With the adoption of standardized neonatal acute kidney injury (AKI) definitions over the past decade and the concomitant surge in research studies, the epidemiology of and risk factors for neonatal AKI have become much better understood. Thus, there is now a need to focus on strategies designed to improve AKI care processes with the goal of reducing the morbidity and mortality associated with neonatal AKI. The 22nd Acute Dialysis/Disease Quality Improvement (ADQI) report provides a framework for such quality improvement in adults at risk for AKI and its sequelae. While many of the concepts can be translated to neonates, there are a number of specific nuances which differ in neonatal AKI care. A group of experts in pediatric nephrology and neonatology came together to provide neonatal-specific responses to each of the 22nd ADQI consensus statements.
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Stoops C, Boohaker L, Sims B, Griffin R, Selewski DT, Askenazi D, et al. The association of intraventricular hemorrhage and acute kidney injury in premature infants from the assessment of the worldwide acute kidney injury epidemiology in neonates (AWAKEN) study. Neonatology. 2019;116:321–30.
Selewski DT, Gist KM, Nathan AT, Goldstein SL, Boohaker LJ, Akcan-Arikan A, et al. The impact of fluid balance on outcomes in premature neonates: a report from the AWAKEN study group. Pediatr Res. 2020;87:550–7.
Kirkley MJ, Boohaker L, Griffin R, Soranno DE, Gien J, Askenazi D, et al. Acute kidney injury in neonatal encephalopathy: an evaluation of the AWAKEN database. Pediatr Nephrol. 2019;34:169–76.
Charlton JR, Boohaker L, Askenazi D, Brophy PD, Fuloria M, Gien J, et al. Late onset neonatal acute kidney injury: results from the AWAKEN Study. Pediatr Res. 2019;85:339–48.
Charlton JR, Boohaker L, Askenazi D, Brophy PD, D’Angio C, Fuloria M, et al. Incidence and risk factors of early onset neonatal AKI. Clin J Am Soc Nephrol. 2019;14:184.
Kraut EJ, Boohaker LJ, Askenazi DJ, Fletcher J, Kent AL. Incidence of neonatal hypertension from a large multicenter study [assessment of worldwide acute kidney injury epidemiology in neonates-AWAKEN]. Pediatr Res. 2018;84:279–89.
Bakhoum CY, Basalely A, Koppel RI, Sethna CB. Acute kidney injury in preterm infants with necrotizing enterocolitis. J Matern Fetal Neonatal Med. 2019;32:3185–90.
Jetton JG, Boohaker LJ, Sethi SK, Wazir S, Rohatgi S, Soranno DE, et al. Incidence and outcomes of neonatal acute kidney injury (AWAKEN): a multicentre, multinational, observational cohort study. Lancet Child Adolesc Health. 2017;1:184–94.
Ueno K, Seki S, Shiokawa N, Matsuba T, Miyazono A, Hazeki D, et al. Validation of acute kidney injury according to the modified KDIGO criteria in infants after cardiac surgery for congenital heart disease. Nephrology. 2019;24:294–300.
Srinivasan N, Schwartz A, John E, Price R, Amin S. Acute kidney injury impairs postnatal renal adaptation and increases morbidity and mortality in very low-birth-weight infants. Am J Perinatol. 2018;35:39–47.
Madsen NL, Goldstein SL, Frøslev T, Christiansen CF, Olsen M. Cardiac surgery in patients with congenital heart disease is associated with acute kidney injury and the risk of chronic kidney disease. Kidney Int. 2017;92:751–6.
Maqsood S, Fung N, Chowdhary V, Raina R, Mhanna MJ. Outcome of extremely low birth weight infants with a history of neonatal acute kidney injury. Pediatr Nephrol. 2017;32:1035–43.
Harer MW, Pope CF, Conaway MR, Charlton JR. Follow-up of acute kidney injury in neonates during childhood years (FANCY): a prospective cohort study. Pediatr Nephrol. 2017;32:1067–76.
Abitbol CL, Bauer CR, Montane B, Chandar J, Duara S, Zilleruelo G. Long-term follow-up of extremely low birth weight infants with neonatal renal failure. Pediatr Nephrol. 2003;18:887–93.
Crump C, Sundquist J, Sundquist K. Risk of hypertension into adulthood in persons born prematurely: a national cohort study. Eur Heart J. 2020;41:1542–50.
Calderon-Margalit R, Golan E, Twig G, Leiba A, Tzur D, Afek A, et al. History of childhood kidney disease and risk of adult end-stage renal disease. N. Engl J Med. 2018;378:428–38.
Low Birth W. Nephron number working G. The impact of kidney development on the life course: a consensus document for action. Nephron. 2017;136:3–49.
Stritzke A, Thomas S, Amin H, Fusch C, Lodha A. Renal consequences of preterm birth. Mol Cell Pediatr. 2017;4:2.
