The leaders of an innovative project at Children’s of Alabama are looking to add a strategy that could help them identify an acute kidney injury (AKI) earlier.
The Baby Nephrotoxic Injury Negated by Just-in-Time Action, or Baby NINJA, project at Children’s of Alabama was established in 2015 to reduce the use of nephrotoxic medications and monitor neonates for early signs of AKI, which is a common complication in the Neonatal Intensive Care Unit (NICU) because very low birthweight infants are typically exposed to nephrotoxic medications during their stay. In Baby NINJA’s first 18 months, this first-of-its-kind program—which has now been validated at other major children’s hospitals—led to a 42% drop in nephrotoxic medication exposure and a 78% drop in AKI prevalence, according to Baby NINJA team leader Christine Stoops, D.O., M.P.H. The improvements have continued through 2022.
Stoops, a neonatologist at Children’s, hopes recent research will lead to even better outcomes for Children’s patients. In 2019 and 2020, Stoops worked with investigators at Cincinnati Children’s Hospital to see if a noninvasive urinary marker, neutrophil gelatinase-associated lipocalin (NGAL), could provide an earlier warning sign of AKI. The results of the study, which was funded by the National Institutes of Health, were strong, and Stoops hopes Children’s will ultimately be able to incorporate NGAL into its Baby NINJA program.
NGAL can provide a timely way to predict which babies are at risk of AKI because it accumulates in the kidney tubules and urine after an injury, such as those caused by nephrotoxic medications. Studies in other settings show that NGAL elevations occur a couple of days before changes in serum creatinine, which is the traditional method of screening for AKI. But serum creatinine involves a needle stick and waiting for lab results. By the time babies show high levels of creatinine, they are already far along in the AKI. NGAL, in addition to being an earlier marker of AKI, is noninvasive, requiring just a few drops of urine. “The benefits of a noninvasive marker for kidney injury are a win all around for our babies, their families and the caregivers,” Stoops said.
In the NGAL study, researchers obtained daily creatinine and urine samples from 148 NICU babies for up to seven days after they were exposed to nephrotoxic medication, plus two days after they stopped the medication and/or when their AKI resolved. They identified the positive and negative predictive values of NGAL for AKI, confirming the results with the creatinine test. Stoops hopes the study and others like it will lead to FDA approval of NGAL as a test for AKI so Children’s of Alabama can incorporate its use into their Baby NINJA program and the very tiny babies in the NICU will receive far fewer blood draws.