Up to 87% of very low-birthweight infants in the neonatal intensive care unit (NICU) are exposed to at least one nephrotoxic medication during their stay. About 1 in 4 of those experience at least one episode of acute kidney injury (AKI), which can lead to increased length of stay and mortality. , ,  There is also evidence that even a single incidence of AKI increases the risk of chronic kidney disease.
To address this problem, in 2015 Children’s of Alabama began the first initiative in the country designed to reduce the use of nephrotoxic medications in the NICU. The initiative, called “Baby NINJA,” was so successful it is now being validated at several other major children’s hospitals.
The effort builds off the NINJA (Nephrotoxic Injury Negated by Just-in-Time Action) project, a joint endeavor between Children’s and the Cincinnati Children’s Hospital Medical Center that started in 2011 in non-critically ill children. The goal was to ensure that children only receive the nephrotoxic medications that they needed for as long as they needed them, and that their kidney function was closely monitored for any signs of AKI.
The NINJA initiative reduced exposure to nephrotoxic medications by 38% and concomitant AKI by 64%. As a result, last year it was added to the Solutions for Patient Safety consortium and instituted at 147 children’s hospitals worldwide.
The Baby NINJA project at Children’s has demonstrated similarly stellar outcomes, noted Christine Stoops, D.O., assistant professor of pediatrics at the University of Alabama at Birmingham (UAB) and the primary investigator on the initiative. In the 18 months after implementing the program, nephrotoxic medication exposure dropped 42% and AKI prevalence fell 78%, she said. Meanwhile, the rate of patients with AKI who had also been exposed to nephrotoxic medications fell 64%, while patients spent 68% fewer days in AKI.
The program’s key players are the two NICU pharmacists, Sadie Stone, PharmD, and Emily Evans, PharmD, who round daily with the multidisciplinary team, which includes neonatologists and nurse practitioners, to identify at-risk babies, Stoops said. Once identified, a magnet is put on the patient room entryway denoting that the the infant is on “NINJA Watch,” which serves as a reminder to closely review medications. “The success of the program is due to in large part to the strong pharmacist support,” she said.
The pharmacists review a screening report of patients with high NTM exposure each morning and manually verify the exposure. Infants with a high exposure then receive a daily serum creatinine test during and for two days post-exposure or post-AKI resolution, whichever occurred last. During this time, the team discusses possible alternative medications, drug dosages, timing of drug levels, and hydration status. Previously, the infants would have only received the test every three to five days.
“It tells the neonatologist that this kidney is at risk of injury and makes everyone ask, ‘are these the medications the baby needs? Could we adjust them, even if we just reduce the dose? How do we reduce the risk of AKI if they really do need these medications?’” Stoops said. Often, she said, “It’s just a simple act of being mindful about what you’re doing.”
The NINJA program is now being rolled out throughout Children’s in other intensive care units, and validated at Cincinnati Children’s Hospital.
Help for Children With Kidney Disease
Learn about the Pediatric
and Infant Center for Acute Nephrology at Children’s of Alabama.
 Rhone ET, Carmody JB, Swanson JR, Charlton JR. Nephrotoxic medication exposure in very low birth weight infants. J Matern Fetal Neonatal Med. 2014;27(14):1485-90.
 Jetton J, Boohaker L, K Sethi S, Wazir S, Rohatgi S, Soranno D, et al. Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study. The Lancet Child & Adolescent Health. 2017;1(3):184-94.
 Askenazi DJ, Griffin R, McGwin G, Carlo W, Ambalavanan N. Acute kidney injury is independently associated with mortality in very low birthweight infants: a matched case-control analysis. Pediatr Nephrol. 2009;24(5):991-7.
 Menon S, Kirkendall ES, Nguyen H, Goldstein SL. Acute kidney injury associated with high nephrotoxic medication exposure leads to chronic kidney disease after 6 months. J Pediatr. 2014;165(3):522-7 e2.
 Goldstein SL, Mottes T, Simpson K, et al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney Int. 2016;90(1):212-21.