P1.248: Bridging The Gap: Enhancing AKI Diagnosis and Management in Extremely Premature Infants

Purpose/Objectives:

Purpose: Acute kidney injury (AKI) occurs in 29% of all NICU infants and 47% of premature infants and is associated with morbidity and mortality. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines recommend that all NICU patients with AKI have clinical investigation performed based on their stage of AKI (Fig. 1). However, AKI is often not diagnosed in premature infants in the first week of life because diagnosis and staging require assessment of serum creatinine (SCr) and urine output (UOP) trends compared to baseline over several days. Infant SCr initially reflects maternal creatinine, leading to fluctuations in baseline SCr in the 1st week. Early detection of AKI in the NICU can guide short term management, facilitate follow-up screening, and improve long-term outcomes for affected infants.

Objectives: Determine baseline incidence of AKI within the first week of life in extremely preterm infants and quantify improvement in adherence to KDIGO recommendations for evaluation, surveillance, and follow-up in the first week of life.

Design/Methods: We conducted a retrospective chart review of infants < 32 weeks gestational age or < 1500 g birth weight admitted to two level 3/4 NICUs. Baseline serum creatinine (SCr) was defined as the lowest SCr value recorded within the first week of life. An automated, interactive spreadsheet was developed to calculate KDIGO AKI stage based on daily urine output and baseline SCr. This tool was used to assess guideline adherence rates quarterly from June 2023 to March 2025, following two separate interventions: a department-wide lecture in November 2024 and the integration of the spreadsheet onto all unit workstations in January 2025.

Results: Of the 157 patients analyzed, 24 (16%) had Stage 1 AKI, 2 (1%) had Stage 2 AKI, and 1 (1%) had Stage 3 AKI. The proportion of AKI diagnoses appropriately documented in clinical notes increased from 0–50% during June 2023–November 2024 to 100% during December 2024–March 2025 following both QI interventions. Similarly, rates of urinalysis (UA) obtained after AKI diagnosis improved from 0–40% to 100% over the same time periods.

Conclusion/Discussion: AKI is common in premature infants during the 1st week of life but rarely recognized, and few patients received adequate KDIGO evaluation and follow-up. Our algorithm for identifying premature infants with AKI in the first week is unique as it considers both the moving baseline SCr and UOP as markers. Education and the use of our AKI calculator improved performance of appropriate evaluation (UA) and follow-up (documentation in chart) of AKI in the first week of life in NICU infants. This evidence demonstrates AKI staging in real time enhances clinical adherence to institutional AKI practice guidelines.​ Future directions include developing an app for increased accessibility to our AKI staging technology.