ASSESSMENT OF HIGH NEPHROTOXIC MEDICATION EXPOSURE IN HOSPITALIZED NON-CRITICALLY ILL CHILDREN IN AN URBAN TERTIARY CARE CENTER- A RETROSPECTIVE DESCRIPTIVE ANALYSIS

Introduction:

AKI is a leading cause of increased morbidity and mortality in hospitalized children. High Nephrotoxic medication exposure (NTMx) is one of the important causes of AKI. Recent data from western countries have shown that there is an increasing trend of high NTMx exposure and AKI among them. Studies like NINJA have shown that there is high NTMx exposure and AKI among non-critically ill children and judicious monitoring of serum creatinine can prevent AKI in them. Such data is lacking in our country. Hence, we conducted this study. 

The primary aim is to assess the high nephrotoxic medication exposure in hospitalized non-critically ill children in a tertiary care center with no preexisting renal insufficiency. We also studied the rate of AKI, high NTMx exposure intensity and the trend of renal function monitoring in our institution.

Methods:

We did a retrospective study in all hospitalized non-critically ill children (1month -18 years) hospitalized for  72 hours (April-September 2023). Data including demographics, length of hospitalization (LOH), nephrotoxic medication exposure and renal function tests were noted. NTMx list was used as per NINJA study. We calculated high NTMx exposure prevalence rate (3 or more NTMx in one day or aminoglycoside exposure for 3 consecutive days), AKI prevalence rate in our patients. We assessed the adequacy of renal function monitoring (at least 2 serum creatinine measurements 72 hours apart).

Results:

A total of 3286 days in 672 patients was analyzed. The mean LOH was 4.9± 1.9 days. Of 672 patients, 149 (22.2%) had high NTMx exposure, 30.9% (46/149) had 3 NTMx simultaneously, 38.2% (57/149) received 3 days of amikacin, 30.9% (46/149) met both criteria. Anti-microbials were the most used medication (478 patients- 89.5%) Aminoglycosides with ceftriaxone were the most administered combination of antimicrobials. 17.15% (82/478) Proton pump inhibitors (PPI) were the second commonly used drug, 40.48% (215/531) among which pantoprazole was commonly administered. (Figure 2) The medication exposure intensity was high in our patients with 61.7% (92/149) having an exposure intensity of ≥3 and the mean exposure was 1.74 drugs.  AKI was seen in 1.93% (13/672), 23% (3/13) had stage-3 AKI. The NTMx exposure/1000 days was 45.34. An AKI prevalence/1000 day was 3.65. The rate of AKI in patients with high NTMx exposure was 8.72% (13/149). Of the 672 patients, only 36(5.35%) had adequate renal function monitoring. Patients with AKI had higher LOH (7.07 days vs 4.85 days), more cumulative NTMx exposure (median days 5 vs 4, p =0.018), received more NTMx (p=0.001) and had higher NTMx exposure (p = 0.005) compared to patients with no AKI. 35.28% (237/672) patients were discharged with a nephrotoxic medication and PPIs were the most prescribed drug at discharge.

Conclusions:

Studies like NINJA have highlighted the magnitude of NTMx exposure and deficit in AKI monitoring in developed countries. They implemented a daily serum creatinine monitoring program for all non-critically ill children with high NTMx exposure and within 1 year they observed a 42% reduction in AKI days because of daily creatinine monitoring. They further demonstrated successful dissemination of this program in nine other pediatric institutions. In our study too the rate of NTMx exposure and AKI is high with a high medication exposure intensity and there is a lag in serum creatinine monitoring. Our study shows that NTMx is high in our patients and associated with AKI despite inadequate monitoring. More vigilance is needed to decrease NTMx exposure and to identify AKI in these patients.

I have no potential conflict of interest to disclose.

I did not use generative AI and AI-assisted technologies in the writing process.