Low hemoglobin levels are independently associated with neonatal acute kidney injury: a report from the AWAKEN Study Group

Background: Studies in adults showed a relationship between low hemoglobin (Hb) and acute kidney injury (AKI). We performed this study to evaluate this association in newborns. Methods: We evaluated 1891 newborns from the Assessment of Worldwide AKI Epidemiology in Neonates (AWAKEN) database. We evaluated the associations for the entire cohort and 3 gestational age (GA) groups: <29, 29–<36, and ≥36 weeks’ GA. Results: Minimum Hb in the first postnatal week was significantly lower in neonates with AKI after the first postnatal week (late AKI). After controlling for multiple potential confounders, compared to neonates with a minimum Hb ≥17.0 g/dL, both those with minimum Hb ≤12.6 and 12.7–14.8 g/dL had an adjusted increased odds of late AKI (aOR 3.16, 95% CI 1.44–6.96, p = 0.04) and (aOR 2.03, 95% CI 1.05–3.93; p = 0.04), respectively. This association was no longer evident after controlling for fluid balance. The ability of minimum Hb to predict late AKI was moderate (c-statistic 0.68, 95% CI 0.64–0.72) with a sensitivity of 65.9%, a specificity of 69.7%, and a PPV of 20.8%. Conclusions: Lower Hb in the first postnatal week was associated with late AKI, though the association no longer remained after fluid balance was included. Impact: The current study suggests a possible novel association between low serum hemoglobin (Hb) and neonatal acute kidney injury (AKI).The study shows that low serum Hb levels in the first postnatal week are associated with increased risk of AKI after the first postnatal week.This study is the first to show this relationship in neonates.Because this study is retrospective, our observations cannot be considered proof of a causative role but do raise important questions and deserve further investigation. Whether the correction of low Hb levels might confer short- and/or long-term renal benefits in neonates was beyond the scope of this study.