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. 2023 Sep 22;8(12):2690-2700.
doi: 10.1016/j.ekir.2023.09.019. eCollection 2023 Dec.

Real-Time Acute Kidney Injury Risk Stratification-Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults

Stuart L Goldstein  1 , Kelli A Krallman  1 , Jean-Philippe Roy  1 , Michaela Collins  1 , Ranjit S Chima  1 , Rajit K Basu  2 , Lakhmir Chawla  3 , Lin Fei  1
Affiliations

Real-Time Acute Kidney Injury Risk Stratification-Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults

Stuart L Goldstein et al. Kidney Int Rep. .

Abstract

Introduction: Critically ill admitted patients are at high risk of acute kidney injury (AKI). The renal angina index (RAI) and urinary biomarker neutrophil gelatinase-associated lipocalin (uNGAL) can aid in AKI risk assessment. We implemented the Trial in AKI using NGAL and Fluid Overload to optimize CRRT Use (TAKING FOCUS 2; TF2) to personalize fluid management and continuous renal replacement therapy (CRRT) initiation based on AKI risk and patient fluid accumulation. We compared outcomes pre-TF2 and post-TF2 initiation.

Methods: Patients admitted from July 2017 were followed-up prospectively with the following: (i) an automated RAI result at 12 hours of admission, (ii) a conditional uNGAL order for RAI ≥8, and (iii) a CRRT initiation goal at 10% to 15% weight-based fluid accumulation.

Results: A total of 286 patients comprised 304 intensive care unit (ICU) RAI+ admissions; 178 patients received CRRT over the observation period (2014-2021). Median time from ICU admission to CRRT initiation was 2 days shorter (P < 0.002), and ≥15% pre-CRRT fluid accumulation rate was lower in the TF2 era (P < 0.02). TF2 ICU length of stay (LOS) after CRRT discontinuation and total ICU LOS were 6 and 11 days shorter for CRRT survivors (both P < 0.02). Survival rates to ICU discharge after CRRT discontinuation were higher in the TF2 era (P = 0.001). These associations persisted in each TF2 year; we estimate a conservative $12,500 health care cost savings per CRRT patient treated after TF2 implementation.

Conclusion: We suggest that automated clinical decision support (CDS) combining risk stratification and AKI biomarker assessment can produce durable reductions in pediatric CRRT patient morbidity.

Keywords: acute kidney injury; children; continuous renal replacement therapy; neutrophil gelatinase associated lipocalin; renal angina index.

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Figures

None
Graphical abstract
Figure 1
Figure 1
The TAKING FOCUS 2 Clinical Decision Support Pathway. The current manuscript incorporates all components of the pathway except for the furosemide stress test. ICU, intensive care unit; NGAL, neutrophil gelatinase-associated lipocalin; PICU, pediatric intensive care unit; RAI, renal angina index; RRT, renal replacement therapy.
Figure 2
Figure 2
CONSORT Diagram for patients on CRRT according to inclusion and exclusion criteria by TF2 era. CRRT, continuous renal replacement therapy; PICU, pediatric intensive care unit; TF2, TAKING FOCUS 2.
Figure 3
Figure 3
Annual rates or median values for primary and secondary outcomes. All columns represent median values, error bars represent 25th and 75th quartiles and dots represent individual outlier patients. TAKING FOCUS 2 was implemented July 1, 2017, and data are presented through December 31, 2021. (a) Annual Pre-CRRT Initiation Comparisons Between the Pre-TF2 and TF2 Eras. (b) Annual CRRT Treatment Course Parameters (CRRT Survivors Only). (c) Annual PICU length of stay (days). CRRT, continuous renal replacement therapy; PICU, pediatric intensive care unit; TF2, TAKING FOCUS 2.
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