Paediatrica Indonesiana

VOLUME 53 July  NUMBER 4

Original Article

Acute kidney injury in asphyxiated neonates

Roy Amardiyanto, Partini Pudjiastuti Trihono, Lily Rundjan, Hardiono D. Pusponegoro

W
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
RQWKHGHWHUPLQDWLRQRIDFXWHNLGQH\LQMXU\$.,LQQHRQDWHV DVSK\[LDLQYDULRXVFRXQWULHVUDQJHVIURPWR
making establishment of the diagnosis and its management
EHFRPHV GLIILFXOW 7KH $FXWH .LGQH\ ,QMXU\ 1HWZRUN $.,1
UHFRPPHQGV$.,FULWHULDEDVHGRQLQFUHDVHGVHUXPFUHDWLQLQH
level and reduced urine output.
Objectives 7R LGHQWLI\ WKH SUHYDOHQFH RI $., LQ DVSK\[LDWHG
of live birth. ,Q ,QGRQHVLD HVWLPDWHG LQFLGHQFH
RIQHRQDWDODVSK\[LDLVRIOLYHELUWK4 A study
performed at the Department of Child Health,
8QLYHUVLW\ RI ,QGRQHVLD 0HGLFDO 6FKRRO&LSWR
QHRQDWHVXVLQJWKH$.,1FULWHULDWRFRPSDUHWKHGLIIHUHQFHRI 0DQJXQNXVXPR +RVSLWDO 56&0 LQ  UHSRUWV
$.,VWDJHVDQGWKHJORPHUXODUILOWUDWLRQUDWHV*)5EHWZHHQ
PRGHUDWHDQGVHYHUHDVSK\[LD
Methods 7KLVZDVDFURVVVHFWLRQDODQDO\WLFDOVWXG\FRQGXFWHG
EHWZHHQ-XO\DQG-DQXDU\6XEMHFWVZHUHDOODVSK\[LDWHG
 QHRQDWDO DVSK\[LD RI DOO ELUWK5 +\SR[LD DQG
DFXWHLVFKHPLDGXHWRDVSK\[LDFDXVHPXOWLRUJDQG\V
function including renal dysfunction which reached
QHRQDWHV$SJDUVFRUHDWILIWKPLQXWHZLWKJHVWDWLRQDODJHRI
>35 weeks delivered and hospitalized in Cipto Mangunkusumo
+RVSLWDO DQG .RMD 'LVWULFW +RVSLWDO -DNDUWD ,QGRQHVLD
Glomerular filtration rate was calculated using the components
RI XULQH FUHDWLQLQH VHUXP FUHDWLQLQH DQG XULQH RXWSXW ZKLOH
$.,VWDJHVZHUHGHWHUPLQHGDFFRUGLQJWR$.,1FULWHULD8ULQDU\
output was measured via urethral catheterization.
FDVHV7KHRFFXUUHQFHRI$.,LQQHRQDWHVZLWK
$SJDUVFRUHRQILUVWPLQXWHLVDQGLQDERXW
RIWKHPWKHNLGQH\LQMXU\FRQWLQXHVXQWLO
hours after birth. Until now, no universal definition
H[LVWVDERXW$.,0RVWVWXGLHVXVHGVHUXPFUHDWLQLQH
OHYHO RI !PJG/ DV D FXWRII SRLQW RI $., LQ
Results2IVXEMHFWVWKHUHZHUHQHRQDWHVZLWKPRGHUDWH
DQGQHRQDWHVZLWKVHYHUHDVSK\[LDZLWKWKHSUHYDOHQFHRI$.,
ZDV7ZHQW\RQHRXWRIQHRQDWHVZLWKVHYHUHDVSK\[LD
H[SHULHQFHG$.,ZKLOHQHRQDWHVZLWKPRGHUDWHDVSK\[LDZKR
neonates. $FXWH .LGQH\ ,QMXU\ 1HWZRUN $.,1
UHFRPPHQGVFULWHULDRI$.,EDVHGRQWKHLQFUHDVHRI
VHUXPFUHDWLQLQHOHYHODQGRUGHFUHDVHRIXULQHRXWSXW
H[SHULHQFHG$.,ZDVRXWRIVXEMHFWV7ZRWKLUGRI
QHRQDWHVZLWKVHYHUHDVSK\[LDZKRH[SHULHQFHG$.,KDGVWDJH
RI$.,0RUHVHYHUH$.,VWDJHVDQGORZHUPHGLDQ*)5ZHUH
IRXQGLQQHRQDWHVZLWKVHYHUHFRPSDUHGWRPRGHUDWHDVSK\[LD
DQGFODVVLILHV$.,LQWRWKUHHVWDJHVVWDJHPLOG
(moderate), and 3 (severe).
We aimed to LGHQWLI\WKHSUHYDOHQFHRI$.,RQ
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
UR\DPDUGL\DQWR#JPDLOFRm

