Fluid overload (FO) is a common and modifiable risk factor in critically ill neonates. FO is associated with prolonged mechanical ventilation, multi-organ dysfunction, and increased mortality. Despite substantial observational evidence and consensus-driven guidelines, standardized fluid management strategies are inconsistently applied across neonatal intensive care units (NICUs). A critical knowledge gap exists between evidence and practice. Early single-center studies suggest bundle feasibility and effectiveness but are limited in scope and generalizability. Incorporating implementation science frameworks and electronic health record (EHR) data pipeline integration can strengthen adoption, fidelity, adaptation, and sustainability of these interventions across diverse NICU settings. Pragmatic, multicenter studies that utilize EHR-based approaches are needed to help determine how to best implement functional fluid management strategies that improve patient-centered outcomes. Such bundles integrate evidence-based interventions that collectively identify high-risk patients, track, prevent, and treat FO. A structured pathway is needed to enhance scalability and uptake, systematically address barriers, tailor strategies to local contexts, and engage interdisciplinary teams. Bridging the gap between evidence and implementation through collaborative, pragmatic research has the potential to meaningfully reduce FO-related morbidity and mortality and advance neonatal critical care.

The interactions of pulmonary and renal physiology that underlie acute lung injury (ALI) and acute kidney injury (AKI) have been recognized for nearly a century. The understanding of lung-kidney crosstalk has evolved and is recognized as an important factor in patient management and outcomes. We aim to describe the association between fluid accumulation (FA) and ALI with outcomes of critically ill children and young adults requiring continuous renal replacement therapy (CRRT). Planned secondary analysis using data from the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK). ALI severity was defined using the Berlin oxygenation criteria. Fluid accumulation was categorized as ≤ 10

Acute kidney injury (AKI) is a common and serious complication among infants admitted to neonatal intensive care units, affecting up to one-third of hospitalized neonates and contributing to significant short- and long-term morbidity and mortality. The unique physiology of the developing kidney, coupled with diverse neonatal comorbidities, creates both susceptibility to injury and challenges in timely diagnosis. Recent multicenter epidemiologic studies have clarified the incidence, risk factors, and outcomes of neonatal AKI, emphasizing the importance of standardized definitions and early recognition. Advances in monitoring strategies—including near-infrared spectroscopy and early biomarkers of renal stress—offer opportunities for earlier detection, while heightened attention to fluid balance, nephrotoxic stewardship, and targeted pharmacologic interventions support primary and secondary prevention. For infants requiring kidney support, technological innovation has expanded the feasibility and safety of renal replacement therapies, even in the smallest patients. Emerging evidence also highlights strong associations between neonatal AKI, prematurity, and long-term kidney health, prompting new consensus recommendations for risk-stratified outpatient surveillance. This review synthesizes current knowledge and recent advances in neonatal AKI, underscoring the need for proactive, multidisciplinary approaches to preserve kidney health from the earliest stages of life into child- and adulthood.

Biological sex plays a crucial role in the pathophysiology of morbidities related to preterm birth. Studies specifically investigating the role of biological sex in neonatal kidney disease are lacking. This study aimed to determine the association between biological sex and kidney outcomes in preterm infants. We hypothesized that male infants would be more likely to have poor kidney outcomes, including acute kidney injury (AKI), hypertension and chronic kidney disease. Given data on the relationship between sex, AKI and lung disease, we also evaluated lung disease as a secondary outcome. Retrospective analysis of the Preterm Erythropoietin Neuroprotection Trial data. For adjusted models, we used covariates associated with adverse outcomes a priori (gestational age, SGA status) and a lasso regression. AKI was defined using creatinine only neonatal modified KDIGO criteria and bronchopulmonary dysplasia (BPD) by Neonatal Research Network criteria. Of the 923 infants included, 479 (51.8

Acute kidney injury (AKI) occurs in approximately one-third of babies treated in a neonatal intensive care unit. The establishment of consensus standardized definitions has improved clinical recognition and research into neonatal AKI. Neonatal AKI is now recognized for its independent associations with increased morbidity and neonatal intensive care unit mortality. Current definitions use increasing serum creatinine and/or decreasing urine output to diagnose AKI; however, these biomarkers reflect organ dysfunction long after injury has begun. Furthermore, they are impractical and insensitive metrics of kidney function in neonates, particularly in preterm neonates or the first weeks of life, when the risk is greatest. Given the lack of symptoms and limitations of current criteria, risk recognition and stratification are imperative to focus AKI stewardship. Urinary biomarkers (such as neutrophil gelatinase-associated lipocalin), which have demonstrated some challenges in adult studies, appear more promising in their capacity to reliably detect early pediatric and neonatal AKI. Even without novel biomarkers, numerous multidisciplinary AKI education and stewardship programs have demonstrated capacity to substantially reduce risk and incidence of AKI, particularly those focusing on the risk represented by nephrotoxic medication exposure. This narrative review reflects on the evolution of neonatal AKI definitions and how the improved epidemiologic understanding of the condition has been leveraged to drive quality improvement initiatives, development of risk stratification tools, improved diagnostics, and potential preventative therapies. Future integration of this burgeoning body of collaborative research will expedite accurate neonatal AKI diagnosis, while scaffolding kidney health surveillance into follow-up for the improvement of short- and long-term outcomes for these most vulnerable patients.

