Incidence of Acute Kidney Injury and its predictors among neonates admitted at neonatal intensive care unit, university of Gondar, Debretabor and Tibebe Ghion Amhara Region Comprehensive Specialized Hospitals, Northwest Ethiopia, 2023

doi:10.21203/rs.3.rs-2991272/v1

Background: Although acute kidney injury is a major cause of neonatal morbidity and mortality worldwide, it is a serious problem in low and middle-income countries, particularly in sub-Saharan Africa such as Ethiopia. Moreover, there are few studies in developing countries. However, the aim of this study was to investigate the incidence and predictors of acute kidney injury in neonates admitted to the neonatal intensive care unit of some specialized hospitals in the Amhara region of northwestern Ethiopia.

Methods: A facility-based retrospective follow-up study was conducted with 634 neonates from January 2020 to December 2022. Data were collected by reviewing patient charts using simple random sampling with a pretested checklist, entered using Epi-data 4.6, and analyzed using STATA 14. Median survival time, Kaplan-Meier survival curve, and log-rank test were calculated. Bivariable and multivariable Cox hazard models were used to determine the determinants of acute kidney injury. A hazard ratio with a 95% confidence interval was calculated. Variables with p-values less than 0.05 were considered statistically significant.

Results: The proportion of acute kidney injury among neonates admitted to the three selected specialized neonatal intensive care units was (20.19%) (95% CI: 17.23-23.50) with an incidence of 14.9 per 1000 (95%CI: 12.5-17.7) neonates with sepsis (AHR: 2.59; 95%CI: 1.21-5.56), neonates with perinatal asphyxia [(AHR: 2.70; 95%CI: 1.29-5.65) were taking gentamicin drugs [(AHR=1.74; 95%CI: 1.03-2.94], were preterm [(AHR; 1.77: 95%CI: 1.05 -2.98], hyponatremia [(AHR: 2.14; 95%CI: (1.00 -4.9)] and hyperkalemia [(AHR: 2.64; 95 CI: (1.11- 6.2)] were found to be significant predictors of acute kidney injury.

Conclusions: The incidence of acute kidney injury in neonates was high. Premature infants, neonates with sepsis, who suffered perinatal asphyxia, took gentamicin drugs, whose sodium levels decreased and potassium levels increased were at higher risk of developing acute kidney injury. All concerned agencies should work to prevent acute kidney injury and pay special attention to multifactorial causes. Therefore, strategies need to be developed and/or strengthened to prevent the occurrence of acute kidney injury in infants with sepsis, neonates who suffered perinatal asphyxia, and preterm infants whose sodium levels decreased and potassium levels increased.

Acute kidney injury

Ethiopia

Incidence

Neonate

and Predictors

Acute kidney injury (AKI), is defined by an acute and reversible increment in serum creatinine (SCr) levels associated or not with a reduction in urine output (UO) or oliguria or anuria (1), AKI is associated with increased risk of morbidity and mortality in critically ill neonates (2) the disease imposes a severe burden of morbidity and mortality, with a major economic effect on health-care expenditure worldwide, especially in low-resource settings.(3)

Globally, the 2015 study also estimated that, in 2015, 1.2 million people died from kidney failure, an increase of 32% since 2005, and an estimated 2.3-7.1 million people with end-stage kidney disease died without access to chronic dialysis in 2010, but an estimated 1.7 million people die from acute kidney injury each year (4-7) occurring in more than 13 million people every year, 85% of whom live in low- or middle-income countries (3)

The fact that AKI survivors have an increased risk of developing CKD or end-stage renal disease (ESRD), the poor prognosis of many patients after an episode of AKI, the public health ramifications of progression to late-stage CKD, and the need to identify clinical risk factors for progression in patients with and without pre-existing CKD who have survived an episode of AKI are urgently needed (8)