232Paediatr Indones, Vol. 53, No. 4, July 2013

 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV
IRUWKHUHODWLRQVKLSRI$.,VWDJHVZLWKWKHVHYHULW\
RIDVSK\[LDDQGWRLGHQWLI\WKHJORPHUXODUILOWUDWLRQ
rate (GFR) in neonates with moderate and severe
DVSK\[LD
Methods
$FURVVVHFWLRQDODQDO\WLFDOVWXG\ZDVSHUIRUPHGLQ
the Neonatology Division of Cipto Mangunkusumo
Hospital (RSCM) and District Hospital (RSUD) Koja
-DNDUWDIURP-XOLWR-DQXDUL6XEMHFWVZHUH
all neonates with gestational age >35 weeks with
$SJDUVFRUHRQWKHILIWKPLQXWHZKRZHUHERUQDQG
KRVSLWDOL]HGLQ56&0DQG568'.RMD:HH[FOXGHG
neonates with major congenital malformation on
SK\VLFDOH[DPLQDWLRQDWELUWKRUGHWHFWHGSUHYLRXVO\
E\ XOWUDVRXQG RQ SUHQDWDO H[DPLQDWLRQ QHRQDWHV
with syndromes, neonates who received vancomycin,
IXURVHPLGH LQGRPHWKDFLQ RU LEXSURIHQ DV ZHOO DV
QHRQDWHV GLHG EHIRUH  KRXUV RU SDUHQWV GLG QRW
give any consent to follow the study. Subjects were
WDNHQ FRQVHFXWLYHO\ $ VDPSOH RI  QHRQDWHV ZDV
needed based on single sample formula to estimate
a proportion of a population. A minimal subjects of
HDFKQHRQDWHVIRUHDFKVWDJHRIDVSK\[LDPRGHUDWH
characteristics of the neonates and mothers were
recorded, anthropometries data were measured, and
the estimation of gestational age was performed by
using Ballard chart. The history of pregnancy and
delivery, the diagnosis of hospitalization, and data of
resuscitation in the delivery or operating room were
recorded. Mothers serum creatinine level before
delivery was also recorded, but if the data was not
available, then mothers serum creatinine level was
PHDVXUHGLQKRXUVDIWHUKDYLQJELUWK
An urethral catheter was performed in neonates
to measure the time of first micturition, then the
TXDQWLW\ RI XULQH ZDV FROOHFWHG E\ QXUVHV XQWLO 
KRXUVRIDJH All neonates were using diapers, so
that if there was a leak from the catheter, the diapers
ZHUHZHLJKWHGZLWKDJUDPVHQVLWLYLW\VFDOH The
VXEMHFWZDVH[FOXGHGIURPWKLVVWXG\LIXULQHTXDQWLW\
ZDVQRWPHDVXUHGLQPRUHWKDQKRXUV:KHQWKH
QHRQDWHVDJHGKRXUVDPOEORRGVDPSOHZDV
taken to measure serum creatinine level and urine
ZDVFROOHFWHGIRUKRXUVWRPHDVXUHXULQHFUHDWLQLQH
Blood and urine samples were taken simultaneously.
The measurement of serum and urine creatinine
level was performed by using Enzymatic Creatinine_2
ADVIA 1800 machine with enzymatic method.
Glomerular filtration rate (GFR) was calculated based
and severe) was needed, based on formula two
independent group proportions.
eCCl = UCr x urine (mL/menit) x 1.73
SCr BSA
Apgar score estimation was performed on
PLQXWH st, 5th DQG th by pediatricians, residents
RUE\QXUVHVPLGZLYHVEDVHGRQUHOLDELOLW\WHVWZLWKD
.DSSDVFRUH0RGHUDWHDVSK\[LDZDVGHILQHGDV
WKH$SJDUVFRUHRIWRRQWKHILIWKPLQXWHZKLOH
VHYHUH DVSK\[LD ZDV WKH $SJDU VFRUH RI  RQ WKH
fifth minute. The parents were informed about the
study and were asked for the consent. The baseline
Table 1#-+0ETKVGTKC9
Stage Serum creatinine
1 Increase >0.3 mg/dL or
increase >150-200% baseline
2 Increase >200-300% baseline
3 Increase >300% baseline or
> 4.0mg/dL with acute increase
> 0.5mg/dL
on estimated creatinine clearance H&&ORQ
hours age using the following formula::
mL/minute/1.73 m2 BSA
$FXWHNLGQH\LQMXU\LVGHILQHGDVVHUXPFUHDWL
QLQH OHYHO LQFUHDVHG E\ RU PRUH WKDQ  PJG/
measured by the difference between mothers and
QHRQDWHVVHUXPFUHDWLQLQHOHYHOVDWKRXUVRU
the increase of percentage neonates serum creatinine
OHYHOVDWKRXUVE\FRPSDUHGWRPRWKHUV
serum creatinine levels, or a decrease in urine output
P/NJKRXUPRUHWKDQKRXUVDIWHUILUVWXULQH
Urine output
<0.5 mL/kg/hour over 6 hours
<0.5 mL/kg/hour over 12 hours
<0.3 mL/kg/hour over 24 hours
or no urine for 12 hours
Paediatr Indones, Vol. 53, No. 4, July 2013233
 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV

