Clinical Scenario:
A term male infant is born following a prolonged shoulder dystocia. He requires endotracheal intubation and positive-pressure ventilation for 8 minutes before spontaneous respiration is established. At 18 hours of age, he develops generalized seizures and is admitted to the NICU.
Investigations reveal:
- Serum creatinine: 1.8 mg/dL
- Urine output: 0.4 mL/kg/hour
- ALT: 210 U/L
- Platelet count: 85 × 10⁹/L
- Troponin-I: Elevated
Cranial ultrasound shows diffuse cerebral edema.
Which of the following organ systems is most commonly affected after the central nervous system in infants with moderate-to-severe perinatal asphyxia?
A. Cardiovascular system
B. Gastrointestinal system
C. Hematological system
D. Renal system
E. Respiratory system
Correct Answer & Explanation:
Explanation
Correct Answer: D. Renal system
Explanation: Perinatal Asphyxia
Perinatal asphyxia can cause multiorgan hypoxic–ischemic injury due to inadequate oxygen delivery and impaired tissue perfusion. Although hypoxic–ischemic encephalopathy (HIE) is the major determinant of neurological outcome, the kidneys are among the most frequently affected extracerebral organs.
During hypoxia, blood flow is redistributed toward vital organs, while renal perfusion may decrease. This can result in renal ischemia and acute kidney injury (AKI). Renal dysfunction may occur even when urine output is initially preserved, so assessment should not rely on oliguria alone.
Clinical manifestations of renal involvement include:
Oliguria or reduced urine output
Rising serum creatinine
Electrolyte abnormalities, including hyperkalemia
Fluid retention and impaired fluid balance
AKI is particularly important in infants with moderate-to-severe HIE, and its reported frequency varies according to the population, severity of illness, and diagnostic criteria used.
Why the other options are incorrect
A. Cardiovascular system
Myocardial ischemia, ventricular dysfunction, hypotension, and pulmonary hypertension may occur after significant perinatal asphyxia. Cardiovascular involvement is important but is not generally considered the most frequently affected extracerebral organ in this classic examination question.
B. Gastrointestinal system
Intestinal hypoperfusion can cause feeding intolerance and, in severe cases, intestinal ischemia or necrotizing enterocolitis. These are not the best answer to the question asking for the most frequently affected extracerebral organ.
C. Hematological system
Thrombocytopenia and coagulopathy may develop following severe hypoxia–ischemia, sometimes in association with hepatic dysfunction and disseminated intravascular coagulation.
E. Respiratory system
Respiratory dysfunction may accompany perinatal asphyxia and can include pulmonary hypertension or respiratory failure. However, the kidneys are the expected answer when the question specifically asks for the most frequently affected extracerebral organ.
High-Yield Examination Pearl
In a neonate with significant perinatal asphyxia, assess for multiorgan dysfunction, particularly:
Neurological: encephalopathy and seizures
Renal: AKI, reduced urine output, and rising creatinine
Cardiovascular: myocardial dysfunction and hypotension
Other systems: hepatic injury, coagulopathy, and gastrointestinal dysfunction
Monitor urine output, serum creatinine, electrolytes, and fluid balance closely. Remember that non-oliguric AKI can occur, so apparently adequate urine output does not exclude renal injury.
Find high yield Pediatric MCQs Bank for Post graduate Exam preperation.
External Resources
1. Acute Kidney Injury Post Neonatal Asphyxia – PubMed – Reviews the frequency, diagnosis, investigation, and management of acute kidney injury following neonatal asphyxia.
2. Management of Renal Dysfunction Following Term Perinatal Hypoxia-Ischaemia – PubMed – Discusses renal injury after perinatal hypoxia–ischaemia, monitoring, and supportive management.
3. Post-asphyxia Acute Kidney Injury in Neonates: A Systematic Review – Reviews reported AKI incidence, diagnostic challenges, risk factors, and outcomes in neonates following perinatal asphyxia.
4. Pathophysiology of Perinatal Asphyxia in Humans and Animal Models – Full Text – Explains the mechanisms of hypoxic–ischaemic injury and multiorgan dysfunction, including renal and cardiovascular involvement.
References
1. Durkan AM, Alexander RT. Acute kidney injury post neonatal asphyxia. J Pediatr. 2011;158(2 Suppl):e29-e33. doi: 10.1016/j.jpeds.2010.11.010.
2. Sweetman DU, Riordan M, Molloy EJ. Management of renal dysfunction following term perinatal hypoxia-ischaemia. Acta Paediatr. 2013;102(3):233-241. doi: 10.1111/apa.12116.
3. Aderounmu T, Adeyemi B, Bolarinwa A. Post-asphyxia acute kidney injury in neonates: a systematic review. Eur J Pediatr. 2026;185:357. doi: 10.1007/s00431-026-07021-2.
4. Fatemian T, et al. Pathophysiology of perinatal asphyxia in humans and animal models. Full-text article.
