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Photo of Dr. Kristen Pederson and Lilanie CruzFeature
in action

How a Winnipeg doctor and a group of
local donors teamed up to help reduce
the risk of acute kidney injury among
children in hospital
Dr. Kristen Pederson (left) helped develop the SPOT AKI program with Lilanie Cruz.
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By Susie Strachan
Photography by Marianne Helm
Mar/Apr 2019

As a pediatric nephrologist, Dr. Kristen Pederson understands the importance of patient safety, especially when it comes to caring for children.

So when Pederson took in a presentation by an American physician about a program that improves care by reducing the risk of kidney injury among kids in hospital, she was sold.

"I thought we could do this at our Children's Hospital," she says.

And so, Pederson returned to Winnipeg determined to launch a program similar to the Nephrotoxic Injury Negated by Just-in-time Action (NINJA) program started by Dr. Stu Goldstein at the Cincinnati Children's Hospital Medical Centre.

The idea was simple enough.

Kids who have serious illnesses such as blood or urinary tract infections are often treated with various medications, including antibiotics and pain relievers. Individual doses of these medications are usually safe. But administering a combination of these drugs over a period of time may increase the risk of kidney injury. By having the hospital pharmacy screen which medications are being given to children and for how long, it is possible to identify a child who may be at risk of injury and notify their care team of the potential danger.

There was just one tiny problem, says Pederson.

Photo of Dr. Shyamala Dakshinamurti
Dr. Shyamala Dakshinamurti provides an update on a project funded by the Innovators last year.

"I came back from that conference, and got into discussions with our pharmacy team here at children's, but quickly realized we didn't have anyone who had the time to develop a program."

Nonetheless, Pederson remained committed to the concept.

She started discussing the idea with another group in the hospital, the Anti-Microbial Stewardship Program. That program had run a pilot, but didn't have ongoing funding. Together, they started looking for a new source of cash.

And that's when the story took a fortuitous twist.

At about the same time that Pederson and her colleagues were trying to find funding for the kidney monitoring program, another group of people at the Children's Hospital Foundation were developing an idea to help fund projects to improve care for children.

That group was led by Carmyn Aleshka, a member of the Children's Hospital Foundation Board, and included Nicole LaTourelle, who at the time was a major gifts officer with the foundation.

Aleshka had learned of a program to help fund various projects at the Hospital for Sick Kids in Toronto that was based on Dragons' Den, a television show in which aspiring entrepreneurs go before a panel of venture capitalists to seek investments for their business.

The concept appealed to Aleshka, who believed it would entice people to participate.

"Winnipeggers are passionate and looking for unique ways to give back," she says. "There are many people with great ideas that just need a platform to share them."

After making a few modifications, the Winnipeg version of the program was launched in 2017 as "Innovators." Under the program, a group of people commit to donating a set sum of money to a project. Health-care providers and researchers are then invited to appear before the group to pitch their proposals for funding. Following the vetting process, the Innovators select a winner.

In the first year, Aleshka and LaTourelle managed to recruit 10 donors, mostly young professionals and business people, who committed $3,000 each for two years, for a total of $60,000.

Researchers and clinicians from Children's Hospital and the Children's Hospital Research Institute of Manitoba were then invited to make presentations before the donors and give them a tour of their office or lab.

"The part they [the donors] find exciting is the ability to go into depth when they learn about the projects," says LaTourelle, adding that the vetting process can take several months.

Pederson says she approached pediatrician Dr. Aaron Chui and asked him to become involved in the project. "He put together a PowerPoint presentation, and took the lead in making the presentation to the Innovators," says Pederson.

As it turned out, her proposal won, and the project was awarded $25,000.

With funding in place, Pederson and her colleagues started developing the kidney screening program, now known as SPOT AKI (Surveillance of Patients On nephroToxic medications for Acute Kidney Injury).

Photo of Dr. Melanie Morris
Dr. Melanie Morris pitches a proposal to accelerate cultural safety for Indigenous families at the Children's Hospital in collaboration with Indigenous elders during a meeting of the Innovators. The project is now being funded by the Children's Hospital Foundation of Manitoba.

The first order of business was assigning pharmacist Lilanie Cruz to work on the project in 2018.

Drawing from the nephrotoxic drug list for NINJA used at Cincinnati children's and about a dozen other pediatric centres across the United States, she created a list of 50 medications that can cause damage to the kidneys, as well as screening and monitoring tools, which were then implemented in May of the same year.

The Children's Hospital pharmacy started monitoring pediatric patients in the general medical wards, surgical wards, and more recently, in the intensive care wards, via each patient's electronic medical record, which includes the medications they are taking.

"Every morning, the pharmacy flags patients who are on medications considered to be nephrotoxic [hazardous to kidneys], and specific combinations that can put patients at higher risk for kidney injury," says Cruz, noting that SPOT AKI is now managed by the Children's Hospital as part of its regular pharmacy program.

Once patients have been identified, the monitoring phase of the program kicks in. Health-care teams monitor the patient's kidney function for five days, or for the duration of the patient being on a particular medication.

Photo of Carmyn Aleshka and Nicole LaTourelle
Carmyn Aleshka (left) and Nicole LaTourelle worked to create the Innovators program.

"Most children who are in hospital are already getting blood work done, so we make use of that to look at their creatinine levels," says Cruz, adding that it is a good measure of kidney function.

Historically, acute kidney injuries have been considered "transient" in nature, meaning that a child who suffered one would eventually recover. But health experts aren't so sure about this anymore, says Pederson. "There is more and more information in the literature saying that there is a risk of long-term kidney dysfunction if patients have had [an acute kidney injury]."

Pederson says the program flags about 40 children a month who are potentially at risk for acute kidney injury, a number that often includes those who are receiving antibiotics like vancomycin or drugs used to treat cancer. Of those flagged, Pederson says about two or three will turn out to have a problem that needs to be monitored.

The potential risk of kidney damage from medication underscores the challenges in treating sick children.

"If you have an infection that we don't treat appropriately, there are going to be lots of problems related to that," says Pederson. "So when we are doing this, it is all a balancing act: Is this the right treatment to give in the circumstances, or is there something else that could be given?"

While Pederson doesn't have any numbers for children who would have developed an acute kidney injury prior to the Spot AKI program's launch, she reiterates that the point of the program is to change behaviour among the health-care teams at the hospital.

"We're seeing that behavioural change. They [the health teams] are not putting them [children] on the medications in the first place, or switching them off those combinations, to reduce the risk," she says. "People are much more conscious about what they're doing."

The Spot AKI program has also developed information kits for patients' families to keep them informed about potential issues after discharge from hospital.

Pederson is grateful for the support the Innovators gave her.

"We would not have done what we did without the Innovators," she says.

The Innovators received 10 applications in the first year of the program. That increased to six basic science and six clinical applications last year, when Dr. Shyamala Dakshinamurti's project on treating blue babies - babies who are unable to get oxygen from their breaths after birth - received funding.

The search for projects to support continues this year, with seven basic science and four clinical applicants seeking funding for various projects, says LaTourelle.

"It's a lovely way for people to become more involved in funding the future of health care," she says.

Susie Strachan is a communications specialist with the Winnipeg Regional Health Authority.

To learn more about the Innovators program, click here.