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 
ZLWK  QHRQDWHV IXOILOOHG WKH LQFOXVLRQ FULWHULD UDQJHPJG/UHVSHFWLYHO\

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)

234Paediatr Indones, Vol. 53, No. 4, July 2013

 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV

7KHGHWHUPLQDWLRQRI$.,VWDJHVEDVHGRQ$.,1 GHFUHDVHRIKRXUVXULQHRXWSXWFROOHFWHGDIWHUILUVW
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$.,ZDVVXEMHFWV creatinine level and a lower median (range) of GFR
7KHUHZHUHQHRQDWHVZLWK$.,VWDJH FRPSDUHG WR WKH PRGHUDWH DVSK\[LD 3 
 1HRQDWHV ZLWK $., EDVHG RQ LQFUHDVH RI VHUXP 3UHVSHFWLYHO\
FUHDWLQLQHOHYHORQO\ZHUHWKLVZDVFRPSULVH
RIQHRQDWHVZLWKVWDJH$.,7KHQHRQDWHV
ZLWK$.,EDVHGRQGHFUHDVHRIKRXUVXULQHRXWSXW Discussion
DIWHUILUVWPLFWXULWLRQZDVDPRQJVWWKHP
QHRQDWHVKDGVWDJHRI$.,Table 3). The numbers of neonates with moderate and severe
7KHFRPSDULVRQRISUHYDOHQFHDQGVWDJHRI$., DVSK\[LDZHUHDQGFRQVHFXWLYHO\
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
%JK5SWCTGVGUV-QNOQIQTQX5OKTPQXVGUV

