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Tiffany Kaczorowski: Welcome to Inside Pediatrics, a podcast brought to you by Children's Hospital of Alabama in Birmingham. I'm Tiffany Kaczorowski. And we're here today with Dr. David Askenazi, who is a pediatric nephrologist at Children's of Alabama. Dr. Askenazi is a professor at UAB, the University of Alabama at Birmingham, and is Director of the Pediatric and Infant Center for Acute Nephrology at Children's. Welcome, Dr. Askenazi.

Dr. David Askenazi: Hi, thanks for having me.

Tiffany Kaczorowski: So we're talking about an amazing innovation here at Children's of Alabama that you and your team have worked on. Basically, it's transformed the way we take care of babies with kidney failure over the last several years.

Dr. David Askenazi: Correct.

Tiffany Kaczorowski: All right. So let's jump in and talk about this. First of all, what is the job of the kidneys? Let's just get basic for a minute.

Dr. David Askenazi: Yeah, so the kidneys have lots of roles. Most people understand that the kidney makes urine, but the kidney also has a role in filtering the waste products and holding onto the good stuff that the body needs to hold on to like blood cells and protein. The kidney also has a really important job in balancing all the electrolytes, in balancing the acid-base balance that we have in our bodies. It helps make red blood cells. It has an important role in making sure the bones are healthy and that many other aspects of our body, including things like vitamin D and other minerals.

Tiffany Kaczorowski: Okay. What's happening here with some of these babies that are born with either-- they might be born with congenital kidney disease or they may be born with kidney failure or shut down due to something else going?

Dr. David Askenazi: We've recently been taking care of more and more babies who are born without kidney function or very minimal kidney function. So that makes up a big group of kids that we really kind of transform how we think about them. And then at the same time, in the intensive care units, whether you're in adult unit or pediatric unit, or in this case in a neonatal unit, many times the kidneys shut down in context of shock or sepsis, whether it's because they have shock from their heart not functioning well or perhaps they have shock because of sepsis or dehydration. And so many times the kidneys can shut down.

Tiffany Kaczorowski: We used to go through this very arduous process when we were trying to dialyze these kids or to help them along. Can you explain a little bit about that?

Dr. David Askenazi: I've learned is that if the kidney is unable to do its job, then the patient really starts to be compromised. You can imagine that if you can't make urine, but you're still needing lots of fluids that are provided by your team for nutrition or blood products, then the patient would become more swollen and swollen and swollen, which then has really negative consequences to organ function.

Your lungs can't breathe as well. Your heart doesn't function as well. Your kidneys actually get swollen and then they have less chance to recover. Your liver gets swollen. Your intestines get swollen, and then you also have problems with, you know, electrolytes and problems with waste products. And so what we've learned in not only small children, but in other folks, is that coming in and really supporting the patient while they're critically ill has an important role in getting them to have a higher chance for survival.

Tiffany Kaczorowski: So there is a machine that was previously used in adults for fluid removal. And you guys have basically adapted it to be able to help dialyze these infants.

Dr. David Askenazi: That's right. So the challenge that we had, Tiffany, is that we were having to use these big machines that were really not made for babies, which would require us to take a lot of the blood out of the baby, sometimes 50% of their total blood volume or more to even get them started on the machine.

So we found that there was a smaller circuit that was about the third the size of our traditional circuits. And what we did is we took that machine that's designed to remove fluid and we've made a couple of adjustments so that not only can we remove fluid, but we can also clean waste products, balance electrolytes, make the acid-base balance how it needs to be.

Tiffany Kaczorowski: And I mean, this took a very large team effort, right? This wasn't just you, but you're talking about nurses and techs and biomed, I mean, this was a multidisciplinary group.

Dr. David Askenazi: That's right. We needed to make sure that nursing understood what was happening. We needed biotech to help us with some of the engineering of the machine to, you know, put a heater on it because the kids would get real cold if we didn't have a heater on it, and some other aspects. Certainly we needed buy-in from the neonatal group, because these are, you know, fragile babies that they're taken care of. And so we needed them to understand what was happening and really think through with us who was the right patient that could benefit from these types of support therapies.

Tiffany Kaczorowski: So give us a scenario of what used to happen, you know, before like 2013, when you were trying to help these kiddos and now, how much easier and safer it is.

Dr. David Askenazi: Yeah. So that's been really the biggest difference is really putting these patients on the machine without them having problems. It was not uncommon for us to have patients do very poorly when we put them on the big adult machines. We would have to have a neonatologist and a nephrologist there at the bedside. We would walk through some of the things we would potentially do and think about what we would do first if the patient stops breathing or our patients, you know, plummets their blood pressure. And we would open up the crash cart that we use to resuscitate people, to make sure that we have medicines available in case they went and started having a bad problem.

What we've learned over the last four or five years in using the smaller circuit is that that just doesn't happen anymore. We track our data very closely and we've been able to show that 97% of the time. We put them on the machine without having to do anything, without having to give him medicines or calciums or change their breathing machines or anything. They just go on very smoothly and it makes our life a lot easier. And as you could imagine, it gives a family a lot more comfort that this is going smoothly and that things are going okay. And it makes the babies happier.

