Nephrotoxic-Associated Kidney Injury in the General Pediatric Unit: An Abstract from Akron Children’s Hospital Resident and Fellow Academic Day

There is significant evidence regarding the rates of nephrotoxic-associated acute kidney injury (NAKI) in the ICU and oncology settings, but data in the general pediatric unit are limited (Goldstein et al, 2011). We conducted a study to evaluate the incidence and duration-dependent risk of NAKI in a non-ICU pediatric population. This was a mixed-methods study with prospectively collected data and a retrospective analysis. Data were collected through the Children’s Hospitals’ Solutions for Patient Safety NAKI database from 2018 to 2025. Nephrotoxic medication exposure (NTMx) was defined by NINJA criteria. NAKI was defined using the pRIFLE criteria. We evaluated the four most common categories of nephrotoxic exposure in our cohort: vancomycin alone, vancomycin plus ≥2 additional NTMx, IV contrast plus ≥2 NTMx, and aminoglycosides. Exposure duration was stratified into length of exposure groups (1-2 days, 3-5 days, 6-9 days, and ≥10 days). We modeled duration using Fisher’s exact test to determine whether duration alone predicted NAKI or whether multiple nephrotoxic medications had an effect. Among 1,055 nephrotoxic exposures from 954 unique patients, overall NAKI incidence, which included meeting any of the pRIFLE criteria, was 3.8%. In vancomycin-only exposures (n=375), NAKI incidence increased from 0% at 1-2 days to 4.4% at 3-5 days, 5.3% at 6-9 days, and 43. % at ≥10 days. In vancomycin plus ≥2 NTMx (n=282), NAKI incidence was steady at approximately 2% on 1-2 days and 3-5 days but rose to 8.3% on 6-9 days and 71.4% at ≥10 days. Duration ≥10 days was significantly associated with NAKI compared to shorter exposure (Fisher’s exact test, p <0.001) for both groups. Aminoglycoside-only exposures (n=43) were not associated with NAKI. Contrast exposure alone did not account for any NAKI, and contrast plus ≥2 NTMx resulted in a 2.2% incidence of NAKI. Overall, the NAKI incidence in our population was low. NAKI risk was strongly duration-dependent with a marked increase in NAKI incidence beyond 10 days of NTMx exposure, suggesting that the duration-dependent relationship is not linear. This effect was amplified in patients who received vancomycin in combination with ≥2 NTMx. These findings suggest exposure duration may be a modifiable risk factor for NAKI in noncritically ill children.