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

• Published in: Kidney international reports Vol. 8; no. 12; pp. 2690 - 2700
• Main Authors: Goldstein, Stuart L., Krallman, Kelli A., Roy, Jean-Philippe, Collins, Michaela, Chima, Ranjit S., Basu, Rajit K., Chawla, Lakhmir, Fei, Lin
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2023; Elsevier
• Subjects: Acute kidney injury; children; Clinical Research; continuous renal replacement therapy; neutrophil gelatinase associated lipocalin; renal angina index; renal angina index; neutrophil gelatinase associated lipocalin; children; continuous renal replacement therapy; Acute kidney injury; acute kidney injury
• ISSN: 2468-0249; 2468-0249
• DOI: 10.1016/j.ekir.2023.09.019

Critically ill admitted 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 CRRT initiation based on AKI risk and patient fluid accumulation. We compared outcomes pre- and post-TF2 initiation. Patients admitted from 07/2017 were followed prospectively with: (1) automated RAI result at 12 hours of admission, (2) conditional uNGAL order for RAI>8 and (3) a CRRT initiation goal at 10-15% weight-based fluid accumulation. 286 patients comprised 304 ICU RAI+ admissions; 178 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 after CRRT discontinuation and total ICU length of stay were six 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 healthcare cost savings per CRRT patient treated after TF2 implementation. We suggest automated clinical decision support combining risk stratification and AKI biomarker assessment can produce durable reductions in pediatric CRRT patient morbidity.