The overall incidence of AKI in the multicenter multinational studies was 30% (9) in Serbia 44% (10),in turkey 20% (11) in Saudi Arabia 56% (12), in Taiwan 56% (13), in Egypt 10.8% (14) in Tanzania 31.5% (15) in Kenya 36.1% (16), in Sudan 54.1% (17)

Those risk factors that contribute to the development of AKI in neonates, such as perinatal asphyxia, respiratory distress syndrome (RDS), prematurity, sepsis, umbilical catheterization, early drug administration, especially aminoglycosides, necrotizing enterocolitis (NEC), volume deficiency, placental insufficiency, intrauterine growth retardation (IUGR), maternal medication, hemodynamically significant patent ductus arteriosus, and urogenital abnormalities (12, 18, 19).

Most of these areas suffer from poverty, poor sanitation, poor water quality and hygiene, lack of education, and poor access to health care. AKI is preventable if detected early enough and treated promptly (3).

Implementation of this program in low- and middle-income countries faces serious obstacles due to lack of resources, lack of information on the epidemiology, cause-and-effect relationships, and determinants of AKI in our countries, especially in neonatal intensive care unit guidelines, lack of resources for diagnosis and treatment of AKI, and lack of knowledge on the impact of AKI and treatment outcomes. However, there is a lack of knowledge about the incidence and predictors factors of AKI in our study settings. As a result, the increase in regular health care costs for newborns in the first month of life remains a major community health problem in a low-income country such as Ethiopia. These high medical costs can burden parents, their families, and the community at large. A research strategy is currently being developed to eliminate preventable causes of neonatal death. In addition, few studies in developing countries, including Ethiopia, have provided the data needed to address the problem. Therefore, the aim of this study is to determine the incidence and predictors of acute kidney injury in newborns admitted to the Amhara region comprehensive specialty hospitals at Gondar, Debre Tabor, and Tibebe Ghion universities in 2023

An institution-based retrospective follow-up study design was conducted among a cohort of neonates in the previous two consecutive years, from January 1, 2020 to December 30, 2022.

Study area

The study was conducted in the Northwest Amhara region's comprehensive specialized hospitals. In the Northwest Amhara region, there are three comprehensive specialized hospitals (CSH). Those are the University of Gondar CSH, Tibebe Ghion CSH, and Debre Tabor CSH. UoGCSH is located in Gondar town and has an average annual admission of 4560 and an average monthly admission of 380 neonates. Tibebe Ghion CSH is found in Bahir Dar city. These hospitals have an average annual neonatal admission of 1920 neonates and an average monthly admission of 160, respectively. Debre Tabor CSH, which is found in Debre Tabor town, has an average annual neonatal admission of 1560 and an average monthly admission of 130. These hospitals are the final referral choice for other health institutions. Those hospitals have NICUs with mixed health professionals (neonatal and comprehensive nurses, general practitioners, pediatricians, and other staff). The major services in the NICU include general neonatal care services, blood and exchange transfusions, phototherapy, and ventilation support such as continuous positive air pressure

Source and Study Population

Source populations

The source population included all neonates admitted to the NICUs of the three Amhara Region hospitals, Comprehensive Specialized Hospitals Northwest Ethiopia.

Study populations

From January 1, 2020, to December 30, 2022, all neonates admitted to the three selected comprehensive specialized hospitals in Amhara Region, Northwest Ethiopia.

Eligibility criteria

All neonates’ medical cards documented in the previous two years from the study period were recruited and incomplete cards were excluded.

Sample size determination and sampling procedures

Sample size determination

The sample size was calculated using the single population proportion formula; considering the following: 95% confidence interval(CI), 50% proportion of neonates with acute kidney injury and 5% margin of error. The required sample was calculated using the following formula.

By adding a 10 % chart attrition, a total of 634 charts were included in the study.

Sampling procedures

There are three comprehensive specialized hospitals in the Amhara region. Based on the data, UoGCSH has 9120/2 years, TGCSH has 3840/2 years and DTCSH has 3120/2 years, 16,080 newborns were admitted to the hospitals from January 1, 2020 to December 30, 2022.