Tiffany Kaczorowski: I would imagine, you know, before you probably had to have that difficult conversation with parents that they may not make it through this. But now, you know, even in two-pound babies, you're able to put them on this machine and really provide hope to that family that this is going to work. And what is the ultimate goal really when you're talking about a poor kidney function? You want the baby to grow, to be a certain size so that they can be available for a transplant eventually, right?

Dr. David Askenazi: That's right. So in babies who are born without sufficient kidney function to sustain them, we have changed our trajectory of the probability of survival for these patients. And because we have been able to do that and we have confidence in our program, our conversation with families have changed.

It's still a very difficult conversation because not all of them will survive. It's still a very difficult conversation because even if we get them to grow well and to go home, they're going to eventually need a kidney transplant, which can impact their life in many ways. But now, we now can provide them hope. They can have a child that can grow up and go to school and do well and graduate high school more than we could before.

Tiffany Kaczorowski: And we're not just keeping all this data and all of this research right here at Children's. Tell me about the papers that you guys have published and how we've involved some other centers around the country, trying to teach them about what we're doing here and why it's so successful.

Dr. David Askenazi: Yeah. So we published our experience in 2015, where we took our first 12 patients that we did here at Children's of Alabama, that we supported with therapy. And we described what we did. We described how we arrange the pumps and how we put this program together. And we started describing the patients that we were caring for and their outcomes and describing that, you know, weren't seeing these complications that we used to.

Since that time, couple of our friends across the country, the group in Seattle at University of Washington and the group of Cincinnati Children's Hospital, we've partnered together and through what we've helped them understand, they've been able to develop programs in their hospitals. And we've recently published our experience of 112 kids that have been cared for with these types of machines.

Now, in 2020, there's now over 10 or 12 hospitals across the country that have already started their programs or about to start their programs with, again, some of the protocols and procedures that we've developed here at Children's.

Tiffany Kaczorowski: And then also you're training some of those staff members too. You've had neonatal intensive course on kidney support or the NICs course. Tell us a little bit about that. Your nurse practitioner, Kara Short, has been very involved in that too.

Dr. David Askenazi: That's right. So the next commitment that we had for these babies was that it wasn't enough for us to really keep all that information for ourselves. And so what we've done is we've partnered with Children's of Alabama to develop a course where people from across the country and really across the world can learn about how to take care of small children and babies who need kidney support therapy in the form of dialysis.

This course has been very popular. We sell out, you know, in less than a week. We have both physicians and nurses join our course, and we are able to bring in all the specialists from here at Children's, as well as some external experts. And we bring our surgeons, we bring our dieticians, we bring our pharmacists, our physicians, our nurse practitioners, our nurses, and we've put together kind of a curriculum where we spend a day and a half learning about all different aspects of care for these babies.

We partnered with the simulation center here at Children's. So we do case scenarios where we put the team in an environment where we create a situation that maybe doesn't go so well and they have to figure out how to fix it. And it's been a really wonderful program and we plan to have four in 2021.

Tiffany Kaczorowski: And of course, they've been virtual in 2020. But eventually you'd like to bring people on campus.

Dr. David Askenazi: We look forward to bringing everybody to see our beautiful campus and our city and do this face to face.

Tiffany Kaczorowski: Okay. So what is next? I know we're talking about grants and NIH. Tell us about the exciting news that's on the horizon.

Dr. David Askenazi: Yeah. We're working with a company that's called CHS Solutions to really think about kind of the next generation machine so that we can, you know, take this machine to the next level, by using some of the things that we've learned about the ways that we can make it even better, that's specifically designed for babies and we've partnered with them and submitted an application that has had a great score through the NIH and we're anticipating that that will happen. With our partnership, we're going to work to make an even better machine.

In addition, there has recently been some great news that a machine that was designed in Italy called the Carpediem has recently been FDA approved to be used in the United States. So now, we have, you know, multiple new options for these babies to really give them the best chance for success and for them to live,

Tiffany Kaczorowski: To survive and thrive. Right. So thinking about the worldwide impact, you mentioned the Italian machine, but then also you've been contacted by other physicians, other programs throughout the world who need help.

Dr. David Askenazi: Yeah, that's right. Because one of the things that we've learned is that it's not just about having new technology, but it's really about gaining knowledge across the program. It's not just enough to have a machine that works, but you have to think about who's the right patient, when you're going to use it, how are you going to facilitate their ability to breathe and their lung function and the medications they get and the nutrition.

So it's very dynamic and there's lots of different parts to it. And we're working to kind of help everybody learns whether they have the Italian machine called the Carpediem or whether they're using the Aquadex machine that we've been using here or whether they don't have either and they're using some of the bigger machines that are available or different types of dialysis. We want to be able to help as many we can across the world.

Tiffany Kaczorowski: Sure and use your experience to help them moving forward.

Dr. David Askenazi: That's right.

Tiffany Kaczorowski: So if people would like some resources, I know we have our website. That's childrensal.org/pican, that's P-I-C-A-N for Pediatric and Infant Center for Acute Nephrology. All right, thanks so much, Dr. Askenazi, for joining us today.

Dr. David Askenazi: Thank you.

Tiffany Kaczorowski: Thanks for listening to Inside Pediatrics. More podcasts like this one can be found at childrensal.org/insidepediatrics.