Acute Care Nephrology Program Sets Standard in Preventing Kidney Injuries

Nearly one in four kids will sustain an acute kidney injury (AKI) during a stay in the hospital. At Children’s Hospital Colorado, the Acute Care Nephrology Program is designed to help prevent, diagnose and manage patients with AKI.

AKI is a sudden decrease in kidney function — usually diagnosed with labs or a noticeable change in urine output. The severity can range from minor loss to complete failure. While AKI is often a complication of another disease, this type of kidney damage can develop due to low blood pressure, sepsis, nephrotoxic medications and other factors

“Unfortunately, the kidneys are often innocent bystanders,” says Weiwan (Vivian) Shih, MD, pediatric nephrologist and Medical Director of the Acute Care Nephrology Program.

Right now, there isn’t treatment for AKI. After a patient is diagnosed, specialists work to mitigate any worsening and try to improve the conditions that may cause further damage, such as medication and blood pressure management.

Approximately 10% of patients who experience AKI will go on to develop some form of chronic kidney disease later in life. The Acute Care Nephrology Program oversees a range of initiatives, each targeting a different aspect of prevention and management.

Acute kidney injury prevention

The NINJA program, which stands for Nephrotoxic Injury Negated by Just-in-time Action, aims to reduce the rate of nephrotoxin-associated acute kidney injury or NAKI.

“The goal is to make care teams aware when patients are on a combination or a singular medication that could lead to a nephrotoxic kidney injury,” Dr. Shih says. “It helps guide them on deciding whether it’s required or truly needed.”

The team has rolled out a new clinical pathway that shows providers what to do if they flag for NINJA, meaning they suspect a patient may be at risk of sustaining an AKI secondary to nephrotoxic medications. They have added the option of a urine test if a blood test is not possible to help give providers the most information possible for early detection of AKI.

The NINJA program is exploring various strategies to enhance the effectiveness of the pharmacy-driven program. The team is in the process of developing a NAKI safety bundle, a set of standardized practices aimed at reducing preventable harm and ensuring consistent, high-quality care.

Continuous renal replacement therapy

For pediatric patients with AKI who require renal support, the Acute Care Nephrology Program provides continuous renal replacement therapy (CRRT). This therapy offers 24/7 removal of waste and fluid, making it ideal for critically ill patients who cannot tolerate intermittent dialysis. Our team has implemented the following innovative technologies:

• PrisMax: This device is the most used dialysis machine in our program. It’s FDA-approved for patients weighing 44 pounds or more. However, the team cares for smaller patients using the device in an off-label capacity when clinically appropriate. The machine provides gentle, continuous therapy suited for critically ill patients in intensive care settings who may not otherwise tolerate shorter, less frequent sessions.
• CARPEDIEM: Specifically designed for the smallest and most fragile patients, this newer device supports neonates and infants with congenital kidney anomalies or perinatal kidney injury. Its design allows for precise, fine-tuned adjustments tailored to the needs of these vulnerable patients.
• Aquadex: While not currently in use, the team plans to implement this device in the near future. Originally developed for fluid removal in adult congenital heart patients, Aquadex can be adapted for pediatric use to support both fluid removal and solute clearance. Its lower sensitivity to patient movement makes treatment easier to manage at the bedside.

In addition to their clinical work in AKI care, the acute care nephrology team is heavily involved in research and other initiatives, including WE-ROCK, the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Diseases, and ICONIIC, Improving CRRT Outcomes in Neonates and Infants through Interdisciplinary Collaboration.

Last year, Dr. Shih co-authored a paper titled, “The Landscape of Pediatric Acute Care Nephrology Programs: A National Survey from the American Society of Pediatric Nephrology” published in Kidney360.  According to the paper’s findings, Children’s Colorado has long been ahead of the curve. Many programs across the country still do not have medical directors or assigned nursing managers. Among those with a designated medical director, 45% reported having either no or less than 10% full-time equivalent protected time for this work.

“Awareness is gradually increasing.” Dr. Shih says. “I’d say it’s not uncommon to have a program, but it’s less common to have dedicated support for that program.”

While there’s still more work to be done, the proactive approach at Children’s Colorado is working. For Dr. Shih and the team, the goal isn’t to dictate therapy. Instead, the Acute Care Nephrology Program emphasizes collaboration and education, ensuring every care team is empowered with the knowledge and tools needed to prevent and mitigate AKI.