A total of 634 samples were selected from 16,080 newborns. From the final sample size, a proportional allocation was made for each hospital. The sampling frame was established after the identification numbers of the admitted patients were recorded from the registration book. After identifying patients who met the inclusion criteria, study participants were selected by simple random sampling using computer-generated methods.

Study Variables

Dependent variable

Incidence of Neonatal Acute kidney injury

Independent variables

Socio-demographic maternal and neonatal

Age, sex, gestational age, and Age of the mother, birth weight, weight of Gestation

Maternally related factors

Placental hemorrhage, prenatal steroids, Prolonged rupture of membranes (PROM), ANC, Placental hemorrhage, Polyhydramnios, oligohydramnios, Place of delivery, preeclampsia, gestational hypertension, DM, Prolonged labor, and Parity),

Clinical factors

Neonatal Sepsis, necrotizing enterocolitis, MAS, Shock, RDS, IVH, Low APGAR, hypoxic-ischemic encephalopathy (HIE) Congenital heart disease (CHD) and Persistent pulmonary hypertension (PPH)Sodium level, potassium level

Operational definition

Acute kidney injury: is defined as a serum creatinine level of 1.5 mg/dl or an increase in serum creatinine of 0.2 to 0.3 mg/dl within 48 hours (20).

Censored: newborn who did not develop the outcome of interest (AKI) until the end of the follow-up period or lost to follow-up, recovery from illness, discharged against medical advice, or transfer out to other health institutions without knowing the outcome.

Outcome: newborn who were develop the outcome during the study period

Data collection tools

A pretested checklist was used to collect the required data from patients' medical records. Consistency was checked. Data were collected by reviewing the complete patient chart for the last two consecutive years of the study period. AKI was confirmed by reviewing the medical records.

Data quality control

Data quality was ensured by developing appropriate data abstraction tools. The checklist was evaluated by experienced researchers. The data collection instrument was pretested on 5% of the sample size. Both data collectors and supervisors were thoroughly trained on the data collection checklist and the data collection process. During data collection, strict monitoring and supervision was performed by the supervisors and the investigator. Data entry was also performed using Epi data 4.6 software.

Data processing, analysis, and presentation:

After data collection, the data were cleaned, edited, and coded. Errors identified at this time were corrected after a review of the original data using the code numbers. Data were entered using Epi-Data version 4.6 and analyzed using STATA 14 statistical software. Descriptive statistics were performed using mean, frequency, percentage, tables, and numbers. In addition, a log-rank test was used to compare AKI survival among different categorical predictor variables. The variance inflation factor (VIF = 1.83) was used to test the multicollinearity test showing the association between predictor variables.at risk for follow-up and reported per 100-person day. Kaplan-Meir was used to estimate mean survival.

Based on the Cox proportional hazard assumption test using Schoenfeld residuals and a log-log plot (graphical), all covariates met the assumption, and the overall global model met the proportional hazard assumption (global test, p = 0.6638). The Cox-Snell residual test was used to test goodness of fit. A 95% confidence interval (CI) for the adjusted hazard ratio (AHR) was estimated to determine the strength of the association. Statistical significance between predictors and AKI was determined with a P value of 0.05.

A total of 634 neonates who were admitted from January 2020 to December 2022 in selected Amhara comprehensive specialized hospitals were included.

Socio-demographic characteristics of mothers and neonates

In the neonatal socio-demographics, the majority of patients at admission 575 (90.69%) were between the ages of the first seven days. Out of 634 neonates, 392 (61.83 %) were male neonates. The majority of the neonates, 567 (89.43%), were born in health institutions with skilled health professionals. The mean maternal age of the neonates was 29.15 (SD6.457) years, with 425 (67.03) being between the ages of 20 and 34. More than half of the mothers were urban residents (53%) (Table 1).