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

Paediatr Indones, Vol. 53, No. 4, July 2013235

 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV

DQG Almost all neonates with serum creatinine level compared to this study.
DVSK\[LDKDGILUVWPLFWXULWLRQLQKRXUVDIWHUELUWK
7KHUHZDVQHRQDWHZLWKVHYHUHDVSK\[LDKDGLWVILUVW
PLFWXULWLRQDWKRXUV0DQRHet al reported 3 out of
QHRQDWHVZLWKDVSK\[LDKDGWKHLUILUVWPLFWXULWLRQ
LQKRXUVDIWHUELUWK,QQHRQDWHVZLWKDVSK\[LD
DSDUDO\VLVRIEODGGHUPLJKWWHPSRUDULO\H[LVWZKLFK
may cause urine tardiness. The low prevalence of
QHRQDWHV ZLWK DVSK\[LD ZLWK ILUVW PLFWXULWLRQ !
hours in this study might be because of the use of
urinary catheter which ensure urine output, although
there might be temporary bladder paralysis.
,QWKLVVWXG\QHRQDWHVKDG$.,EDVHG
RQDGHFUHDVHRIKRXUVXULQHRXWSXWFROOHFWHGDIWHU
first micturition. Perlman et alUHSRUWHGWKDWRXWRI
QHRQDWHVZLWKDVSK\[LDKDGROLJXULD Mohan et al
UHSRUWHGWKDWRXWRIQHRQDWHVZLWKDVSK\[LDKDG
oliguria. Vasoconstriction of afferent arterioles which
RFFXUUHDWWKHWLPHRIK\SR[HPLDOHDGVWRDGHFUHDVH
in urine output due to a decrease of blood flow to the
kidneys. Perlmans report was similar to this study,
probably because of relatively similar subject criteria
although they added the parameters of pH and pCO
,QWKLVVWXG\QHRQDWHVZLWKDVSK\[LDKDG
$.,EDVHGRQLQFUHDVHRIVHUXPFUHDWLQLQHOHYHODQGRU
decrease of urine output. The result is similar to a report
from Aggarwal et al and Karlowicz et al who reported
DQGQHRQDWHVZLWKDVSK\[LDKDGDFXWHUHQDO
failure, consecutively. Askenazi et alUHSRUWHG
RIXPELOLFDOFRUGDUWHU\LQGLDJQRVLQJDVSK\[LDThe
high incidence of oliguria in Mohans report might be
because of kidney injury occurred more severe than
those in our study. Mohan used tighter criteria for
QHRQDWDODVSK\[LDWKRVHZHUHORZHU$SJDUVFRUHDQG
WKH RFFXUUHQFH RI K\SR[LF LVFKHPLF HQFHSKDORSDWK\
QHRQDWHVZLWKDVSK\[LDKDG$.,DQG6HOHZHVNLet al
UHSRUWHGQHRQDWHVZLWKDVSK\[LDZKRZHUHWUHDWHG
ZLWKK\SRWKHUPLFPHWKRGKDG$.,DFFRUGLQJWR$.,1
FULWHULD7KHKLJKSUHYDOHQFHRI$.,LQWKLVVWXG\PLJKW
EHGXHWRVHYHUHDQGORQJK\SR[LDDQGK\SRSHUIXVLRQ
of the kidney. This in turn caused a disturbance in the
+,(+\SR[LFLVFKHPLFHQFHSKDORSDWK\LQGLFDWHV
WKH VHYHULW\ RI K\SR[LD LQ WKH ERG\ ZKLFK LQGXFHV
organs, including kidney, to have worse disruptions
FRPSDUHGWRDVSK\[LDZLWKRXW+,(
7KHSUHYDOHQFHRI$.,LQPRGHUDWHDQGVHYHUH
DVSK\[LDEDVHGRQWKHLQFUHDVHRIVHUXPFUHDWLQLQH
nephrons which will increase the serum creatinine level OHYHODQGRUWKHGHFUHDVHRIXULQHRXWSXWZDV
DQGGHFUHDVHRIXULQHRXWSXW7KHORZLQFLGHQFHRI$.,
in the study by Askenazi et al might be due to subject
analysis was only performed on neonates with moderate
DVSK\[LDZKLOHWKHORZLQFLGHQFHRI$.,LQWKHVWXG\RI
Seleweski et al might be due to the effect of hypothermic
WKHUDS\LQWKHNLGQH\VRIQHRQDWHVZLWKDVSK\[LD
7KH SUHYDOHQFH RI $., EDVHG RQ LQFUHDVH RI
DQGFRQVHFXWLYHO\7KHGLIIHUHQFHRI$.,
SUHYDOHQFH EHWZHHQ PRGHUDWH DQG VHYHUH DVSK\[LD
ZDV  5DGLW\R et al reported the difference of
SUHYDOHQFH RI  +LJK SUHYDOHQFH RI $., LQ
VHYHUH DVSK\[LD SUREDEO\ GXH WR WKH K\SR[LD DQG
hypoperfusion conditions of the kidney are more
severe and longer standing compared to moderate
VHUXP FUHDWLQLQH OHYHO RQO\ ZDV   0DQRH DVSK\[LD0RUHQHSKURQGLVUXSWLRQVLQVHYHUHDVSK\[LD
et alUHSRUWHGWKDWRXWRIQHRQDWHVZLWK
ILIWKPLQXWH$SJDUVFRUHKDGDQLQFUHDVHRIVHUXP
creatinine level. The assault of the nephrons due to
K\SR[LD RU K\SRSHUIXVLRQ ZLOO OHDG WR D GHFUHDVH LQ
creatinine clearance which in turn will increase serum
creatinine level. 7KH SUREOHP RI GLDJQRVLV RI $.,
based on serum creatinine level only in neonates is that
neonates serum creatinine level is still influenced by
the creatinine level of the mother. The serum creatinine
level was still similar to mothers.,QWKLVVWXG\WKH
increase of serum creatinine level was measured by
FRPSDULQJQHRQDWHVVHUXPFUHDWLQLQHOHYHODW
hours with mothers serum creatinine level. The low
SUHYDOHQFHRI$.,LQWKHVWXG\E\0DQRHet al might
be due to the difference of measurement of neonates
236Paediatr Indones, Vol. 53, No. 4, July 2013
lead to more increase of serum creatinine level and
GHFUHDVH RI XULQH RXWSXW WKDQ PRGHUDWH DVSK\[LD
7KH ILQGLQJV WKDW PRUH $., ZDV IRXQG LQ VHYHUH
DVSK\[LDWHGQHRQDWHVFRPSDUHGWRPRGHUDWHDVSK\[LD
are similar to other previous studies.
This study also indicates that neonates with
VHYHUHDVSK\[LDDUHPRUHOLNHO\WRKDYHPRUHVHYHUH
$., VWDJHV FRPSDUHG WR PRGHUDWH DVSK\[LD 7KLV
PLJKW EH GXH WR VHYHUH K\SR[LD RQ QHRQDWHV ZLWK
VHYHUH DVSK\[LD ZKLFK OHDGV WR GLVUXSWLRQ RI EORRG
IORZWRNLGQH\FRPSDUHGWRPRGHUDWHDVSK\[LD
7KHPHGLDQRIVHUXPFUHDWLQLQHOHYHORQQHRQD
WHVZLWKVHYHUHDVSK\[LDZDVKLJKHUWKDQPRGHUDWH
DVSK\[LD7KLVUHVXOWLVVLPLODUZLWKRWKHUVWXGLHV
This might happen due to more nephron disruptions
 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV
LQVHYHUHDVSK\[LDWKDQPRGHUDWHDVSK\[LD
7KHPHGLDQ*)5RQVHYHUHDVSK\[LDZDVORZHU
WKDQ PRGHUDWH DVSK\[LD 7ZR PHDQV FRPSDULVRQ
analysis for the difference of GFR in severe and
PRGHUDWHDVSK\[LDUHYHDOVDVLJQLILFDQWGLIIHUHQFH:H
FDQFRQFOXGHWKDWWKHPRUHVHYHUHWKHDVSK\[LDWKH
lower the value of GFR. Umboh reports that there
ZDVDVLJQLILFDQWGLIIHUHQFHRI*)5LQPLOGPRGHUDWH
DVSK\[LDFRPSDUHGWRVHYHUHDVSK\[LD7KHPHGLDQ*)5
IRUPRGHUDWHDQGVHYHUHDVSK\[LDUHSRUWHGLQWKDWVWXG\