The prospective pediatric Continuous Renal Replacement Therapy (ppCRRT) registry identified the degree of fluid accumulation (FA) at continuous kidney replacement therapy (CKRT) initiation as a predictor of adverse outcomes in children. These predate major advancements in CKRT technology and fluid stewardship. We aimed to describe the epidemiology of FA at CKRT initiation and associated outcomes in a contemporary paediatric cohort. Secondary analysis of Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK), a retrospective, multicenter study (35 centers, 9 countries) of patients ≤ 25 years treated with CKRT from 2015 to 2021. Primary Outcome: survival to ICU discharge. Secondary outcomes: ventilator-free and ICU-free days. A total of 1027 patients were included in this analysis. Survival to ICU discharge was 64.5

Acute kidney injury (AKI) and fluid accumulation (FA) are common during extracorporeal membrane oxygenation (ECMO) support and are associated with increased morbidity and mortality. Despite their clinical importance, contemporary data describing the epidemiology and management of these conditions remain limited. Founded in 2021, the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) seeks to improve outcomes for children requiring extracorporeal organ support. This report describes the design of the WE-ROCK ECMO study, an international, multicenter, retrospective cohort of patients supported with ECMO from 2018 to 2022. We include 1,264 children aged 0-25 years treated at 43 centers across 10 countries. Collected data include demographics, clinical characteristics before ECMO initiation, and detailed information from the first 14 days of ECMO support, including fluid intake and output, diuretic use, and continuous renal replacement therapy (CRRT) practices. Primary outcomes include major adverse kidney events at 90 days (mortality, dialysis dependence, and persistent kidney dysfunction) as well as functional status outcomes. The WE-ROCK ECMO study represents the largest international investigation of kidney and fluid-related variables in pediatric ECMO, providing critical insight into practice variation and the relationships among AKI, FA, CRRT, and clinical outcomes, and establishing a foundation for future interventional trials.

Over the past decade, advances in neonatal nephrology have expanded the ability to provide kidney replacement therapy to increasingly smaller and more medically complex infants. The development and adaptation of devices designed specifically for infants have facilitated safer delivery of continuous kidney replacement therapy (CKRT), with reduced extracorporeal circuit volumes, smaller filters, lower blood flow requirements, and improved precision of fluid balance. As a result, CKRT use in critically ill neonates continues to increase. Indications for neonatal CKRT include acute kidney injury and fluid overload, as in older children and adults, but also extend to congenital kidney failure and inborn errors of metabolism. The neonatal population presents unique challenges related to vascular access and the need to provide adequate nutrition to support growth. A thorough understanding of solute clearance mechanisms, dosing strategies, device selection, anticoagulation options, and complication management is essential to optimize outcomes. This case-based educational review summarizes current principles, technologies, and available evidence guiding neonatal CKRT practice, with special considerations for neonates receiving prolonged course of CKRT for kidney failure. A higher resolution version of the Graphical abstract is available as Supplementary information.

Preterm birth increases the risk of chronic kidney disease (CKD) and hypertension later in life. To address these risks, the National Institutes of Health sponsored the Neonatal Kidney Health Consensus Workshop in February 2024, where a multidisciplinary group of experts reviewed current evidence, identified knowledge gaps, and developed consensus-based recommendations for kidney health follow-up in infants born <34 weeks. Key recommendations include a kidney evaluation before NICU discharge and at two years of age, with comprehensive kidney assessment for those at highest risk (birth <28 weeks, with acute kidney injury, intrauterine growth restriction, or small for gestational age). Cohesive, evidence-based parental education at multiple timepoints was emphasized to support early CKD detection and long-term management. This consensus provides a framework to optimize follow up and highlights research priorities aimed at improving risk stratification, early diagnosis, and interventions in individuals born preterm.

