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Cori Cross, MD: Welcome to peds cast a podcast brought to you by children's of Alabama at Birmingham

Cori Cross, MD (Host): I'm pediatrician, Dr. Cori Cross.

Today, we'll be speaking with Dr. David Askenazi. He is a professor and the W. Charles Mayer Endowed Chair in Pediatric Nephrology, and the director of the Pediatric and Infant Center of Acute Nephrology at Children's of Alabama at Birmingham.

Today, we'll be discussing neonatal dialysis, PICAN, NICKS. Dr. Askenazi is here to help us with all of these acronyms and to understand the amazing care available in Alabama for infants and children in need of kidney support and nephrologic care. Dr. Askenazi, thank you so much for sharing your expertise with us today.

Dr. David Askenazi: Thank you so much for having me.

Cori Cross, MD (Host): Let's start with PICAN, which is an acronym which stands for Pediatric and Infant Center for Acute Nephrology.

Dr. David Askenazi: Yeah. So PICAN's mission is to provide the best comprehensive clinical care, transform our ability to care for patients by making innovations and research and to educate ourselves and others around our country as well as across the world on the best approaches to providing key support therapy in the form of dialysis.

Cori Cross, MD (Host): So PICAN both does education and research but also clinical care. So you have some very state-of-the-art equipment at Children's of Alabama. Can you tell us a little bit about those machines and how they make dialysis better for your patient?

Dr. David Askenazi: Yeah, we have several types of dialysis that we do in both the outpatient and the inpatient setting. My role is primarily in the inpatient setting, where we have peritoneal dialysis that we do very often in neonates after cardiopulmonary bypass surgery, but we also have a way to do dialysis through the blood, through different machines.

The classic machine that people use is a machine called the PrisMax. We were the first in the state of Alabama to have this not only in pediatrics but also through adults. It's a new machine that came out about a year ago that really facilitates the care at the bedside. It's got a lot of features that the nurses really like, and it's very hands on and intuitive. In addition, we brought in a machine in late 2013 called the Aquadex machine that has the ability to care for the smallest of our kids. And so we use the Aquadex machine when we need blood purification in children less than 10 kilos.

Cori Cross, MD (Host): And are you the only hospital in the state that has that machine as well?

Dr. David Askenazi: So we were the first in the country to really adopt this machine that was available for adults with heart failure and adopted to serve a different purpose to dialyze small babies. And so since that time, we were the first hospital to try that and we've been very successful. We've taken care of over a hundred neonates less than four kilos with this machine. And we've helped other programs across the country to establish this machine into their neonatal intensive care unit. To my knowledge, as of last spring, there was 12 other pediatric hospitals around the country that were using the Aquadex machine for their children.

Cori Cross, MD (Host): And is it true that in the state of Alabama, you are the only pediatric dialysis center?

Dr. David Askenazi: Correct. And it makes it very challenging because families have to travel up to Birmingham to get this kind of care.

Cori Cross, MD (Host): I bet it makes you also very busy.

Dr. David Askenazi: It does. There's six of us, six pediatric nephrologists. And we have several nurse practitioners that end up caring for really the entire population of Alabama, as well as some of the areas nearby. And because we offer the neonatal dialysis program, we've had people from all over the country, recently from Arkansas and Dallas, from Charlotte, from Florida, that have come to our neonatal ICU to receive dialysis services.

Cori Cross, MD (Host): Can you explain to me a little bit about the multidisciplinary approach and how it improves outcomes for your patients? You mentioned the nurse practitioners, but there are child life specialists and social workers, and a lot of other people involved in this care. Can you explain to our listeners how that affects patient care and outcome?

Dr. David Askenazi: Yeah. So many times when neonate are born with congenital kidney failure, they rely on us to help them for their first several months, sometimes all the way, you know, to six months or longer that they have to have their care taken here at our hospital. And in order for us to successfully get them home, we rely on a lot of people that have to work very well together. These include the surgeons that place the catheters for us to be able to dialyze them, the dialysis nurses that kind of initiate the therapies, the bedside nursing team, the neonatologists, as well as other people on our team. We rely on our pharmacists, our social workers, our child life specialists, occupational therapists, to really kind of optimize these kids' outcomes, get them out of bed so to speak or out of the crib so to speak, so that they're able to make their way home.

Cori Cross, MD (Host): I wanted to pivot a little bit and talk about NINJA, which from what I understand stands for Nephrotoxic Injury Negated by Just-In-Time Action. It's obviously in the running for the best acronym, but tell us what it means to negate nephrotoxic injury and how NINJA is making a difference.

Dr. David Askenazi: Yeah, thank you. So NINJA's a quality improvement program that we have been running since 2015. We participate in several collaboratives. And the idea and the mission is that children should only get the nephrotoxic medications that they need for the duration that they need them. And so in our hospital, we screen every patient that comes through our hospital for high exposure, which means that they would be on three concomitant nephrotoxic medications or three days of aminoglycoside or vancomycin. And then, through that process, we are then able to focus on those high-risk patients and ask our teams to take a look and watch their kidney function closely and to consider adjusting medications based on the patient's needs.

Cori Cross, MD (Host): So you mentioned that this is a QI project, right? That's how it started?

Dr. David Askenazi: Correct.

Cori Cross, MD (Host): So, in implementing it, have you seen differences have you seen improvement in outcomes in children when you're really focusing in on this from the get-go?

