Assessment of a renal angina index for prediction of severe acute kidney injury in critically ill children: a multicentre, multinational, prospective observational study

AWARE study investigators

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Abstract

Background: Acute kidney injury occurs in one in four children admitted to an intensive care unit (ICU) and its severity is independently associated with increased patient morbidity and mortality. Early prediction of acute kidney injury has the potential to improve outcomes. In smaller, single-centre trial populations, we have previously derived and validated the performance of a renal angina index, a context-driven risk stratification system, to predict severe acute kidney injury in children and adolescents. Here, we tested the predictive accuracy of this index for severe acute kidney injury in a large heterogeneous population. Methods: We did a prospective, observational study (AWARE) that recruited patients in the ICUs of 32 hospitals in nine countries across Asia, Australia, Europe, and North America. All patients aged between 3 months and 25 years who were admitted to an ICU at least 48 h previously were eligible. Exclusion criteria were a history of stage 5 chronic kidney disease (ie, estimated glomerular filtration rate <15 mL/min per 1·73m2 or on maintenance dialysis) or kidney transplantation in the preceding 90 days. Patients' medical records were reviewed to collect data up to 3 months before (serum creatinine only), daily during the first 7 days, and on day 28 after ICU admission. For the assessment of the renal angina index, we included patients from the AWARE study who had full data from the day of ICU admission, day 3, and day 28, including serum creatinine concentrations and urine output measurements. The primary outcome was the presence of severe acute kidney injury (stage 2–3 acute kidney injury, according to Kidney Disease Improving Global Outcomes [KDIGO] guidelines) on the third day after ICU admission. We compared the performance of the renal angina index with changes in serum creatinine relative to baseline for prediction of the primary outcome. A score of eight points or more on the renal angina index defined fulfilment of renal angina; serum creatinine concentration relative to baseline was calculated using maximum serum creatinine concentration in the first 12 h of ICU admission). This trial is registered with ClinicalTrials.gov, number NCT01987921. Findings: Between Jan 1 and Dec 31, 2014, we obtained data for 1590 patients. 286 patients (18%) had fulfilment of renal angina. At day 3, severe acute kidney injury occurred in 121 (42%) patients positive for renal angina and 247 (19%) patients negative for renal angina (relative risk [RR] 2·23, 95% CI 1·87–2.66, p<0·0001). Of 368 (23%) patients with severe acute kidney injury, more had increased use of renal replacement and increased mortality than of the 1222 (77%) patients without severe acute kidney injury (40 [11%] vs 18 [2%], p<0.0001; and 28 [8%] vs 53 [4%], p=0·01). Fulfilment of renal angina showed better prediction for severe acute kidney injury than serum creatinine greater than baseline (RR 1.61, 95% CI 1·33–1·93; p<0·0001), which was maintained on multivariate regression (independent odds ratio for fulfilment of renal angina 3·21, 95% CI 2·20–4·67 vs serum creatinine greater than baseline 0·68, 0·49–4·94). Interpretation: Earlier and better prediction of severe acute kidney injury has the potential to improve patient outcomes associated with acute kidney injury. Compared with isolated, context-free changes in serum creatinine, renal angina risk assessment improved accuracy for prediction of severe acute kidney injury in critically ill children and young people. Funding: US National Institutes of Health.

Original languageEnglish (US)
Number of pages1
JournalThe Lancet Child and Adolescent Health
Volume2
Issue number2
DOIs
StatePublished - Feb 1 2018

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Acute Kidney Injury
Critical Illness
Observational Studies
Prospective Studies
Kidney
Creatinine
Intensive Care Units
Serum
Mortality
National Institutes of Health (U.S.)
Kidney Diseases
North America
Glomerular Filtration Rate
Chronic Renal Insufficiency
Kidney Transplantation
Population
Medical Records
Dialysis
Odds Ratio
Maintenance

All Science Journal Classification (ASJC) codes

  • Pediatrics, Perinatology, and Child Health
  • Developmental and Educational Psychology