 &KULVWRSKHU3%DUQHWW0D[33DXO*(&OLQLFRSDWKRORJLFDO
FRUUHODWLRQLQSRVWDVSK\[LDORUJDQGDPDJHDGRQRURUJDQ
SHUVSHFWLYH3HGLDWULFV
 /HH$&&0XOODQ\/&7LHOVK-0.DW]-.KDWU\6./H&OHUT
SC, et al. Risk factors for neonatal mortality due to birth
DVSK\[LDLQ6RXWKHUQ1HSDODSURVSHFWLYHFRPPXQLW\EDVHG
FRKRUWVWXG\3HGLDWULFV
4. Alisjahbana A, Hidayat S, Mintardaningsih, Primardi A,
Herliani E, Sofiatin Y, et al.0DQDJHPHQWRIELUWKDVSK\[LD
ZDV6'DQG6'P/PLQP,
consecutively. We found a larger difference between
PHGLDQ *)5 RI QHRQDWHV ZLWK VHYHUH DVSK\[LD DQG
PRGHUDWHDVSK\[LDFRPSDUHGWR8PERKVVWXG\7KLV
might be because the difference of diagnostic criteria of
DVSK\[LDXVHG$VSK\[LDWHGQHRQDWHVLQ8PERKVVWXG\
ZDVGHILQHGDV$SJDUVFRUHDWWKHILUVWPLQXWHZKLOH
LQRXUVWXG\ZHGHILQHGDVSK\[LDDVWKH$SJDUVFRUH
DWWKHILIWKPLQXWH/RQJVWDQGLQJDQGVHYHUHK\SR[LDLQ
this study compared to Umbohs probably has an effect
WRWKHORZHU*)5LQVHYHUHDVSK\[LD
Limitations of this study were the criteria for
DVSK\[LDEDVHGRQO\RQ$SJDUVFRUHRQILIWKPLQXWH
RI  WKH QHRQDWHV VHUXP FUHDWLQLQH OHYHO ZDV
H[DPLQHG RQFH DW  KRXUV DQG WKH HWLRORJ\ RI
$., ZDV QRW H[SORUHG IXUWKHU %XW WKLV VWXG\ DOVR
has superiority, where urinary output was monitored
carefully using urinary catheter therefore we could
JHWH[DFWDPRXQWRIXULQHDQGWKHVHUXPFUHDWLQLQH
level was performed using an enzymatic method thus
hemolysis, icteric serum, and albumin level did not
disturb the result.
:H FRQFOXGH WKDW $., SUHYDOHQFH EDVHG RI
$.,1FULWHULDVRQQHRQDWDODVSK\[LDLVWKHPRUH
VHYHUHWKHDVSK\[LDWKHPRUHSUHYDOHQFHDQGVHYHULW\
RIWKH$.,VWDJHV7KHPHGLDQRI*)5EDVHGRQH&&O
LQ QHRQDWHV ZLWK PRGHUDWH DVSK\[LD LV KLJKHU WKDQ
WKHVHYHUHDVSK\[LD&RQVLGHULQJ$.,SUHYDOHQFHLV
KLJKLQQHRQDWHVZLWKDVSK\[LDDQGORZ*)5LQVHYHUH
DVSK\[LDPHGLFDOSURIHVVLRQDOVQHHGWRDOHUWRQWKH
SRVVLELOLW\ RI $., LQ QHRQDWDO DVSK\[LD WKHUHIRUH
prompt interventions can be made.
References
 :RUOG +HDOWK 2UJDQL]DWLRQ %DVLF QHZERUQ UHVXFLWDWLRQ
a practical guide. Geneva: World Health Organization.
DWKRPHDQGKHDOWKFHQWHU3DHGLDWU,QGRQHV

