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NINJA

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.

Nephrology

Baby NINJA Fights Back Against AKI

Nephrology_Baby_NINJA

The Pediatric and Infancy Center for Acute Nephrology (PICAN) at Children’s of Alabama, in partnership with the University of Alabama at Birmingham (UAB) Department of Pediatrics, has served children in Alabama and across the world since its 2013 inception. PICAN’s three-pronged model provides the best available comprehensive multidisciplinary clinical care, education, and research for children with acute kidney injury (AKI) and neonates with kidney disease.

“We believe that if we provide the best care, make important discoveries and educate our staff and those beyond our institution, we can make a huge impact in this field,” said David Askenazi, M.D., MSPH, PICAN director and UAB professor of pediatrics.

As a part of its efforts, PICAN implemented Nephrotoxic Injury Negated by Just-in-Time Action (NINJA), a collaboration between Children’s and Cincinnati Children’s Hospital Medical Center. Via NINJA, hospitalized patients receiving medications that can cause kidney injury are automatically identified by using the electronic medical record system and scheduled for dose adjustments and increased renal function surveillance. The rate of acute renal injury in inpatients has been decreased by more than 60 percent, resulting in substantially decreased morbidity across the hospital and reduced hospitalization duration. The NINJA program is so successful that this year it became the first new program added to the Solutions For Patient Safety consortium and instituted at 147 children’s hospitals worldwide.

A recent application of NINJA in Children’s Neonatal Intensive Care Unit (NICU) referred to as Baby NINJA, a project exclusive to Children’s, has nearly eliminated medication associated acute kidney injury in the most vulnerable premature infants. In March 2018, Baby NINJA won the Best Abstract Award at the 23rd International Conference on Advances in Critical Care Nephrology in San Diego, California.

“What’s exciting about Baby NINJA is the simplicity of the approach,” said Christine Stoops, D.O., MPH, Baby NINJA co-investigator and UAB assistant professor in the Division of Neonatology. “It’s looking at all infants exposed to nephrotoxic medications for potential kidney injury with a daily lab level (serum creatinine), and paying careful attention to whether a baby still needs these medications or can benefit from a lower daily dose.”

“With that easy shift in our mindset, we have shown greater than an 80 percent reduction in kidney injury in high-risk patients,” Stoops said. “This has the potential to reduce chronic kidney disease in these already at-risk infants.”

In addition, PICAN has one of the most successful Continuous Renal Replacement Therapy (CRRT) programs to support critically ill patients who have lost kidney function. For example, PICAN in 2014 studied a new dialysis device called Aquadex FlexFlow ™ and adapted the device to treat neonates and premature infants with kidney failure who are too small for hemodialysis. As a result, children as small 1 kilogram can now receive this lifesaving therapy. Children’s is the first pediatric hospital in the country to successfully adapt Aquadex for use on infants, and the device is now being used at other major children’s hospitals, including Cincinnati Children’s, Boston Children’s Hospital and Seattle Children’s Hospital.

“We do more dialysis in newborns than other hospitals in the world,” Askenazi said. “We have cared for 70 babies with CRRT and have great success in initiating the machine without cardiovascular compromise, which was a problem before using Aquadex. Our survival rate in babies has increased from 30 percent to 55 percent over the last few years.”

PICAN is also the driving force behind the international Neonatal Kidney Collaborative (NKC). Under the direction of Askenazi, this network of neonatologists, pediatric nephrologists, epidemiologists and statisticians from the U.S., as well as India, Canada, and Australia, are committed better understanding AKI in neonates.

The inaugural project of NKC is the Assessment of Worldwide Acute Kidney Injury Epidemiology in Neonates (AWAKEN) study. The 24-center study captured data from over 2,000 neonates admitted to the NICU who were on intravenous fluids for at least 48 hours.

“We have learned a tremendous amount from the AWAKEN database. We can now show that AKI is very common in select groups of patients. Those patients with AKI were four times more likely to die, even after controlling other factors that are associated with neonatal death,” Askenazi said.

“We have recently reported that caffeine can be a protective agent against AKI, and we have 12 other manuscripts in preparation as well. Our plans are to submit a [National Institutes of Health] grant to continue our research and answer more questions on this topic in the future.”


Nephrology Fellowship Program

Learn more about the Pediatric Nephrology Fellowship Program at UAB at https://www.childrensal.org/FellowshipProgram.