidney-protective strategies in the pre-, peri-, and postoperative period may improve the morbidity and mortality associated with severe AKI in neonates with NEC.

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Dr. Keia Sanderson is supported by Grant 2015213 from the Doris Duke Charitable Foundation.

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P.M.G. designed the study; P.M.G., A.B.B., S.S., D.K.B., J.L.P., N.B.O., M.A.Y.A., K.R.S., and D.A. collected and analyzed the data; P.M.G., D.A., M.A.Y.A., and K.R.S. wrote the manuscript. All the authors contributed to and approved the manuscript.

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Correspondence to Parvesh Mohan Garg.

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Garg, P.M., Britt, A.B., Ansari, M.A.Y. et al. Severe acute kidney injury in neonates with necrotizing enterocolitis: risk factors and outcomes. Pediatr Res (2021).

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