Browsing Tag

Baby NINJA

Neonatology

Study Identifies Noninvasive Marker for Risk of Acute Kidney Injury

Dr. Christine Stoops is a neonatologist and the leader of the Baby NINJA team at Children’s of Alabama.

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.

January 16, 2023 by
Neonatology

Baby NINJA: Reducing Acute Kidney Injury One Preemie at a Time

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. [1], [2], [3] There is also evidence that even a single incidence of AKI increases the risk of chronic kidney disease.[4]

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%.[5] 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.

[1] 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.

[2] 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.

[3] 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.

[4] 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.

[5] 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.

August 20, 2019 by