Pediatric Nephrology

, Volume 33, Issue 3, pp 511–520 | Cite as

Fluid overload independent of acute kidney injury predicts poor outcomes in neonates following congenital heart surgery

  • Kenneth E. Mah
  • Shiying Hao
  • Scott M. Sutherland
  • David M. Kwiatkowski
  • David M. Axelrod
  • Christopher S. Almond
  • Catherine D. Krawczeski
  • Andrew Y. Shin
Original Article



Fluid overload (FO) is common after neonatal congenital heart surgery and may contribute to mortality and morbidity. It is unclear if the effects of FO are independent of acute kidney injury (AKI).


This was a retrospective cohort study which examined neonates (age < 30 days) who underwent cardiopulmonary bypass in a university-affiliated children’s hospital between 20 October 2010 and 31 December 2012. Demographic information, risk adjustment for congenital heart surgery score, surgery type, cardiopulmonary bypass time, cross-clamp time, and vasoactive inotrope score were recorded. FO [(fluid in–out)/pre-operative weight] and AKI defined by Kidney Disease Improving Global Outcomes serum creatinine criteria were calculated. Outcomes were all-cause, in-hospital mortality and median postoperative hospital and intensive care unit lengths of stay.


Overall, 167 neonates underwent cardiac surgery using cardiopulmonary bypass in the study period, of whom 117 met the inclusion criteria. Of the 117 neonates included in the study, 76 (65%) patients developed significant FO (>10%), and 25 (21%) developed AKI ≥ Stage 2. When analyzed as FO cohorts (< 10%,10–20%, > 20% FO), patients with greater FO were more likely to have AKI (9.8 vs. 18.2 vs. 52.4%, respectively, with AKI ≥ stage 2; p = 0.013) and a higher vasoactive-inotrope score, and be premature. In the multivariable regression analyses of patients without AKI, FO was independently associated with hospital and intensive care unit lengths of stay [0.322 extra days (p = 0.029) and 0.468 extra days (p < 0.001), respectively, per 1% FO increase). In all patients, FO was also associated with mortality [odds ratio 1.058 (5.8% greater odds of mortality per 1% FO increase); 95% confidence interval 1.008,1.125;p = 0.032].


Fluid overload is an important independent contributor to outcomes in neonates following congenital heart surgery. Careful fluid management after cardiac surgery in neonates with and without AKI is warranted.


Congenital heart defects Cardiopulmonary bypass Postoperative care Fluid balance Acute kidney injury Critical care outcomes 



This study was supported by the Cardiovascular Intensive Care Unit (CVICU) Fund, Heart Center at Lucile Packard Children’s Hospital Stanford, Stanford University School of Medicine (principal investigator, A.Y.S.)

Compliance with ethical standards

Conflict of interest

The authors declare they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study formal consent is not required.


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Copyright information

© IPNA 2017

Authors and Affiliations

  • Kenneth E. Mah
    • 1
    • 2
  • Shiying Hao
    • 2
    • 3
  • Scott M. Sutherland
    • 2
    • 4
  • David M. Kwiatkowski
    • 1
    • 2
  • David M. Axelrod
    • 1
    • 2
  • Christopher S. Almond
    • 1
    • 2
  • Catherine D. Krawczeski
    • 1
    • 2
  • Andrew Y. Shin
    • 1
    • 2
    • 5
    • 6
  1. 1.Division of Pediatric Cardiology, Department of Pediatrics, Stanford Cardiovascular Research InstituteStanford University School of MedicineStanfordUSA
  2. 2.Lucile Packard Children’s Hospital StanfordPalo AltoUSA
  3. 3.Division of Pediatric Cardiac Surgery, Department of Cardiothoracic SurgeryStanford University School of MedicineStanfordUSA
  4. 4.Division of Nephrology, Department of PediatricsStanford University School of MedicineStanfordUSA
  5. 5.Center for Quality and Clinical Effectiveness, Stanford Children’s HealthStanford University Medical CenterPalo AltoUSA
  6. 6.Lucile Packard Children’s Hospital StanfordStanford University Medical CenterPalo AltoUSA

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