BACKGROUND AND OBJECTIVES:Up to 50% of children with urinary tract infections (UTIs) have vesicoureteral reflux (VUR). Severe VUR can lead to reflux nephropathy (RN) and end-stage kidney disease (ESKD). In 2011, the American Academy of Pediatrics UTI guidelines suggested selective voiding cystourethrogram (VCUG), departing from previous recommendations to obtain VCUG after all febrile UTIs in children aged less than 2 years. It is unknown whether the subsequent decrease in VCUG has led to increased preventable kidney damage. This study's objective is to evaluate recent trends in the US incidence of pediatric ESKD owing to RN. METHODS:This retrospective cohort study used the US Renal Data System, a database that includes all US patients with ESKD. We identified patients aged 24 years and younger with ESKD attributed to RN from 2002 to 2021 as well as diagnoses that may overlap with RN. We used the US Census Bureau data to ascertain population incidence and a Poisson regression model for average annual percentage change (AAPC). RESULTS:There were 46 000 cases of ESKD. The all-cause incidence of ESKD decreased (AAPC of -1.0%; 95% CI, -1.4% to -0.7%) as did the incidence of ESKD owing to RN (AAPC of -4.4%; 95% CI, -5.8% to -3.0%). The incidence of ESKD from obstructive uropathies and renal dysplasia also decreased; however, the incidence of other nonspecific congenital anomalies of the kidney and urinary tract increased. CONCLUSIONS:The declining use of VCUG over the last decade has not resulted in a measurable worsening of ESKD related to identified RN at the population level. Continued surveillance over time and investigations into shorter-term kidney outcomes are needed.

Acute kidney injury is common among neonates with critical cardiac disease. Risk factors and associations with kidney‐related outcomes are heterogeneous and distinct from other neonates. As survival of children with critical cardiac disease increases to adulthood, the burden of chronic kidney disease is increasing. Thirty percent to 50% of adults with congenital heart disease have impaired kidney function, even in the absence of prior kidney injury episodes. This may be related to the current standardized acute kidney injury criteria, which may not fully capture clinically meaningful kidney injury and long‐term kidney health risks. An improved understanding of which neonates with critical cardiac disease should undergo kidney health follow‐up is imperative. During the National Institutes of Health–supported Neonatal Kidney Health Consensus Workshop to Address Kidney Health meeting conducted in February 2024, a panel of 51 neonatal nephrology experts focused on at‐risk groups: (1) preterm infants, (2) critically ill infants with acute kidney injury, and (3) infants with critical cardiac disease. The critical cardiac disease subgroup, comprising multidisciplinary experts, used a modified Delphi process to achieve consensus on recommendations for kidney health follow‐up. In this report, we review available data on kidney health follow‐up in critical cardiac disease and summarize the 2 consensus‐based recommendations. We introduce novel diagnostic and risk‐stratification tools for acute kidney injury diagnosis in neonates with cardiac disease to guide follow‐up recommendations. Finally, we identify important knowledge gaps, representing areas of focus for future research. These should be prioritized to understand and improve long‐term kidney health in critical cardiac disease.

Introduction:Fluid overload, the pathologic state of positive fluid balance, is common in the pediatric intensive care unit (PICU) and is independently associated with poor outcomes. Quality improvement-based processes to measure and assess fluid balance in critically ill children are lacking. Methods:The primary aim was to develop and implement a fluid management strategy that includes the standardized measurement and assessment of fluid balance, which is adhered to in at least 50% of all PICU patients. The 4 components of the strategy include (1) creating a fluid balance dashboard that tracks percent cumulative fluid balance over time, (2) documentation of daily weights, (3) fluid balance reporting and discussion incorporated into standardized rounds, and (4) active total intravenous (IV) fluid order. Results:We reviewed 280 patient encounters between May 2023 and April 2024 and achieved the primary aim of at least 50% compliance with the fluid management strategy and maintained this success over time. Achieving the primary aim coincides with implementing daily weights and total IV fluid orders into PICU admission order sets. Conclusions:In this quality improvement project, we develop, implement, and maintain compliance with a fluid management strategy. Future work will involve daily utilization of the fluid balance dashboard and monitoring compliance with total IV fluid orders. Implementing a quality improvement-based fluid management strategy may lead to improved awareness of the fluid status of patients and the prescription of fluid therapy to mitigate the harmful effects of fluid overload.