 'DWD 'LYLVL 1HRQDWRORJL 'HSDUWHPHQ ,.$ ).8,56&0

 6KDK 3 5LSKDJHQ 6 %H\HQH - 3HUOPDQ 0 0XOWLRUJDQ
G\VIXQFWLRQLQLQIDQWVZLWKSRVWDVSK\[LDOK\SR[LFLVFKHPLF
HQFHSKDORSDWK\$UF'LV&KLOG)HWDO1HRQDWDO
5.
 .DXU6-DLQ66DKD$&KDZOD'3DUPDU95%DVX6et
al. Evaluation of glomerular and tubular renal function in
QHRQDWHVZLWKELUWKDVSK\[LD$QQ7URS3DHGLDWU
34.
 $JJDUZDO$.XPDU3&KRZGDU\*0DMXPGDU61DUDQJ
$(YDOXDWLRQRIUHQDOIXQFWLRQVLQDVSK\[LDWHGQHZERUQV-
7URS3HGLDWU
 0HKWD 5/ .HOOXP -$ 6KDK 69 0ROLWRULV %$ 5RQFR &
Warnock DG, et al. Acute kidney injury network: Report of
an initiative to improve outcome in acute kidney injury. Crit
&DUH
 *XSWD%'6KDUPD3%DJOD-3DUDNK06RQL-35HQDOIDLOXUH
LQDVSK\[LDWHGQHRQDWHV,QGLDQ3HGLDWU
 0DQRH 90 .HODLQDQ QHIURORJLN SDGD DVILNVLD QHRQDWRUXP
GL 5XPDK 6DNLW 'U &LSWR 0DQJXQNXVXPR >WHVLV@
-DNDUWD8QLYHUVLWDV,QGRQHVLD
 $PLQXOODK $ $VILNVLD ED\L EDUX ODKLU ,Q 0DUNXP $+
,VPDHO6$ODWDV+$NLE$)LUPDQV\DK$6DVWURDVPRUR6
editor. Buku ajar ilmu kesehatan anak. Jakarta: Balai Penerbit
).8,S
 .DUORZLF]0*$GHOPDQ5'1RQROLJXULFDQGROLJXULFDFXWH
UHQDOIDLOXUHLQDVSK\[LDWHGWHUPQHRQDWHV3HGLDWU1HSKURO

