Iranian Journal of Neonatology

Iranian Journal of Neonatology

Low Apgar Score and the Risk of Neonatal Acute Kidney Injury: Evidence from a Matched Retrospective Cohort Study

Document Type : Original Article

Authors
Mehran Hesaraki 1
Mohammad Hassan Mohammadi 2
Khadijeh Saravani 2
Mahdi Afshari 3
Malihe Node 4
Amirhosein Kamrava 4
1 Department of Pediatric, Zabol University of Medical Sciences, Zabol, Iran
2 Department of Pediatrics, School of Medicine, Amir al momenin Hospital, Zabol University of Medical Science
3 Department of Community Medicine, School of Medicine, Pediatric Gastroenterology and Hepatology Research center, Amir al momenin Hospital, Zabol University of Medical
4 Department of Community Medicine, Zabol University of Medical Sciences, Zabol, Iran
10.22038/ijn.2026.87157.2677
Abstract
Background: The Apgar score is a widely used indicator for assessing newborn health immediately after birth. However, its predictive value for specific organ dysfunctions such as acute kidney injury (AKI) remains uncertain. This study aimed to evaluate the association between low 5-minute Apgar scores and the risk of AKI in neonates admitted to the neonatal intensive care unit (NICU).
Methods: In this retrospective matched cohort study conducted between 2022 and 2024 at Amir Al-Momenin Hospital, 80 neonates (40 with Apgar <7 and 40 with Apgar ≥7) were enrolled. Neonates were matched 1:1 for gestational age and admission time. Serum creatinine was measured on days 1, 3, 5, and 7, and urine output was assessed on day 3 to diagnose AKI based on modified neonatal KDIGO criteria. Statistical analyses included the Chi-square test for categorical variables, Mann–Whitney U test for non-normally distributed continuous variables, and logistic regression analysis.
Results: Low 5-minute Apgar scores were associated with a significantly higher incidence of AKI (20% vs. 5%, P = 0.043), with a 6.3-fold increased risk (OR = 6.29, 95% CI: 1.04–37.90, P = 0.045). Gestational age between 28–32 weeks independently increased the risk of AKI (OR = 13.84, P = 0.027). Although day 1 serum creatinine was higher in the normal Apgar group (P = 0.002), no differences were observed afterward. Male sex and vaginal delivery were more common in the low Apgar group but were not associated with AKI in multivariable analysis.
Conclusion: A 5-minute Apgar score <7 and gestational age between 28–32 weeks are significant risk factors for AKI in NICU neonates. These findings highlight the potential of using Apgar score and gestational age for early risk stratification and targeted monitoring.
 