Dr. David Askenazi: Yeah, absolutely. What we've been able to show is improvement year by year to the point that last year was our lowest rates of acute kidney injury from nephrotoxic medications in our hospital. And to give you a sense to the impact that this program has had, we believe that, on any given year compared to our baseline, we have prevented over 150 children from developing acute kidney injury in our hospital.

Again, this isn't with some magic medicine or magic prescription of a new drug. This is by really focusing our teams to identify high-risk patients and then to pay attention to them and potentially hold off on adding a fifth nephrotoxic medication or making sure they're checking levels appropriately. And simply by paying attention, we've been able to reduce the incidence of acute kidney injury in our hospital.

Cori Cross, MD (Host): That is something to me that is just so important when you send your child or your patient to a hospital. You want to make sure that everything that's going on isn't making them worse and that they're making every effort to make sure that they're keeping that child, that body as healthy as it can be. You would think that then NINJA should be really the gold standard across the country.

Dr. David Askenazi: Yeah, it's in some ways a hard program to institute because it takes some, you know, fancy coding in the medical record and it takes again another village of pharmacists and committed people. But you know, we learned very early in our training that prevention is the best medicine. And so this is really a program that's designed to, A, identify the high risk patients. And once we do that, we ask our teams and our residents and our faculty to just pay close attention to this potential harmful effect that we as providers, because we're the ones prescribing these medicines. So it's a hospital-acquired condition that we and others have shown we can reduce simply by helping our teams focus on high-risk patients.

Cori Cross, MD (Host): So I would love to now discuss NICKS, which stands for Neonatal and Infant Course for Kidney Support. Can you tell us about this course and what practitioners will gain by attending it?

Dr. David Askenazi: Yeah. So, as the name implies, this is a course. It's one and a half days that is really designed to educate people so that they can go back to their programs and improve the way they take care of the smallest of their children, the neonates and the infants, who require kidney support therapy, also known as dialysis

Cori Cross, MD (Host): Who is it geared toward? Is it geared toward nephrologists, physicians, nurse practitioners?

Dr. David Askenazi: Yeah. So since two years ago when we started this course, we've trained 350 providers and it's made up of a pediatric nephrologist, as well as intensivist and neonatologist and a few cardiac intensivists. It also is designed to help nurses and really kind of superstars, the ones that are educating their bedside and dialysis nurses back in their home institutions to provide them with the information they need to adequately help and train their staff.

Cori Cross, MD (Host): Got it. And how long is this class or course? What should people who sign up expect?

Dr. David Askenazi: Yeah. So, during this one and a half day course, we spend time with didactic lectures and then we spend time doing skills. And then on the following day, we do about a half day of simulations where we bring all that information and the skills that we learn on day one and apply them to real life case scenarios.

Cori Cross, MD (Host): And tell us, is this offered annually? Is it in Zoom? Is it in person?

Dr. David Askenazi: Yeah. Because of the pandemic, we had a transition from what we wanted to do, which was to be live to a virtual classroom. And now starting next week, we will offer this as a live training again. So Going forward, we recognize that there's value in having a virtual classroom, but we also recognize that having a live classroom also is very important. So we'll be offering both at different time points in the year.

Cori Cross, MD (Host): I was going to say, I think that's what we've all learned from COVID is that there are definitely some good things about Zoom and being able to do things virtually because you're able to bring people in from all over the state. No matter how far they are, they can still participate. But there's something about being in person that just cannot be replicated. So I hear you.

Dr. David Askenazi: Yeah, you're right. I mean, we've been able to help people from really all over the world, from Asia, from Africa, from Europe, from Israel, from Canada, people that would not likely be able to come to Birmingham for a day and a half. But at the same time, we do recognize and are excited to kind of have a more formal setting where we're meeting and kind of participating in a live course.

Cori Cross, MD (Host): And I'm assuming that if our listeners wanted to sign up, that they can find that information at childrens al.org.

Dr. David Askenazi: Yeah, that's right. And certainly, they're welcome to reach out to me through my email at This email address is being protected from spambots. You need JavaScript enabled to view it. as well.

Cori Cross, MD (Host): Thank you. In summary, what would you say sets Children's of Alabama apart from other hospitals in the region?

Dr. David Askenazi: Well, I think we are very fortunate to have a very strong commitment from our leadership and they're committed to the programs that are going to help children. So, Children's of Alabama is open to help others to advance the field, to educate ourselves and each other and people outside of our arena. And we provide the best clinical care available in the area.

Cori Cross, MD (Host): what would be some guidelines of parameters for when to refer to the specialists at Children's of Alabama in the Nephrology Department?

Dr. David Askenazi: Great. Thank you for that question. If you have a baby or a child who has significant kidney disease or really even in utero phase, we want to know about that children because we're seeing that the earlier we have ability to speak to the family, educate them about what may happen and the sooner we have to gain control of their physiology through dialysis and respiratory care, that their outcomes are better. So anybody who's needing, you know, critical care nephrology services that we've spoken about, those are patients that we would love to hear about sooner than later.

Cori Cross, MD (Host): Well, this has been so educational. I want to thank our listeners today and a special thank you to you, Dr. Askenazi. This has been just very informative discussion and we appreciate your time. You've been listening to Children's Hospital of Alabama Peds Cast. And I'm your host, Dr. Cori Cross. For more information or to refer patients to Children's of Alabama, visit childrensal.org.