A multi-center collaborative highlights the differences in nephrotoxic medication exposure and associated AKI in pediatric bone marrow transplant, oncology, and pulmonary service lines.

Introduction: Nephrotoxic medication (NTMx) exposure is a common cause of hospital-acquired acute kidney injury (AKI) in non-critically ill, hospitalized children. NINJA (Nephrotoxic Injury Negated by Just-in-time Action), an AKI screening and quality improvement tool, has successfully decreased exposure to NTMx and associated AKI at various United States children’s hospitals. To further understand patient risk profiles, we explored NTMx exposure and AKI rates by admitting service. Methods: AKI screening was performed by daily serum creatinine when high NTMx exposure criteria were met (≥3 NTMx or ≥3 days of intravenous aminoglycosides or vancomycin). Centers separately reported data from children admitted to hematology-oncology (heme), bone marrow transplant (BMT), and pulmonary services over 5 years (n=11, 2016-2021). Rates for NMTx exposure and AKI were expressed as events per 1000 patient days. AKI intensity (#AKI days/100 exposure days) was assessed. Adherence to recommended serum creatinine monitoring was a surrogate for AKI event reliability (observed/expected x 100). Results: Mean exposure rates were highest in BMT (26.92), then pulmonary (22.73), and heme (13.01). AKI rates were highest in BMT (6.27), then pulmonary (4.24), and heme (1.82). Heme and BMT had the highest AKI intensity (12.93 and 12.25 AKI days per 100 high-NTMx exposure days, respectively) compared to pulmonary (7.50 AKI days/100 high-NTMx exposure days). Serum creatinine monitoring compliance varied between institutions (62.5%-100%). Conclusion: Nephrotoxic exposure and AKI rates vary by patient population, with BMT patients having the highest NTMx exposure, AKI rates, and AKI intensity. These findings suggest that sub-populations have different levels of exposure and may require different strategies to reduce the burden of nephrotoxic medications.