Obstetrical history of mother’s

A total of 599 mothers (94.48%) had ANC follow-up, and of these, 414 (65.30%) had full follow-up throughout their pregnancies. The majority of the mothers in the total samples were multipara 450 (70.95%). Among the 634 mothers, 530 (92.01%) were singletons, accounting for more than half of the 422 (66.56%) mothers who gave birth spontaneously vaginally (Table 2).

Obstetric complications of the mother

In terms of maternal complications, more than one-third of mothers had obstetric complications during the index pregnancy. PROM, eclampsia, placental hemorrhage, gestational diabetes, and polyhydramnios account for 223 (35.17%), 28(4.42%), 49(7.73%), 117 (18.45%), and 80(12.62%) of maternal obstetric complications in the current pregnancy, respectively (Table 3).

Neonatal-related factors

More than half of the neonates' 373 (58.83%) birth weights were greater than 2500 grams, according to the 634 neonatal records reviewed. The mean (SD±) birth weight was 2813 (±720) grams. In terms of gestational age, above half of the babies (324, 51.10%) were born after 37 completed weeks of gestation, and more than three-fourths of the neonates (502, 79.18%) had an appropriate gestational age based on weight for gestational age (Table 4).

Neonatal clinical co-morbidities

In terms of co-morbidities, more than three- fourth of the neonates admitted to the NICU had neonatal sepsis 259(40.85%) 170 (26.81%) %) had meningitis; and 170 (26.81%) had perinatal asphyxia, according to a review of 506 charts (Table 5).

Overall neonatal out-com

From the total follow-up outcome, 6.78% were lost to follow-up or left the hospitals without health professionals' permission or against medical advice (Figure 1).

Proportional hazard assumption

Based on the proportional hazard assumption test using Schoenfeld residual, all of the covariates fulfilled the assumption and the overall global model satisfies the proportional hazard assumption (0.6638 ) Figure 2.

Overall proportion and incidence rate of AKI in neonates

The overall proportion of neonates that develop was found to be 634 neonates who were admitted the NICU, 128 (20.19%) (95% CI: 17.23-23.50) of them developed the event of interest (AKI). Overall incidence rate of AKI was found to be neonate-days observation for the entire follow-up time was 8573 person-days when 634 from the three hospitals with minimum and maximum follow-up times were 1 and 28 days respectively. The median follow-up survival time was 21 days (95% CI: 22-27). The overall incidence of AKI was 14.9 per 1000 neonate- days observations (95%CI: 12.5-17.7) during the entire follow-up time.

Overall failure Function (survivorship function)

The overall Kaplan-Meier failure function showed that the probability of acute kidney injury among neonates was increased during the follow-up period. During the 5-10 days of admission, a 7% probability of AKI was observed (Figure 3).

Predictors of AKI among neonates

The test of equality for survival distribution for different categories of variables was performed with Kaplan-Meier and the log-rank test. In general, the pattern that one group's survivorship function lying above another group showed that the upper curve had a better probability of survival compared to the lower curve. On the other hand, the probability of AKI was high among the lower groups described by the Kaplan-Meier survival curve. Furthermore, the log-rank test confirmed whether the observed difference was seen on the KM graph statistical difference or not

In the current study, new-borns born with preterm have lower survival times compared with normal term and post term neonates. Moreover, neonates without sepsis and PNA have a more favorable survival probability than those neonates with sepsis and PNA respectively. This study also revealed that neonates does not took steroid at NICU during admission had a better probability of survival compared with those neonates take steroids. Furthermore, neonates born from mothers who had taken antenatal corticosteroids had a better probability of survival compared with new-borns born from mothers who did not take antenatal corticosteroids during pregnancy while neonates born single had a better survival probability than those born multiple. These differences were statistically significant with a p-value < 0.001 in a log-rank test (Figure 4).