Acute kidney injury (AKI) occurs commonly in critically ill children. The impact of AKI on pediatric growth outcomes has been sparsely described. To compare growth in children with a history of AKI compared to those without AKI. We hypothesized that children with AKI would have worse growth compared to those without AKI. A convenience sample of existing prospective and retrospective cohorts of children with AKI who had already collected or were able to collect data on growth parameters before and after an episode of AKI. There are < 5 studies in the published literature on growth in children with AKI. These investigators were contacted, and additional studies were added by contacting primary investigators of studies of childhood AKI in which data on growth parameters was able to be collected. Children from existing cohorts evaluating AKI (exposure) during childhood. Each included cohort had previously received local IRB approval per institutional guidelines. As our study was a meta-analysis and only used cohort-level data, no IRB approval was required for this report. Growth parameters (length and weight z-scores) before and after an episode of AKI were compared using a meta-means analysis. MOOSE guidelines were used. Data were pooled using a random-effects model. Hedges g was calculated, and Higgins I2 statistic was used to define variability due to between-cohort heterogeneity. We included 3,586 children from 17 existing cohorts of AKI in various populations, including infants, children with cardiac disease, solid organ transplant and critically ill children without cardiac disease with follow-up from 12 months to 11 years after AKI. At most distant follow-up, those with AKI had lower length z-score than those without AKI (mean difference -0.37 [95

There are limited studies evaluating hyperglycemia in children treated with continuous kidney replacement therapy (CKRT). We evaluated the association of hyperglycemia with kidney outcomes in critically ill children treated with CKRT for acute kidney injury (AKI) or fluid overload. Secondary analysis of the multicenter retrospective observational Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease (WE-ROCK) study (34 centers, 9 countries). Primary exposure was hyperglycemia on days 0–7 of CKRT (average serum glucose of ≥ 150 mg/dL). Average serum glucose < 150 mg/dL was defined as euglycemic. We stratified the hyperglycemic group with cut-offs ≥ 180 mg/dL, ≥ 200 mg/dL, or ≥ 250 mg/dL. The primary outcome was MAKE-90 (death by 90 days or persistent kidney dysfunction [> 125

BACKGROUND AND HYPOTHESIS:Mortality rates of children supported with continuous renal replacement therapy (CRRT) have improved, yet morbidity remains high. We aimed to evaluate the functional outcomes of children receiving CRRT using Functional Status Scale (FSS). We hypothesized that children receiving CRRT will have worse FSS compared with their baseline and acquire new morbidity at hospital discharge and 6 and 12 months post-discharge, and that lack of renal recovery will contribute to worsening functional status. METHODS:This is a retrospective chart review from The Worldwide Exploration of Renal Replacement Outcomes Collaborate in Kidney Disease (WE-ROCK), an international multi-center registry. Twenty-eight centers across five countries participated in this analysis. Children from birth to 25 years, on CRRT for acute kidney injury (AKI) or fluid overload, were included. Patients with underlying kidney disease, on extracorporeal membrane oxygenation and non-survivors were excluded. FSS was collected at discharge (n = 527), 6 months (n = 387) and 12 months post-discharge (n = 344). The primary outcome was FSS at discharge and 6 months. Secondary outcomes included: new morbidity at discharge and 6 months; FSS at 12 months; and the impact of renal recovery on functional outcomes. RESULTS:A total of 527 patients had median FSS of 7 (6, 90) at hospital discharge. Thirty-nine percent (n = 204) had worse FSS. Eighteen percent (95/527) acquired a new morbidity at discharge. Predictors of FSS at discharge were baseline FSS {odds ratio (OR) 1.30 [95% confidence interval (CI) 1.11-1.52]}, weight [OR 0.99 (95% CI 0.98-0.9997)], comorbidities [OR 1.88 (95% CI 1.16-3.04)], mechanical ventilation [OR 1.72 (95% CI 1.04-2.85)] and sepsis on intensive care unit admission [OR 1.46 (95% CI 1.01-2.21)]. A total of 387 patients had median FSS score of 6 (6, 8) at 6 months. Ten percent (n = 39/387) acquired new morbidity at 6 months. The significant predictors of FSS at 6 months were FSS at discharge [OR 2.36 (95% CI 1.95-2.84)] and presence of comorbidities [OR 1.77 (95% CI 1.03-3.06)]. CONCLUSION:This is the first large, multi-center study evaluating functional outcomes of children on CRRT. Persistent morbidity following discharge emphasizes the importance of comprehensive identification and multidisciplinary follow-up to optimize patient outcomes.

IMPACT:The consensus neonatal modified KDIGO definition has been crucial in expanding our understanding of the epidemiology and impact of neonatal AKI. A consensus definition of neonatal AKI remains essential to continuing to advance the field. This manuscript highlights a historical perspective, the strengths, and limitations of the current neonatal AKI definition, and reflects on the optimal characteristics and utility of neonatal AKI definitions. The future of neonatal AKI lies with improved diagnostic precision and consistently incorporating neonatal risk factors into risk stratification incorporating and the deployment of novel biomarkers to aid in earlier identification and improve outcomes in neonatal AKI.

Severe malaria (SM) remains a leading cause of child mortality and an important global contributor to acute kidney injury (AKI), which can progress to chronic kidney disease (CKD) in some survivors. Notably, 80