Abstract Acute kidney injury (AKI) occurs in around one third of babies treated in a neonatal intensive care unit (NICU). 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 NICU mortality. Current definitions utilize 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 where 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 lipocalcin), 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 epidemiological 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, whilst scaffolding kidney health surveillance into follow-up for the improvement of short- and long-term outcomes for these most vulnerable patients.
Forbes et al. (2026) studied this question.