Bivariable and multivariable cox-regression analysis

In the Bi-variable cox regression analysis, place of delivery, neonatal age at admission, gestational DM, chronic hypertension, steroid drug used, polyhydramnios, PROM, prolonged labour, sepsis, types of pregnancy, birth weight, gestational age, NEC, PNA, meningitis, MAS, APGAR score first minute, APGAR score fifth minute, gentamicin, sodium level and potassium level mode of delivery were significant predictors of AKI with P- value less 0.25. However, in the multivariable cox regression analysis, sepsis, PNA, gentamicin, gestational age, potassium level and sodium level were significant predictors of AKI among neonates admitted in NICU.

Keeping out other variables constant, the hazard of AKI among neonates born with sepsis had more than two times (AHR: 2.59; 95%CI: 1.21-5.56) more likely than neonates born without sepsis. Keeping out other variables constant, the hazard of AKI among neonates born with perinatal asphyxia almost three times more likely than neonates born without perinatal asphyxia (AHR: 2.70; 95%CI: 1.29-5.65). Keeping out other variables constant, neonate took gentamicin drugs increased the hazard of developing AKI by 1.74 folds (AHR=1.74; 95%CI: 1.03-2.94) compared to new-borns does not take gentamicin drugs. Moreover, being preterm was an independent predictor of AKI, which increased the hazard of AKI among new-borns two times (AHR; 1.77: 95%CI: 1.05 -2.98) than new-borns being term while holding other variables out constant. Keeping out other variables constant, the sodium level of the neonates develop Hyponatremia the hazard of AKI by almost two times than neonates have with normal sodium level (AHR: 2.14; 95%CI: (1.00 -4.9). by keeping other variables out constant, hyperkalemia was an independent predictor of AKI for neonates which increase the hazard of AKI almost by three times than neonates with normal potassium level (AHR: 2.64; 95 CI: (1.11- 6.2). (Table 6)

In a follow-up of 634 new-borns among neonates, 128 (20.19%) (95% CI: 17.23–23.50) of them experienced the event of interest (AKI). Over the course of the full follow-up period, the overall incidence of AKI was 14.9 per 1000 neonate-day observations (95%CI: 12.5–17.7).

Relatively, the proportion of acute kidney injury is comparable to or in line with studies conducted in the United States (21 %) and Turkey (21%). However, the proportion in this study is lower than in multinational studies. 30 % (9) in Cairo, in Egypt 41%(21) in 56% Saudi Arabia(12) This marked difference might be attributed to some factors, such as the source population; study participants in the multicenter study were all live births, while the current study was exclusively on acute kidney injury. The studies done in single centers, a prospective cohort study of neonates with gestational ages less than 32 using the clinical risk index for babies another possible justification is the study area, as the current study is multi-intuitional in nature. In addition to the above, the study in Saudi Arabia incorporated some neonatal clinical factors like temperature at admission (°C) and base excess, while the possible justification for this difference may be the sample size. While this study was conducted in five hospitals, another possible reason for this difference might be that the study conducted in Cairo, Egypt, was on critically ill neonates only.

On the contrary, the proportion of in this study was higher than the prospective study was Egypt 10.8% (14) in turkey 8.4 (22) in India 12% (23) in Iran 1.54% (24)in USA 9% (25). This variation might be due to differences in the study this marked difference might be attributed to some factors such as the source population, study design, and small sample size, and another possible reason for this difference might be that the study conducted in India was on preterm only.

In this study, the risk of developing acute kidney injury increased more than threefold in neonates admitted to the neonatal intensive care unit with sepsis; this finding was supported by a study conducted in Kenya and South Africa (16, 26) another study south Africa(27) in Sri Lnka (28)in Egypt(14). The potential rationale for life-threatening organ dysfunction caused by a dysregulated host response to infection (29) relies primarily on relative changes in serum creatinine levels and urinary excretion in sepsis. Conventional diagnostic tests of urine biochemistry and microscopy have shown questionable value in distinguishing septic from non-septic AKI (29, 30) The gene expression profile of septic AKI showed increased up regulation of several genes related to inflammation, metabolism, and apoptosis (31).

