Quality improvement in neonatal critical care nephrology and CKRT programs

Research in low-volume, high-complexity populations presents inherent challenges, particularly in pediatrics and neonatology, where patients frequently push physiological and technological boundaries. In these settings, traditional research paradigms are often limited, making quality improvement (QI) methodologies essential to advancing care. Nowhere is this more evident than in neonatal critical care nephrology. Over the past two decades, collaborative, multidisciplinary QI efforts have driven meaningful progress in the identification, risk stratification, and management of acute kidney injury (AKI) in neonates. The development of neonatal-specific AKI definitions, proactive surveillance strategies, nephrotoxin stewardship programs, and consensus-driven approaches to post–neonatal intensive care unit (NICU) discharge follow-up have improved recognition, standardized communication, and reduced practice variability across diverse care settings. As AKI recognition improves, increasing numbers of neonates are identified as candidates for kidney replacement therapy (KRT), exposing parallel gaps in quality metrics and standardized approaches to neonatal continuous kidney replacement therapy (CKRT). Much of current CKRT practice remains extrapolated from adult and older pediatric data, despite important physiological and technical differences in neonates and infants. Recent multicenter registries, dedicated neonatal dialysis platforms, and learning collaboratives have begun to address this gap, demonstrating improved feasibility and survival while highlighting persistent variability in prescription, delivery, and outcomes. This review synthesizes QI-driven advances across neonatal AKI and CKRT, emphasizing the importance of interdisciplinary collaboration, shared data infrastructure, and neonatal-specific quality indicators to advance equitable, standardized kidney care for vulnerable neonatal populations. Graphical Abstract A higher resolution version of the Graphical Abstract is available as Supplementary information.