Derivation and validation of the renal angina index to improve the prediction of acute kidney injury in critically ill children

Abstract

Reliable prediction of severe acute kidney injury (AKI) has the potential to optimize treatment. Here we operationalized the empiric concept of renal angina with a renal angina index (RAI) and determined the predictive performance of RAI. This was assessed on admission to the pediatric intensive care unit, for subsequent severe AKI (over 200% rise in serum creatinine) 72 h later (Day-3 AKI). In a multicenter four cohort appraisal (one derivation and three validation), incidence rates for a Day 0 RAI of 8 or more were 15-68% and Day-3 AKI was 13-21%. In all cohorts, Day-3 AKI rates were higher in patients with an RAI of 8 or more with the area under the curve of RAI for predicting Day-3 AKI of 0.74-0.81. An RAI under 8 had high negative predictive values (92-99%) for Day-3 AKI. RAI outperformed traditional markers of pediatric severity of illness (Pediatric Risk of Mortality-II) and AKI risk factors alone for prediction of Day-3 AKI. Additionally, the RAI outperformed all KDIGO stages for prediction of Day-3 AKI. Thus, we operationalized the renal angina concept by deriving and validating the RAI for prediction of subsequent severe AKI. The RAI provides a clinically feasible and applicable methodology to identify critically ill children at risk of severe AKI lasting beyond functional injury. The RAI may potentially reduce capricious AKI biomarker use by identifying patients in whom further testing would be most beneficial.

Figure 1. Renal angina

(a) The renal angina construct. The juxtaposed graphs depict risk of acute kidney injury (AKI) versus decrease in estimated creatinine clearance from baseline (↓eCCl) and increase in % intensive care unit (ICU) fluid overload (% ↑ICU FO). There are three risk groups defined for the pediatric ICU population (tranches): very high risk (intubated + presence of at least one vasopressor or inotrope), high risk (history of solid organ or bone marrow transplant), and moderate risk (ICU admission). The construct is created such that less sign of injury (estimated creatinine clearance (eCCl) change or FO change) is required for the higher risk tranches to fulfill renal angina (solid red slope line). (Adapted with permission from Goldstein and Chawla.) (b) The renal angina index. On the basis of existing pediatric AKI literature, tiered AKI risk strata were assigned point values for ‘risk’ and ‘signs’ of injury. The worse parameter between change in eCCl from baseline and % FO was used to yield an injury score. The full description of the derivation appears in Supplementary A online. The resultant renal angina index score can range from 1 to 40. A cutoff of ≥8 is used to determine renal angina fulfillment.