A Pathophysiological Approach for Early Detection and Prevention of AKI in the NICU

Objective: To summarize contemporary evidence on the definition, epidemiology, risk factors, and prevention of acute kidney injury (AKI) in critically ill and preterm infants in the NICU, and to highlight prevention-focused strategies to improve outcomes. Study design: Narrative review of the current literature evaluating the burden of AKI, diagnostic criteria, modifiable and non-modifiable risk factors, and preventive interventions in neonatal intensive care settings. Results: AKI is common in critically ill and preterm infants and is associated with increased mortality, prolonged hospitalization, neurodevelopmental impairment, and progression to chronic kidney disease. Modified KDIGO criteria have improved diagnostic consistency and revealed particularly high AKI prevalence in extremely low birth weight infants. Key modifiable risk factors include hemodynamic instability, patent ductus arteriosus, nephrotoxic drug exposure, fluid overload, and sepsis, while preventive strategies span optimized antenatal management, therapeutic hypothermia for hypoxic ischemic encephalopathy, careful postnatal hemodynamic and fluid management, nephrotoxic drug stewardship, early infection control, individualized ductus arteriosus therapy, and potential use of caffeine, alongside emerging urinary biomarkers for earlier detection. Discussion: Given limited therapeutic options once AKI occurs, prevention through structured surveillance, timely identification of high-risk states, and rigorous implementation of kidney protective practices is essential. Integrating quality improvement, protocolized care pathways, and educational outreach within NICUs offers the greatest promise for improving short and long-term outcomes in infants with AKI.