Reducing acute kidney injury in pediatric oncology patients: An improvement project targeting nephrotoxic medications

Abstract

Background Nephrotoxic medication exposure and associated acute kidney injury (AKI) occur commonly in hospitalized children. At Cincinnati Children's Hospital Medical Center, there is an initiative to increase awareness of nephrotoxic medication exposure and decrease rates of associated AKI. The oncology service utilized these data in a quality improvement project to drive reductions in AKI rates. Methods Three interventions were implemented targeted at decreasing the incidence of nephrotoxic exposure, as well as protecting against the conversion of exposures to AKI episodes. Cefepime replaced piperacillin‐tazobactam for febrile neutropenia, vancomycin stewardship limited empiric courses to 72 hours, and nephroprotection for intravenous contrast administration was standardized for defined high‐risk patients. Results The study cohort comprised 42 520 noncritically ill patient days admitted to the oncology service at Cincinnati Children's Hospital Medical Center. A total of 273 unique patients were exposed to combination nephrotoxic medications, leading to 111 AKI episodes. The rate of nephrotoxic medication exposure within the oncology service decreased by 49% from 16.08 to 8.17 per 1000 patient days. Episodes of AKI associated with nephrotoxic medication exposure decreased by 45% from 3.48 to 1.92 per 1000 patient days. Conclusion Interventions to decrease AKI took a three‐pronged approach. Collectively, this approach was proven successful with significant reductions in both rates of nephrotoxic medication exposure and associated AKI among hospitalized oncology patients.

Clusterin as a New Marker of Kidney Injury in Children Undergoing Allogeneic Hematopoietic Stem Cell Transplantation—A Pilot Study

“…This finding justifies the current attempts to prevent renal injury or at least to minimize the impact of potential nephrotoxins on the kidney. The reduction of nephrotoxic exposure is one of the effective tools already used in oncological patients [ 30 ]. The animal models suggest the possibility to prevent AKI with the use of phosphodiesterase-5 inhibitors prior to potentially nephrotoxic treatment [ 31 , 32 ].…”

Nephrotoxin Exposure and Acute Kidney Injury in Adults

“…11 A subsequent multicenter study featuring nine large children's hospitals from across the country observed a significant and sustained lowering of 24% in rates of nephrotoxic AKI. 12 Because of these studies, use of NINJA is becoming increasingly used among pediatric patients, including in the neonatal ICU, 13 in children with cystic fibrosis, 14 in pediatric oncology, 15 and in the bone marrow transplant unit. 16 The success of the NINJA program in the pediatric population has prompted calls from the American Society of Nephrology and others for further validation in adult populations.…”

Impact of a clinical pathway on acute kidney injury in patients undergoing heart transplant

“…Susceptibility to perioperative AKI is multifactorial, with previously reported risk factors of younger age, pre‐existing renal insufficiency, duration of cardiopulmonary bypass (CPB), pre‐ and postoperative low cardiac output and fluid overload, and exposure to nephrotoxic agents 2,9,12–14 . As such, quality improvement (QI) efforts to reduce the incidence and severity of AKI have focused on risk assessment, timely diagnosis, optimization of hemodynamics, and avoidance of nephrotoxic agents 15–23 …”

“…2,9,[12][13][14] As such, quality improvement (QI) efforts to reduce the incidence and severity of AKI have focused on risk assessment, timely diagnosis, optimization of hemodynamics, and avoidance of nephrotoxic agents. [15][16][17][18][19][20][21][22][23] Given its impact on renal health and patient outcomes, our team developed a multi-pronged QI clinical pathway to reduce AKI incidence after HT that included perioperative aminophylline use, optimization of postoperative renal perfusion pressure, and avoidance of nephrotoxic medications. We hypothesized that implementation of a standardized clinical pathway would result in reduced incidence and severity of AKI in patients undergoing HT.…”