Nephrotoxic-Associated Acute Kidney Injury (NAKI) Is Avoidable

Nephrotoxic-Associated Acute Kidney Injury (NAKI) Is Avoidable 375 280 Pam Georgiana

Quality improvement initiative at Nationwide Children’s Hospital leads to significant reductions in NAKI.

Nephrotoxic-associated acute kidney injury (NAKI) — an under-recognized but serious risk in pediatric hospital care — affects up to 25% of hospitalized children. It occurs when medications or toxins reduce kidney function by disrupting blood flow, damaging renal cells or triggering inflammation.

“The consequences of NAKI can be severe,” explains Diana Zepeda-Orozco, MD, pediatric nephrologist at Nationwide Children’s Hospital. “It prolongs hospital stays, drives up costs and increases the likelihood of both short-term complications, such as increased mortality risk, and long-term kidney issues.”

Dr. Zepeda-Orozco, who is also a principal investigator and associate division chief of research in the Kidney and Urinary Tract Research Center at Nationwide Children’s, is a member of the leadership team dedicated to reducing NAKI as part of the Solutions for Patient Safety Collaborative supported by the Center of Clinical Excellence at Nationwide Children’s Hospital.

This quality improvement (QI) initiative, backed by champions in multiple departments across the Nationwide Children’s, uses data-driven methods, evidence-based guidelines and Electronic Medical Record (EMR) decision support. The goals are to reduce nephrotoxic medication exposure and lower NAKI rates in hospitalized patients.

Evaluating Nephrotoxic Medication Need and Kidney Function Monitoring

Many NAKIs go undetected due to a lack of systematic kidney function surveillance. For at-risk patients, EMR pharmacy-driven reports triggers communication between pharmacy and providers to evaluate the need for the nephrotoxic medication and/or regular serum creatinine checks. This approach prompts timely reviews, therapy changes when appropriate, and helps catch early changes in kidney function. In many instances, doctors can replace a nephrotoxic medication with an equally effective but safer alternative. When a nephrotoxic agent is unavoidable, systematic serum creatinine surveillance allows early NAKI identification to reduce its complications.

Two Pivotal Outcome Measures

More than 80% of hospitalized patients receive at least one nephrotoxic medication. When patients receive three or more nephrotoxic agents in one day, or specific nephrotoxic medications for more than 3 days the likelihood of NAKI rises significantly. In response, the QI team monitors two primary outcome measures:

  1. The number of patients exposed to several nephrotoxic medications at once or over consecutive days.
  2. The rate of acquired AKI events among those patients who experience exposures.

Education and Decision Support

The QI team regularly updates providers on emerging evidence, best practices and hospital-specific guidelines. One area of particular focus is the PICU, where children are highly susceptible due to the medical necessity of nephrotoxic medications and their critical illness.

PICU residents receive targeted instruction on recognizing and preventing NAKI. The education includes evidence showing the impact of NAKI in patients’ outcomes, importance of nephrotoxic medication exposure evaluation, NAKI surveillance, and prompt attention to early creatinine rises. Pharmacists collaborate with prescribers to highlight nephrotoxic combinations, suggest alternatives or recommend kidney function evaluation. Each care team member has a role in reducing nephrotoxic exposures and advocating for kidney health.

PICU Results

Since launching the PICU initiative, the team has reduced the rate of nephrotoxic medication exposures by 41% and NAKI events by 52%. There have been similar successes in several other units at Nationwide.

“These outcomes show how powerful clear protocols, vigilant surveillance and collaborative efforts between pharmacists, physicians, and quality improvement specialists can be in improving the care and health of our patients,” says Dr. Zepeda-Orozco, who is also an assistant professor of pediatrics at The Ohio State University College of Medicine.

Despite Successes, Work Continues

The PICU team remains committed to using nephrotoxic medications only when truly necessary, for the shortest duration possible and with ongoing monitoring. The NAKI team’s goal is to sustain and expand the PICU’s impressive results throughout the hospital using data tracking and collaboration.

“The success of our work illustrates a vital truth: NAKI is preventable, even in the PICU. By remaining focused on modifiable risk factors, we can reduce kidney injury and ensure the best possible outcomes for our pediatric patients,” Dr. Zepeda-Orozco concludes.

Nephrotoxic acute kidney injury (NAKI) is one of the most frequent hospital-acquired harms. Since inception, the NAKI team’s work has resulted in significant reductions in NAKI exposures in non-ICU, CTICU and PICU areas, along with notable decreases in NAKI events within our CTICU and PICU units.

About the author

Pam Georgiana is a brand marketing professional and writer located in Bexley, Ohio. She believes that words bind us together as humans and that the best stories remind us of our humanity. She specialized in telling engaging stories for healthcare, B2B services, and nonprofits using classic storytelling techniques. Pam has earned an MBA in Marketing from Capital University in Columbus, Ohio.