(25) Urinary nGAL for AKI Screening in Baby NINJA QI Initiative

Background: Nephrotoxic medication exposure in the NICU is common and is associated with acute kidney injury (AKI). The Baby Nephrotoxic Injury Negated by Just-in-time Action (NINJA) is utilized in many NICUs to reduce nephrotoxic medication exposure and associated AKI. Baby NINJA recommends daily serum creatinine (sCr) monitoring when infants are receiving nephrotoxic medications. At NCH it was found that screening compliance was only 42% at baseline due to challenges such as concern for exposure to repetitive painful procedures and iatrogenic anemia. Urinary neutrophil gelatinase-associated lipocalin (uNGAL) is a biomarker of renal tubular injury and has excellent negative predict value for AKI. Furthermore, a recent single center data showed that uNGAL use, which is less invasive compared to sCr, can increase screening compliance in Baby NINJA programs with a value of 250 ng/mL suggestive of AKI risk.

Objectives: This study initiated a screening protocol that included uNGAL to improve AKI screening compliance.

Design/Methods: The Baby NINJA screening program was adopted by the NICU at NCH in January 2022. Infants receiving 3 or more nephrotoxic medications at one time or 3 or more days of an IV aminoglycoside or IV vancomycin were enrolled in the program. From January 2022-August 2023, the creatinine screening compliance in the NICU was 42% at baseline. Beginning in September 2023, adjustments were made to the screening protocol at NCH wherein urinary NGAL screening could be utilized in place of sCr screening for infants enrolled in the Baby NINJA program. When an infant met baby NINJA exposure criteria, the physician was requested to order either a sCr level if already having a blood draw that day, or a uNGAL otherwise. When the uNGAL was greater than 250ng/mL, the provider was prompted to order a sCr to evaluate for AKI.

Results: AKI screening adherence increase from a baseline of 42% to 82% with the inclusion of uNGAL as a modality for AKI screening. Nephrotoxic medication exposures, nephrotoxic medication-associated AKI, and nephrotoxic AKIs per 1000 patient days did not change during this period.

Conclusion: uNGAL screening can improve screening compliance for AKI in NICUs utilizing the Baby NINJA program. This finding is significant because it is a less invasive test and does not cause associated iatrogenic anemia. With improved screening compliance, AKI is more likely to be detected in neonates receiving nephrotoxic medications which allows the care team to adjust management accordingly to improve long term outcomes.