External validation of the modified sepsis renal angina index for prediction of severe acute kidney injury in children with septic shock

Natalja L Stanski; Rajit K Basu; Natalie Z Cvijanovich; Julie C Fitzgerald; Michael T Bigham; Parag N Jain; Adam J Schwarz; Riad Lutfi; Neal J Thomas; Torrey Baines; Bereketeab Haileselassie; Scott L Weiss; Mihir R Atreya; Andrew J Lautz; Basilia Zingarelli; Stephen W Standage; Jennifer Kaplan; Lakhmir S Chawla; Stuart L Goldstein

doi:10.1186/s13054-023-04746-6

External validation of the modified sepsis renal angina index for prediction of severe acute kidney injury in children with septic shock

Crit Care. 2023 Nov 28;27(1):463. doi: 10.1186/s13054-023-04746-6.

Authors

Natalja L Stanski^{1

2}, Rajit K Basu³, Natalie Z Cvijanovich⁴, Julie C Fitzgerald⁵, Michael T Bigham⁶, Parag N Jain⁷, Adam J Schwarz⁸, Riad Lutfi⁹, Neal J Thomas¹⁰, Torrey Baines¹¹, Bereketeab Haileselassie¹², Scott L Weiss¹³, Mihir R Atreya^{14

15}, Andrew J Lautz^{14

15}, Basilia Zingarelli^{14

15}, Stephen W Standage^{14

15}, Jennifer Kaplan^{14

15}, Lakhmir S Chawla¹⁶, Stuart L Goldstein^{15

17}

Affiliations

¹ Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA. natalja.stanski@cchmc.org.
² Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA. natalja.stanski@cchmc.org.
³ Division of Critical Care Medicine, Ann & Robert Lurie Children's Hospital of Chicago, Northwestern University, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
⁴ UCSF Benioff Children's Hospital Oakland, 747 52nd Ave, Oakland, CA, 94609, USA.
⁵ Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA.
⁶ Akron Children's Hospital, 214 W Bowery St., Akron, OH, 44308, USA.
⁷ Texas Children's Hospital and Baylor College of Medicine, 6621 Fannin Street, Houston, TX, 77030, USA.
⁸ Children's Hospital of Orange County, 1201 W La Veta Ave, Orange, CA, 92868, USA.
⁹ Riley Hospital for Children, 705 Riley Hospital Drive, Indianapolis, IN, 46202, USA.
¹⁰ Penn State Health Children's Hospital, 600 University Drive, Hershey, PA, 17033, USA.
¹¹ University of Florida Health Shands Children's Hospital, 1600 South West Archer Rd, Gainesville, FL, 32608, USA.
¹² Lucile Packard Children's Hospital Stanford, 725 Welch Rd, Palo Alto, CA, 94304, USA.
¹³ Nemours Children's Health, 1600 Rockland Rd, Wilmington, DE, 19803, USA.
¹⁴ Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave MLC 2005, Cincinnati, OH, 45229, USA.
¹⁵ Department of Pediatrics, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH, 45267, USA.
¹⁶ Department of Medicine, Veterans Affairs Medical Center San Diego, 3350 La Jolla Village Drive, San Diego, CA, 92161, USA.
¹⁷ Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.

Abstract

Background: Acute kidney injury (AKI) occurs commonly in pediatric septic shock and increases morbidity and mortality. Early identification of high-risk patients can facilitate targeted intervention to improve outcomes. We previously modified the renal angina index (RAI), a validated AKI prediction tool, to improve specificity in this population (sRAI). Here, we prospectively assess sRAI performance in a separate cohort.

Methods: A secondary analysis of a prospective, multicenter, observational study of children with septic shock admitted to the pediatric intensive care unit from 1/2019 to 12/2022. The primary outcome was severe AKI (≥ KDIGO Stage 2) on Day 3 (D3 severe AKI), and we compared predictive performance of the sRAI (calculated on Day 1) to the original RAI and serum creatinine elevation above baseline (D1 SCr > Baseline +). Original renal angina fulfillment (RAI +) was defined as RAI ≥ 8; sepsis renal angina fulfillment (sRAI +) was defined as RAI ≥ 20 or RAI 8 to < 20 with platelets < 150 × 10³/µL.

Results: Among 363 patients, 79 (22%) developed D3 severe AKI. One hundred forty (39%) were sRAI + , 195 (54%) RAI + , and 253 (70%) D1 SCr > Baseline + . Compared to sRAI-, sRAI + had higher risk of D3 severe AKI (RR 8.9, 95%CI 5-16, p < 0.001), kidney replacement therapy (KRT) (RR 18, 95%CI 6.6-49, p < 0.001), and mortality (RR 2.5, 95%CI 1.2-5.5, p = 0.013). sRAI predicted D3 severe AKI with an AUROC of 0.86 (95%CI 0.82-0.90), with greater specificity (74%) than D1 SCr > Baseline (36%) and RAI + (58%). On multivariable regression, sRAI + retained associations with D3 severe AKI (aOR 4.5, 95%CI 2.0-10.2, p < 0.001) and need for KRT (aOR 5.6, 95%CI 1.5-21.5, p = 0.01).

Conclusions: Prediction of severe AKI in pediatric septic shock is important to improve outcomes, allocate resources, and inform enrollment in clinical trials examining potential disease-modifying therapies. The sRAI affords more accurate and specific prediction than context-free SCr elevation or the original RAI in this population.

Keywords: Acute kidney injury; Pediatrics; Precision medicine; Prediction; Prognostic enrichment; Sepsis; Shock.

Publication types

Observational Study
Multicenter Study

MeSH terms

Acute Kidney Injury* / diagnosis
Acute Kidney Injury* / etiology
Child
Humans
Prospective Studies
Sepsis* / complications
Severity of Illness Index
Shock, Septic* / complications

Abstract

Publication types

MeSH terms

Grants and funding