 $VNHQD]L'-.RUDONDU5+XQGOH\+(0RQWHVDQWL$3DWLO1
Ambalavanan N. Fluid overload and mortality are associated
ZLWK DFXWH NLGQH\ LQMXU\ LQ VLFN QHDUWHUPWHUP QHRQDWH
3HGLDWU1HSKURO
 6HOHZHVNL'7-RUGDQ%.$VNHQD]L'-'HFKHUW5(6DUNDU
6$FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHZERUQVWUHDWHGZLWK
WKHUDSHXWLFK\SRWKHUPLD-3HGLDWU
Paediatr Indones, Vol. 53, No. 4, July 2013237
 Roy Amardiyanto et al: $FXWHNLGQH\LQMXU\LQDVSK\[LDWHGQHRQDWHV
 $ODWDV + $QDWRPL GDQ ILVLRORJL JLQMDO ,Q $ODWDV +
Tambunan T, Trihono PP, Pardede SO, editor. Buku ajar
QHIURORJL DQDN (GLVL NH -DNDUWD %DODL 3HQHUELW ).8,
S
 *XLJQDUG-3'UXNNHU$:K\GRQHZERUQLQIDQWVKDYHD
KLJKSODVPDFUHDWLQLQH"3HGLDWULFV
 3HUOPDQ -0 5HQDO LQMXU\ LQ WKH DVSK\[LDWHG QHZERUQ
infant: relationship to neurologic outcome. J Pediatr.

 0RKDQ393DL305HQDOLQVXOWLQDVSK\[LDQHRQDWRUXP
,QGLDQ3HGLDWU
 -HUQLN$*&HUQDGDV-0&*RUHQVWHLQ$5DPLUH]-$9DLQ
1$UDQGRPL]HGGRXEOHEOLQGSODFHERFRQWUROOHGWULDORI
the effect of prophylactic theophylline on renal function
LQ WHUP QHRQDWHV ZLWK SHULQDWDO DVSK\[LD 3HGLDWULFV
238Paediatr Indones, Vol. 53, No. 4, July 2013

 .RVQDGL/1HIURORJLQHRQDWDO,Q$ODWDV+7DPEXQDQ7
Trihono PP, Pardede SO, editors. Buku ajar nefrologi anak.
(GLVLNH-DNDUWD%DODL3HQHUELW).8,S
 5DGLW\R$1.RVLP060XU\DZDQ+$VILNVLDQHRQDWRUXP
sebagai faktor risiko gagal ginjal akut. Sari Pediatri.

 8PERK$+XEXQJDQDVILNVLDQHRQDWRUXPGHQJDQJDQJJXDQ
IXQJVLJLQMDOSDGDED\LEDUXODKLU6DUL3HGLDWUL
3.
 .RUQKDXVHU & 'XEH\ /$ *DUD\ 0( 3HUH]/XTXH (/
0DODFDUD-09DUJDV2ULJHO$6HUXPDQGXULQDU\LQVXOLQH
OLNHJURZWKIDFWRUDQGWXPRUQHFURVLVIDFWRULQQHRQDWHV
with or without acute renal failure. Pediatr Nephrol.