Diuretic Therapy in Preterm Infants With Acute Kidney Injury Is Common: Should It Be?

Diuretic Therapy in Preterm Infants With Acute Kidney Injury Is Common: Should It Be? 1024 575 Lauren Dembeck
small baby with nose canula

Lack of efficacy and safety data on diuretic therapy in the critically ill infants is cause for concern. Researchers at Nationwide Children’s Hospital are beginning to fill in the gaps.

Despite the common use of diuretic therapy in preterm infants with acute kidney injury, to date, no large studies have evaluated the patterns of prescription for diuretics in patients that develop acute kidney injury and the relationship between the treatment and patient outcomes.

Using a large national database, researchers at Nationwide Children’s Hospital have demonstrated that treatment with diuretics is frequent in critically ill neonates and infants with acute kidney injury and appears to be associated with worse outcomes. The findings were published in Pediatric Nephrology.

“There are no evidence-based guidelines for diuretic use in this setting,” says pediatric nephrologist and Director of Neonatal Nephrology at Nationwide Children’s Tahagod Mohamed, MD, who was the lead author on the study. “We wanted to know the distribution of demographics and characteristics of infants who are treated with these medications when they are in the Neonatal Intensive Care Unit (NICU).”

The multicenter retrospective study included 2121 preterm infants with acute kidney injury diagnosis from 46 hospital NICUs born at less than 37 weeks gestational age. The investigators evaluated treatment with diuretics, practice patterns across the NICUs and associated outcomes.

“Diuretics are often used off-label for indications such as bronchopulmonary dysplasia, but we just don’t know a lot about how beneficial they are and what harmful side effects they may have,” says Jonathan Slaughter, MD, MPH, senior study author, neonatologist and principal investigator in the Center for Perinatal Research within the Abigail Wexner Research Institute at Nationwide Children’s.

A majority of the infants, 76%, received at least one dose of diuretics, with a median treatment duration of 18 days. Practice patterns for diuretic therapy varied significantly across hospitals, ranging from 42% to 96% of patients.

Diuretics were used more frequently in infants with younger gestational age, 22-28 weeks, than those with older gestational age,29-36 weeks, and with lower birth weight. Short diuretic courses (median, 4 days) were prescribed at a younger age (median, 14 days old) to neonates and infants with older gestational age. In contrast, longer diuretic courses (median, 55 days) were prescribed at older age (median age, 27 days old) to neonates and infants with younger gestational age.

“Diuretics are used for different purposes. The late preterm babies probably had more complications early on just after admission to the NICU, while the early preterm babies had probably developed lung problems, such as bronchopulmonary dysplasia,” says Dr. Mohamed.

Additional analyses revealed that infants with who received diuretics at or before 28 days postnatally had worse survival, even after adjusting for known confounders and regardless of the duration of treatment.

“It is likely that these babies were already at higher risk for mortality due to more severe underlying illness,” says Dr. Slaughter. “That is something that will need to be teased apart in future studies.”

While diuretics have been used for decades in the NICU setting, novel procedures to remove extra fluid from the body have been developed, such as aquapheresis, explains Dr. Mohamed. “With novel therapies available for neonates, we have to ask if preterm babies who would typically get diuretics will benefit more from another therapy. This needs to be addressed in the future.”

The Nationwide Children’s team is currently designing prospective studies to properly evaluate patient safety and outcomes with diuretic treatment in preterm infants with acute kidney injury.



Mohamed TH, Klamer B, Mahan JD, Spencer JD, Slaughter JL. Diuretic therapy and acute kidney injury in preterm neonates and infants. Pediatric Nephrology. 2021 May 21. [Epub ahead of print] doi: 10.1007/s00467-021-05132-6.

About the author

Lauren Dembeck, PhD, is a freelance science and medical writer based in New York City. She completed her BS in biology and BA in foreign languages at West Virginia University. Dr. Dembeck studied the genetic basis of natural variation in complex traits for her doctorate in genetics at North Carolina State University. She then conducted postdoctoral research on the formation and regulation of neuronal circuits at the Okinawa Institute of Science and Technology in Japan.