The risk of AKI was 2.70 higher in neonates born with perinatal asphyxia than in neonates born without perinatal asphyxia. This finding is supported by Congo(32) India (33) Kenyan (34) Sudan (35) Birth asphyxia is impairment of the fetus or newborn due to lack of oxygen (hypoxia) and/or lack of blood flow (ischemia) to various organs of sufficient magnitude and duration to cause functional and/or biochemical changes, this leads to vasoconstriction of the afferent arterioles and a reduction in blood flow to the kidneys, so that the glomerular filtration rate decreases, resulting in oliguria and even anuria(36) Renal failure without oliguria is a recognized consequence of birth asphyxia. Renal blood flow (RBF) auto regulation, in which small changes in systemic blood pressure lead to parallel changes in afferent renal vascular resistance so that a constant RBF is maintained over a range of BP, is set to a lower range of BP in neonates compared with adults. This reduces the neonate's ability to compensate for significant hemodynamic changes and may result in impaired renal function (37-39) In addition, severe asphyxia in neonates results in widespread tubular injury and deformity due to sodium depletion or continued water reabsorption, leading to decreased glomerular filtration rate, high renin activity, and high renal vascular resistance in neonates with acute tubular necrosis after asphyxia, after develop tubular necrosis or cortical necrosis the neonates decrease glomerular filtration as well as develop acute kidney injury (21, 40, 41).

The risk of AKI was increased 1.74-fold in neonates taking gentamicin compared with neonates not taking gentamicin medication. This study is supported by (15),USA(42) another study in Alabama, USA (43, 44) the possible reason Age, pharmacogenomics, severity of illness, dosage, duration, and concomitant medication all influence the severity of a nephrotoxic insult as well as the epidemiology impact of AKI caused by nephrotoxic medication in hospitalized non-critically ill neonates. Whenever patients with AKI had an increased length of stay in the hospital, it was noted that the majority of nephrotoxic medications to which patients were exposed were antimicrobial agents (43, 44)

In this study, being preterm neonates was an independent predictor of AKI that increased the risk of AKI twofold in neonates compared with term infants, This finding is confirmed by Italy (45)France(46) University of Alabama(2) University of Wisconsin-Madison(47) Preterm infants are at high risk for acute kidney injury (AKI) due to vasomotor nephropathy; their glomerular filtration rate (GFR) is low and unstable; they have a lower adaptability to stressful situations, hemodynamic instability, and nephrotoxic drugs commonly used in neonatal intensive care units (NICU). Neonatal AKI occurs during the crucial period when incomplete nephrogenesis may be further compromised. Reduced nephron number in autopsies of preterm infants with AKI Preterm infants who developed neonatal AKI may have shown earlier signs of nephron reduction (46, 48, 49)

Being hyponatremia increases the risk of AKI almost twofold compared with neonates with normal sodium levels. This finding is supported by Sudan (17) India(50) The capacity of sodium reabsorption is limited, and when the amount of sodium reaching the distal tubules increases significantly, reabsorption does not occur proportionally and the amount of sodium is excreted in the urine. Other Contributing Factors Hyponatremia may lead to contraction of intravascular volume, further limiting renal function. Asphyxia-induced reduction in the number of functional nephrons leading to ARF elicits compensatory hypertrophy of the remaining nephrons, resulting in improved renal function in the first months of life and decreased creatinine clearance, renal tubular acidosis, or concentration defect. AKI was predicted by abnormal renal electrolyte imbalance and hyponatremia (50-52)

Holding other variables constant, hyperkalemia was an independent predictor of AKI in neonates, increasing the risk of AKI almost three fold compared with neonates with normal potassium levels. this study finding is supported by the Maimonides Medical Center(53) USA(54) The cause of severe hyperkalemia requires administration of calcium to stabilize the myocardium, followed by drugs that shift extracellular potassium to the intracellular compartment, such as bicarbonate, glucose-insulin drip, and inhaled beta-agonists. Hyperkalemia is a major contributor to acute renal injury and results in decreased glomerular filtration rate, decreased tubular potassium secretion, tissue breakdown with intracellular potassium release, and metabolic acidosis with a trans cellular potassium shift per 0.1 unit decrease in arterial PH. increase serum potassium by 0.3 mEq/L (54)

Limitations

Because this was a secondary design, the study could not exhaustively examine all predictor variables that might have an impact on AKI.