Keywords
Acute kidney injury
Apgar score
Neonatal intensive care unit
Neonates
Renal function 
  1. Michel A. Review of the reliability and validity of the apgar score. Adv Neonatal Care. 2022;22(1):28-34.
  2. Shalaby MA, Sawan ZA, Nawawi E, Alsaedi S, Al-Wassia H, Kari JA. Incidence, risk factors, and outcome of neonatal acute kidney injury: a prospective cohort study. Pediatr Nephrol. 2018;33(9):1617-1624.
  3. Nada A, Bonachea EM, Askenazi DJ. Acute kidney injury in the fetus and neonate. Semin Fetal Neonatal Med. 2017;22(2):90-97.
  4. Selewski DT, Charlton JR, Jetton JG, Guillet R, Mhanna MJ, Askenazi DJ, et al. Neonatal Acute Kidney Injury. Pediatrics. 2015;136(2):e463-473.
  5. Charlton JR, Guillet R. Neonatal acute kidney injury: diagnosis, exposures, and long-term outcomes. NeoReviews. 2018;19(6):e322-e336.
  6. Bansal SC, Nimbalkar AS, Kungwani AR, Patel DV, Sethi AR, Nimbalkar SM. Clinical profile and outcome of newborns with acute kidney injury in a level 3 neonatal unit in Western India. J Clin Diagn Res. 2017;11(3):Sc01-sc4.
  7. Jayashree G, Dutta AK, Sarna MS, Saili A. Acute renal failure in asphyxiated newborns. Indian Pediatr. 1991;28(1):19-23.
  8. Alaro D, Bashir A, Musoke R, Wanaiana L. Prevalence and outcomes of acute kidney injury in term neonates with perinatal asphyxia. Afr Health Sci. 2014;14(3):682-688.
  9. Askenazi DJ, Ambalavanan N, Goldstein SL. Acute kidney injury in critically ill newborns: what do we know? What do we need to learn? Pediatr Nephrol. 2009;24(2):265-274.
  10. Chishala M, Machona-Muyunda S, Mwaba C. Acute kidney injury in neonates admitted to a low-resource neonatal intensive care unit in Lusaka, Zambia. Can J Kidney Health Dis. 2024; 11:20543581241263160.
  11. Jetton JG, Boohaker LJ, Sethi SK, Wazir S, Rohatgi S, Soranno DE, et al. Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study. Lancet Child Adolesc Health. 2017;1(3):
    184-194.
  12. Hanna MH, Askenazi DJ, Selewski DT. Drug-induced acute kidney injury in neonates. Curr Opin Pediatr. 2016;28(2):180-187.
  13. Mohamed TH, Abdi HH, Magers J, Prusakov P, Slaughter JL. Nephrotoxic medications and associated acute kidney injury in hospitalized neonates. J Nephrol. 2022;35(6):1679-1687.
  14. De Mul A, Parvex P, Héneau A, Biran V, Poncet A, Baud O, et al. Urine output monitoring for the diagnosis of early-onset acute kidney injury in very preterm Infants. Clin J Am Soc Nephrol. 2022;17(7):949-956.
  15. Gul R, Anwar Z, Sheikh M, Salamat A, Iqbal S, Saleem F, et al. Neonatal AKI profile using KDIGO guidelines: A cohort study in tertiary care hospital ICU of Lahore, Pakistan. Frontiers in Pediatrics. 2022;Volume 10 - 2022.
  16. Nagy E, Orvos H, Bakki J, Pal A. Sex-differences in Apgar scores for full-term neonates. Acta Paediatr. 2009;98(5):898-900.
  17. Katugume B, Muzungu J, Okello N, Kigongo E, Namutebi DA. Prevalence of neonatal sepsis and associated factors among neonates admitted in the neonatal intensive care unit at Lira Regional Referral Hospital, Northern Uganda. PLoS One. 2025;20(1):e0315794.
  18. Lidya M, Fetriyah UH, Rahmayani D, Ariani M. The relationship between Apgar score and gender with the incidence of neonatal sepsis: systematic review. Int J Community Med Public Health. 2021; 8(11):5473-80.
  19. Fajar JK, Andalas M, Harapan H. Comparison of Apgar scores in breech presentations between vaginal and cesarean delivery. Tzu Chi Med J. 2017;29(1):24-29.
  20. Paudyal L. Comparison of APGAR score of newborns with mode of delivery and its associated factors. International Journal of Social Sciences and Management. 2020;7(3):176-182.
  21. Gupta S, Gaur BK, Jain R, Singh RR. Incidence, risk factors, and outcomes of acute kidney injury in preterm neonates hospitalized in the neonatology unit, North India: A single-center experience. Saudi J Kidney Dis Transpl. 2023;34(6):592-601.
  22. Zhang SJ, Fang TF, Lin MY, Shu NN, Zhou M, Gu HB, et al. Risk factors for acute kidney injury in preterm neonates after noncardiac surgery: a single-center retrospective cohort study. Sci Rep. 2024; 14(1):17965.
  23. Üstün N. WIncidence, risk factors, and adverse outcomes of acute kidney injury in very premature neonates: a single center experience. Turk J Med Sci. 2021;51(5):2641-2648.
  24. Mohr Lytsen R, Taageby Nielsen S, Kongsgaard Hansen M, Strandkjær N, Juul Rasmussen I, Axelsson Raja A, et al. Markers of kidney function in early childhood and association with maternal comorbidity. JAMA Netw Open. 2022;5(11): e2243146.
  25. Lorenz JM. Monitoring fluid and electrolyte therapy in the newborn intensive care unit. Acutecaretesting org. 2004.
  26. Gohiya P, Nadkarni J, Mishra M. Study of neonatal acute kidney injury based on KDIGO criteria. Pediatr Neonatol. 2022;63(1):66-70.
  27. Go H, Momoi N, Kashiwabara N, Haneda K, Chishiki M, Imamura T, et al. Neonatal and maternal serum creatinine levels during the early postnatal period in preterm and term infants. PLoS One. 2018;13(5):e0196721.
  28. Ahn YH, Lee J, Chun J, Jun YH, Sung TJ. Urine biomarkers for monitoring acute kidney injury in premature infants. Kidney Res Clin Pract. 2020;39(3):284-294.
  29. Hanna M, Brophy PD, Giannone PJ, Joshi MS, Bauer JA, RamachandraRao S. Early urinary biomarkers of acute kidney injury in preterm infants. Pediatr Res. 2016;80(2):218-223.
  30. Allegaert K, Smits A, van Donge T, van den Anker J, Sarafidis K, Levtchenko E, et al. Renal precision medicine in neonates and acute kidney injury: how to convert a cloud of creatinine observations to support clinical decisions. Front Pediatr. 2020;8:366.
  31. Correa LP, Marzano ACS, Silva Filha R, Magalhães RC, Simoes ESAC. Biomarkers of renal function in preterm neonates at 72h and 3weeks of life. J Pediatr (Rio J). 2021;97(5):508-513.
  32. Gupta BD, Sharma P, Bagla J, Parakh M, Soni JP. Renal failure in asphyxiated neonates. Indian Pediatr. 2005;42(9):928-934.
  33. Gedefaw GD, Abuhay AG, Endeshaw YS, Birhan MA, Ayenew ME, Genet GB, et al. Incidence and predictors of acute kidney injury among asphyxiated neonates in comprehensive specialized hospitals, northwest Ethiopia, 2023. Sci Rep. 2024;14(1):16480.

 

Iranian Journal of Neonatology
Volume 17, Issue 2
Spring 2026
Pages 39-45