Luyckx VA. Preterm birth and its impact on renal health. Semin Nephrol. 2017;37:311–9.
Chaturvedi S, Ng KH, Mammen C. The path to chronic kidney disease following acute kidney injury: a neonatal perspective. Pediatr Nephrol. 2017;32:227–41.
Khalsa DDK, Beydoun HA, Carmody JB. Prevalence of chronic kidney disease risk factors among low birth weight adolescents. Pediatr Nephrol. 2016;31:1509–16.
White SL, Perkovic V, Cass A, Chang CL, Poulter NR, Spector T, et al. Is low birth weight an antecedent of CKD in later life? A systematic review of observational studies. Am J Kidney Dis. 2009;54:248–61.
Zappitelli M, Ambalavanan N, Askenazi DJ, Moxey-Mims MM, Kimmel PL, Star RA, et al. Developing a neonatal acute kidney injury research definition: a report from the NIDDK neonatal AKI workshop. Pediatr Res. 2017;82:569–73.
Jetton JG, Sorenson M. Pharmacological management of acute kidney injury and chronic kidney disease in neonates. Semin Fetal Neonatal Med. 2017;22:109–15.
Kashani K, Rosner MH, Haase M, Lewington AJP, O’Donoghue DJ, Wilson FP, et al. Quality improvement goals for acute kidney injury. Clin J Am Soc Nephrol. 2019;14:941–53.
Silver SA, Nadim MK, O’Donoghue DJ, Wilson FP, Kellum JA, Mehta RL, et al. Community health care quality standards to prevent acute kidney injury and its consequences. Am J Med. 2020;133:552–60.e3.
Rewa OG, Tolwani A, Mottes T, Juncos LA, Ronco C, Kashani K, et al. Quality of care and safety measures of acute renal replacement therapy: Workgroup statements from the 22nd acute disease quality initiative (ADQI) consensus conference. J Crit Care. 2019;54:52–7.
Selby NM, Casula A, Lamming L, Stoves J, Samarasinghe Y, Lewington AJ, et al. An organizational-level program of intervention for AKI: a pragmatic stepped wedge cluster randomized trial. J Am Soc Nephrol. 2019;30:505.
Meersch M, Schmidt C, Hoffmeier A, Van Aken H, Wempe C, Gerss J, et al. Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive Care Med. 2017;43:1551–61.
Romagnoli S, Ricci Z, Ronco C. Perioperative acute kidney injury: prevention, early recognition, and supportive measures. Nephron. 2018;140:105–10.
Perico N, Askenazi D, Cortinovis M, Remuzzi G. Maternal and environmental risk factors for neonatal AKI and its long-term consequences. Nat Rev Nephrol. 2018;14:688–703.
Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140:e20171904.
Joseph C, Gattineni J. Proteinuria and hematuria in the neonate. Curr Opin Pediatr. 2016;28:202–8.
Ojala R, Ala-Houhala M, Harmoinen AP, Luukkaala T, Uotila J, Tammela O. Tubular proteinuria in pre-term and full-term infants. Pediatr Nephrol. 2006;21:68–73.
Jernigan SM. Hematuria in the newborn. Clin Perinatol. 2014;41:591–603.
Jones RW, Rochefort MJ, Baum JD. Increased insensible water loss in newborn infants nursed under radiant heaters. Br Med J. 1976;2:1347–50.
Goldstein SL, Dahale D, Kirkendall ES, Mottes T, Kaplan H, Muething S, et al. A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children. Kidney Int. 2020;97:580–8.
Goldstein SL, Kirkendall E, Nguyen H, Schaffzin JK, Bucuvalas J, Bracke T, et al. Electronic health record identification of nephrotoxin exposure and associated acute kidney injury. Pediatrics. 2013;132:e756–67.
Goldstein SL, Mottes T, Simpson K, Barclay C, Muething S, Haslam DB, et al. A sustained quality improvement program reduces nephrotoxic medication-associated acute kidney injury. Kidney Int. 2016;90:212–21.
Stoops C, Stone S, Evans E, Dill L, Henderson T, Griffin R, et al. Baby NINJA (nephrotoxic injury negated by just-in-time action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit. J Pediatr. 2019;215:e226.
Selewski DT, Akcan-Arikan A, Bonachea EM, Gist KM, Goldstein SL, Hanna M, et al. The impact of fluid balance on outcomes in critically ill near-term/term neonates: a report from the AWAKEN study group. Pediatr Res. 2019;85:79–85.
Bhojani S, Stojanovic J, Melhem N, Maxwell H, Houtman P, Hall A, et al. The incidence of paediatric acute kidney injury identified using an AKI E-alert algorithm in six english hospitals. Front Pediatr. 2020;8:29.