The incidence of acute kidney injury in neonates was high. Premature infants, neonates with sepsis, who suffered perinatal asphyxia, had taken gentamicin drugs, whose sodium levels decreased, and whose potassium levels increased were at higher risk of developing acute kidney injury.

AHR: adjusted hazard ratio, AKI: acute kidney injury, ANC: antenatal care, APGAR: Activity Pulse Grimace Appearance Respiration, CHD: Congenital Heart Disease, HIE: Hypoxic Ischemic Encephalopathy, IVH: Intra-Ventricular Hemorrhage, MAS: Meconium Aspiration Syndrome, NICU: Neonatal Intensive Care Unit, RDS: respiratory distress syndrome, VIF: Variance Inflation Factor.

Ethics Approval and Consent to Participate

Before conducting this study ethical clearance letter was obtained from the ethical review committee of the school of Nursing on behalf of the institutional review board of the University of Gondar, after approval of the proposal [26/01/2015 E.C or 03/09/2022 G.C] and (Ref. No: - S/N/036/2015). A written permission letter was obtained from Amhara Public Health Institute for each Hospital (Ref.no አሕጤኢ/ዋ/ዳ/03/1479). Waiver permission letter was obtained from hospital administrators before the data collection and since the neonates were not directly involved in this study (the data were obtained from charts review) informed consent was not required, but extracted data from medical record were kept confidentially. All methods were carried out in accordance with the declarations of Helsinki and relevant guidelines and regulations. So, anonymity was maintained by using the identified number instead of the patient’s names. Besides, all data extracted were kept confidential and not used for any other purpose than the stated objective.

Consent to publish: Not Applicable

Availability data and material

The datasets generated and/or analyzed during the current study are not publicly available due to confidentiality but are available from the corresponding author on reasonable request

Competing interest: The authors declare that they have no competing interests.

Funding: This study was funded by the University of Gondar. However, the funder had no role in data collection, preparation of the manuscript, and decision to publish.

Authors’ contributions

GDG: conceptualization, methodology, software, formal analysis, writing original draft. BTL, YSE, HSM, AGA, &ATA validation, data curation, writing reviewing & editing. TMS&GBM: methodology, writing-review & editing. FBG, DTD & MTT: conceptualization, methodology, writing-review & editing. WTW&ATG: methodology, writing-review & editing, data curation. RAS, SKH, TGA & ZAG: methodology, writing-review & editing, data curation, validation. Finally, all authors approved the manuscript.

Acknowledgment: The authors would like to express our gratitude to the respective administrations of each comprehensive hospitals, card class and the data collectors.

All methods were done in accordance with BMC Pediatrics guidelines and regulations

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Table 1: Socio-demographic characteristics of mothers and neonates at NICU in Amhara region, Ethiopia, 2023(n=634)

Variables

Frequency(n)

Percentage (%)

Age_ group of the mother

<20

20-34

≥35

65

425

144

10.25

67.03

22.72

Residency

Urban

Rural

336

298

53

47

Age at the admission of the newborn

0<7

8-15

15-28

575

34

25

90.69

5.36

3.94

Sex of the newborn

Male

Female

392

242

61.83

38.17

Place of delivery

Health institution

Home delivery

567

67

89.43

10.57

Table 2: Obstetric history of mothers whose neonates were admitted at NICU in Amhara region, Ethiopia, 2023(n=634)

Variables

Frequency(n)

Percentage (%)

ANC visit

Yes

No

599

35

94.48

5.52

Number of ANC visit(n=506)

