Inside Pediatrics Spring 2025

UROLOGY

Improving pediatric renal injury care

A collaborative developed by urologists at Children’s and UAB is changing the way physicians manage renal injuries in children. The Trauma Renal Injury Collaborative in Kids (TRICK), developed by Carmen Tong, D.O. , and a team of experts, including David Kitchens, M.D. , consists of five Level-1 tertiary pediatric trauma centers across the United States. It’s aim is to standardize both evaluation and management protocols for pediatric patients with high-grade renal trauma. Tong, Kitchens and the other experts who developed TRICK did so because the prevailing guidelines for the evaluation and management of renal injury focused on adult patients. But because children are anatomically different from adults, they can’t be viewed as little adults. The collaboration has led to some groundbreaking findings. One pivotal discovery revealed that children with gross hematuria (visible blood in urine) following trauma benefit from more extensive radiologic evaluation, similar to adult patients. This novel discovery challenges the prevailing assumption that pediatric and adult renal trauma require vastly different diagnostic approaches. This finding also helps clinicians better recognize pediatric patients at increased risk for surgical intervention who would, by turn, benefit from a more thorough radiographic evaluation. By identifying these children early, healthcare providers can prioritize further radiographic testing. However, for stable, asymptomatic

patients, repeat imaging can often be avoided, reducing both patient risk resulting from radiation and overall health care costs. For parents and guardians, TRICK’s work highlights the importance of vigilance following blunt abdominal trauma. Visible blood in a child’s urine or significant trauma to the side of the body—common in sports injuries or falls—warrants a rapid medical evaluation to rule out renal injury. Educating families about these warning signs promotes early intervention and better outcomes. TRICK’s ongoing efforts aim to standardize imaging protocols, particularly for children with gross hematuria, as a predictor of surgical intervention. Tong predicts that future studies likely will explore additional predictors and refine management strategies, further enhancing pediatric trauma care. Through collaboration and innovation, TRICK continues to make strides in ensuring that children with renal trauma receive the best possible care, tailored to their unique needs.

NEPHROLOGY

Studying outcomes in continuous renal replacement therapy With most research that evaluates a vital form

Children’s serves as a hub for CRRT care for a high volume of pediatric kidney patients. In the decade-plus between 2013 and mid-2024, 602 patients were treated with CRRT at Children’s. Children’s has also long stood out among pediatric hospitals by

offering CRRT to the tiniest infants using modified Aquadex equipment. Aquadex had initially been developed for adult patients with heart failure to remove fluid from the heart, but Children’s nephrologist David Askenazi, M.D. , seized on the technology’s small filters to adapt it for use in neonates. Now, other centers offer neonatal dialysis with modified Aquadex as well. The WE ROCK effort has generated at least 10 published manuscripts so far by study collaborators, with the promise

of dialysis care in children called continuous renal replacement therapy (CRRT) lacking in size and scope—hampering efforts to glean practice-changing insights—an international effort in which Children’s of Alabama is integral is expected to fill the gap. Dubbed WE ROCK (Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease), the retrospective study involves a total of nearly 1,000 children treated at 32 centers in seven countries between 2018 and 2021. Representing the largest international

registry of children receiving CRRT for acute kidney injury or fluid overload—which can result from a variety of factors, including congenital anomalies, nephrotoxins and others—WE ROCK aims to evaluate the association of factors such as fluid balance and timing of CRRT initiation and duration with patient outcomes. “It’s so hard to get data of this type, so this study is very significant,” said Tennille Webb, M.D. , a pediatric nephrologist at Children’s of Alabama.

of many more to come, Webb says. By looking at outcomes such as major adverse kidney events 90 days after CRRT (including mortality, dialysis dependence and persistent kidney dysfunction) as well as functional outcomes, investigators should be able to derive data that could change pediatric nephrology practice. “Having that data from 32 centers, we can see what they’re doing, model it and make some improvements in these patients,” Webb said.

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Inside Pediatrics | Children’s of Alabama