Van Driest SL, Wang L, McLemore MF, Bridges BC, Fleming GM, McGregor TL, et al. Acute kidney injury risk-based screening in pediatric inpatients: a pragmatic randomized trial. Pediatr Res. 2020;87:118–24.
Sandokji I, Yamamoto Y, Biswas A, Arora T, Ugwuowo U, Simonov M, et al. A time-updated, parsimonious model to predict AKI in hospitalized children. J Am Soc Nephrol. 2020;31:1348–57.
Benoit SW, Goldstein SL, Dahale DS, Haslam DB, Nelson A, Truono K, et al. Reduction in nephrotoxic antimicrobial exposure decreases associated acute kidney injury in pediatric hematopoietic stem cell transplant patients. Biol Blood Marrow Transplant. 2019;25:1654–8.
Jetton JG, Guillet R, Askenazi DJ, Dill L, Jacobs J, Kent AL, et al. Assessment of worldwide acute kidney injury epidemiology in neonates: design of a retrospective cohort study. Front Pediatrics. 2016;4:68.
Bagshaw SM. Acute kidney injury care bundles. Nephron. 2015;131:247–51.
Logan R, Davey P, Davie A, Grant S, Tully V, Valluri A, et al. Care bundles for acute kidney injury: a balanced accounting of the impact of implementation in an acute medical unit. BMJ Open Qual. 2018;7:e000392.
Meijers B, De Moor B, Van Den Bosch B. The acute kidney injury e-alert and clinical care bundles: the road to success is always under construction. Nephrol Dial Transplant. 2016;31:1761–3.
Schiffl H. Prevention of severe acute kidney injury by implementation of care bundles: some progress but still a lot of work ahead. Saudi J Kidney Dis Transplant. 2018;29:513–7.
Selby NM, Kolhe NV. Care bundles for acute kidney injury: do they work? Nephron. 2016;134:195–9.
Selby NM, Casula A, Lamming L, Stoves J, Samarasinghe Y, Lewington AJ, et al. An organizational-level program of intervention for AKI: a pragmatic stepped wedge cluster randomized trial. J Am Soc Nephrol. 2019;30:505–15.
Vincent K, Murphy HJ, Ross JR, Twombley KE. Acute kidney injury guidelines are associated with improved recognition and follow-up for neonatal patients. Adv Neonatal Care. 2020;20:269–75.
Lorenzin A, Garzotto F, Alghisi A, Neri M, Galeano D, Aresu S, et al. CVVHD treatment with CARPEDIEM: small solute clearance at different blood and dialysate flows with three different surface area filter configurations. Pediatr Nephrol. 2016;31:1659–65.
Askenazi D, Ingram D, White S, Cramer M, Borasino S, Coghill C, et al. Smaller circuits for smaller patients: improving renal support therapy with Aquadex™. Pediatr Nephrol. 2016;31:853–60.
Ronco C, Garzotto F, Brendolan A, Zanella M, Bellettato M, Vedovato S, et al. Continuous renal replacement therapy in neonates and small infants: development and first-in-human use of a miniaturised machine (CARPEDIEM). Lancet. 2014;383:1807–13.
Mottes TA, Goldstein SL, Basu RK. Process based quality improvement using a continuous renal replacement therapy dashboard. BMC Nephrol. 2019;20:17.
Mottes T, Owens T, Niedner M, Juno J, Shanley TP, Heung M. Improving delivery of continuous renal replacement therapy: impact of a simulation-based educational intervention. Pediatr Crit Care Med. 2013;14:747–54.
Hackbarth R, Bunchman TE, Chua AN, Somers MJ, Baum M, Symons JM, et al. The effect of vascular access location and size on circuit survival in pediatric continuous renal replacement therapy: a report from the PPCRRT registry. Int J Artif Organs. 2007;30:1116–21.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Inter. Suppl. 2012;2:1–138.
Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, et al. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis. 2010;55:316–25.
Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, et al. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med. 2011;37:1166–73.
We acknowledge Drs. Ravi Mehta, John Kellum, and Claudio Ronco for their leadership and vision in leading the ADQI collaborative. Furthermore, we are indebted to all of the members of the 22nd ADQI meeting who worked together to develop and articulate the importance of quality improvement in the field of AKI.
Conflict of interest
The authors have no quality improvement related conflicts of interest to report that would have affected the writing of this publication. For AKI-related research, MZ is a member of the AKI adjudication committee for an industry sponsored study on NGAL as an AKI biomarker (Bioporto Inc.) DJA is consultant for Baxter, CHF solutions, Bioporo, and Medtronic. RKB is a consultant for Baxter, Biomerieux and BioPorto.
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Harer, M.W., Selewski, D.T., Kashani, K. et al. Improving the quality of neonatal acute kidney injury care: neonatal-specific response to the 22nd Acute Disease Quality Initiative (ADQI) conference. J Perinatol 41, 185–195 (2021). https://doi.org/10.1038/s41372-020-00810-z
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