1-3

≥4

185

414

29.18

65.30

Parity

Primi para

Multi-para

184

450

29.02

70.98

Mode of delivery

SVD

C/S

ISD

422

86

126

66.56

13.56

19.87

current pregnancy

Multiple

Single

46

530

7.99

92.01

ANC antenatal care SVD Spontaneous vaginal delivery CS cesarean section ISD instrumental vaginal delivery ¹

Table 3: Obstetric complication of mothers whose babies were admitted to NICU in Amhara region, Ethiopia, 2023(n=634)

Variables

Frequency

Percentage (%

PIH

Yes

No

121

513

19.09

80.91

pre-eclampsia

Yes

No

91

543

14.35

85.65

Eclampsia

Yes

No

28

606

4.42

95.58

GDM

Yes

No

117

517

18.45

81.55

APH

Yes

NO

49

585

7.73

92.27

Polyhydramnios

Yes

NO

80

554

12.62

87.38

Oligohydramnios

Yes

NO

87

447

13.72

86.28

PROM

Yes

NO

223

411

35.17

64.83

Prenatal steroid

Yes

NO

85

549

13.41

86.59

Prenatal antibiotics

Yes

NO

121

513

19.09

80.91

PIH pregnancy induced hypertension APH ante partum hemorrhage PROM prolonged rupture of membrane¹

Table 4 Characteristics of neonates who were admitted at NICU in Northwest Amhara, Ethiopia, 2022(n=634)

Variable

Frequency

Percentage

Birth weight

Low birth weight

Normal birth weight

Macrosomic

235

373

26

37.07

58.83

4.10

Gestational age

Preterm

Term

Post term

275

324

35

43.38

51.10

5.52

Weight for gestation

AGA

SGA

LGA

502

90

42

79.18

14.20

6.62

APGAR score first minute

Low

Mild

Normal

109

72

453

17.19

11.36

71.45

APGAR score five minute

Sever

Mild

Normal

92

89

453

14.51

14.04

71.45

AGA= appropriate for gestational age SGA= Small for gestational age LGA large for gestational age APGAR activity pulse grimace appearance and respiration¹

Table 5: Clinical co-morbidities of the neonates in Amhara region, Ethiopia, 2023(n=634)

Variables

Frequency

Percentage (%

Sepsis

Yes

No

259

375

40.85

59.15

NEC

Yes

No

120

514

18.93

81.07

Shock

Yes

No

99

535

15.62

84.38

Chromosomal abnormality

Yes

No

49

585

7.73

92.27

Pneumonia

Yes

No

44

590

6.94

93.06

Surgical disorder

Yes

No

39

595

6.15

93.85

MAS

Yes

No

145

489

22.87

77.13

CHD

Yes

No

44

590

6.94

93.06

RDS

Yes

No

148

486

23.34

76.66

IVH

Yes

No

40

594

6.31

93.69

PNA

Yes

No

189

445

29.81

70.19

HIE

Stage1

Stage 2

Stage 3

8

66

74

1.26

10.41

11.67

Meningitis

Yes

No

170

464

26.81

73.19

Sodium

Hyponatremia

Normal sodium level

hypernatremia

180

331

123

28.39

52.21

19.40

Potassium

hypokalemia

normo- kalmia

hyperkalemia

71

374

189

11.20

58.99

29.81

Gentamicin

Yes

No

206

428

32.49

67.51

Table 6: Bivariable and multivariable cox-regression analysis

Variables

Incidence of Acute Kidney Injury and its predictors among neonates admitted at neonatal intensive care unit, university of Gondar, Debretabor and Tibebe Ghion Amhara Region Comprehensive Specialized Hospitals, Northwest Ethiopia, 2023

Status:

Journal Publication

Version 1

Abstract

Figures

Introduction

Methods

Study area

Source and Study Population

Source populations

Study populations

Eligibility criteria

Sample size determination and sampling procedures

Sampling procedures

Study Variables

Dependent variable

Independent variables

Operational definition

Data collection tools

Data quality control

Data processing, analysis, and presentation:

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1