A prospective multi-center quality improvement initiative (NINJA) indicates a reduction in nephrotoxic acute kidney injury in hospitalized children


Stuart L. Goldstein, Cincinnati Children's Hospital Medical Center
Devesh Dahale, Cincinnati Children's Hospital Medical Center
Eric S. Kirkendall, Cincinnati Children's Hospital Medical Center
Theresa Mottes, Cincinnati Children's Hospital Medical Center
Heather Kaplan, Cincinnati Children's Hospital Medical Center
Stephen Muething, Cincinnati Children's Hospital Medical Center
David J. Askenazi, Children's Health System
Traci Henderson, Children's Health System
Lynn Dill, Children's Health System
Michael J.G. Somers, Children's Hospital Boston
Jessica Kerr, Children's Hospital Boston
Jennifer Gilarde, Children's Hospital Boston
Joshua Zaritsky, Alfred I. duPont Hospital for Children
Valerie Bica, Alfred I. duPont Hospital for Children
Patrick D. Brophy, University of Iowa Stead Family Children’s Hospital
Jason Misurac, University of Iowa Stead Family Children’s Hospital
Richard Hackbarth, Helen DeVos Children's Hospital
Julia Steinke, Helen DeVos Children's Hospital
Joann Mooney, Helen DeVos Children's Hospital
Sara Ogrin, Helen DeVos Children's Hospital
Vimal Chadha, Chlldren's Mercy HospitalFollow
Bradley A. Warady, Children's Mercy HospitalFollow
Richard K. Ogden Jr., Children's Mercy HospitalFollow
Wendy Hoebing, Children's Mercy HospitalFollow
Jordan Symons, Seattle Children's Hospital
Karyn Yonekawa, Seattle Children's Hospital
Shina Menon, Seattle Children's Hospital
Lisa Abrams, Seattle Children's Hospital
Scott Sutherland, Lucille Packard Children's Hospital
Patricia Weng, UCLA Mattel Children's Hospital
Fang Zhang, Harvard Medical School

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© 2019 International Society of Nephrology Nephrotoxic medication (NTMx) exposure is a common cause of acute kidney injury (AKI) in hospitalized children. The Nephrotoxic Injury Negated by Just-in time Action (NINJA) program decreased NTMx associated AKI (NTMx-AKI) by 62% at one center. To further test the program, we incorporated NINJA across nine centers with the goal of reducing NTMx exposure and, consequently, AKI rates across these centers. NINJA screens all non-critically ill hospitalized patients for high NTMx exposure (over three medications on the same day or an intravenous aminoglycoside over three consecutive days), and then recommends obtaining a daily serum creatinine level in exposed patients for the duration of, and two days after, exposure ending. Additionally, substitution of equally efficacious but less nephrotoxic medications for exposed patients starting the day of exposure was recommended when possible. The main outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) serum creatinine criteria (increase of 50% or 0.3 mg/dl over baseline). The primary outcome measure was AKI episodes per 1000 patient-days. Improvement was defined by statistical process control methodology and confirmed by Autoregressive Integrated Moving Average (ARIMA) modeling. Eight consecutive bi-weekly measure rates in the same direction from the established baseline qualified as special cause change for special process control. We observed a significant and sustained 23.8% decrease in NTMx-AKI rates by statistical process control analysis and by ARIMA modeling; similar to those of the pilot single center. Thus, we have successfully applied the NINJA program to multiple pediatric institutions yielding decreased AKI rates.

Journal Title

Kidney International





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acute kidney injury; nephrotoxicity; pediatric nephrology

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