Cite this

@article{f9e9723cedcc41d293bb301303b56a2a,
title = "Assessment of a renal angina index for prediction of severe acute kidney injury in critically ill children: a multicentre, multinational, prospective observational study",
abstract = "Background: Acute kidney injury occurs in one in four children admitted to an intensive care unit (ICU) and its severity is independently associated with increased patient morbidity and mortality. Early prediction of acute kidney injury has the potential to improve outcomes. In smaller, single-centre trial populations, we have previously derived and validated the performance of a renal angina index, a context-driven risk stratification system, to predict severe acute kidney injury in children and adolescents. Here, we tested the predictive accuracy of this index for severe acute kidney injury in a large heterogeneous population. Methods: We did a prospective, observational study (AWARE) that recruited patients in the ICUs of 32 hospitals in nine countries across Asia, Australia, Europe, and North America. All patients aged between 3 months and 25 years who were admitted to an ICU at least 48 h previously were eligible. Exclusion criteria were a history of stage 5 chronic kidney disease (ie, estimated glomerular filtration rate <15 mL/min per 1·73m2 or on maintenance dialysis) or kidney transplantation in the preceding 90 days. Patients' medical records were reviewed to collect data up to 3 months before (serum creatinine only), daily during the first 7 days, and on day 28 after ICU admission. For the assessment of the renal angina index, we included patients from the AWARE study who had full data from the day of ICU admission, day 3, and day 28, including serum creatinine concentrations and urine output measurements. The primary outcome was the presence of severe acute kidney injury (stage 2–3 acute kidney injury, according to Kidney Disease Improving Global Outcomes [KDIGO] guidelines) on the third day after ICU admission. We compared the performance of the renal angina index with changes in serum creatinine relative to baseline for prediction of the primary outcome. A score of eight points or more on the renal angina index defined fulfilment of renal angina; serum creatinine concentration relative to baseline was calculated using maximum serum creatinine concentration in the first 12 h of ICU admission). This trial is registered with ClinicalTrials.gov, number NCT01987921. Findings: Between Jan 1 and Dec 31, 2014, we obtained data for 1590 patients. 286 patients (18{\%}) had fulfilment of renal angina. At day 3, severe acute kidney injury occurred in 121 (42{\%}) patients positive for renal angina and 247 (19{\%}) patients negative for renal angina (relative risk [RR] 2·23, 95{\%} CI 1·87–2.66, p<0·0001). Of 368 (23{\%}) patients with severe acute kidney injury, more had increased use of renal replacement and increased mortality than of the 1222 (77{\%}) patients without severe acute kidney injury (40 [11{\%}] vs 18 [2{\%}], p<0.0001; and 28 [8{\%}] vs 53 [4{\%}], p=0·01). Fulfilment of renal angina showed better prediction for severe acute kidney injury than serum creatinine greater than baseline (RR 1.61, 95{\%} CI 1·33–1·93; p<0·0001), which was maintained on multivariate regression (independent odds ratio for fulfilment of renal angina 3·21, 95{\%} CI 2·20–4·67 vs serum creatinine greater than baseline 0·68, 0·49–4·94). Interpretation: Earlier and better prediction of severe acute kidney injury has the potential to improve patient outcomes associated with acute kidney injury. Compared with isolated, context-free changes in serum creatinine, renal angina risk assessment improved accuracy for prediction of severe acute kidney injury in critically ill children and young people. Funding: US National Institutes of Health.",
author = "{AWARE study investigators} and Basu, {Rajit K.} and Ahmad Kaddourah and Goldstein, {Stuart L.} and Ayse Akcan-Arikan and Megan Arnold and Cody Cruz and Michele Goldsworthy and Nancy Jaimon and Stephen Alexander and Marino Festa and Deirdre Hahn and Lauren Brown and Ari Jeon and Akash Deep and David Askenazi and Sean Bagshaw and Catherine Morgan and Rashid Alobaidi and Rajit Basu and David Cooper and Stuart Goldstein and Ahmad Kaddourah and Theresa Mottes and Tara Terrell and Patricia Arnold and Christina Metcalf and Shalayna Woodley and Radovan Bogdanović and Natasa Stajić and Branko Kovacevic and Amira Peco-Antic and Aleksandra Paripovic and Patrick Brophy and Timothy Bunchman and Duane Williams and Michelle Hoot and Vimal Chadha and Keefe Davis and Vikas Dharnidharka and Leslie Walther and Vincent Faustino and Janet Taft and Joana Tala and Katja Gist and Danielle Soranno and Ha, {Il Soo} and Kang, {Hee Gyung} and Richard Hackbarth and Mary Avendt-Reeber and Chloe Butler",
year = "2018",
month = "2",
day = "1",
doi = "10.1016/S2352-4642(17)30181-5",
language = "English (US)",
volume = "2",
journal = "The Lancet Child and Adolescent Health",
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TY - JOUR

T1 - Assessment of a renal angina index for prediction of severe acute kidney injury in critically ill children

T2 - a multicentre, multinational, prospective observational study

AU - AWARE study investigators

AU - Basu, Rajit K.

AU - Kaddourah, Ahmad

AU - Goldstein, Stuart L.

AU - Akcan-Arikan, Ayse

AU - Arnold, Megan

AU - Cruz, Cody

AU - Goldsworthy, Michele

AU - Jaimon, Nancy

AU - Alexander, Stephen

AU - Festa, Marino

AU - Hahn, Deirdre

AU - Brown, Lauren

AU - Jeon, Ari

AU - Deep, Akash

AU - Askenazi, David

AU - Bagshaw, Sean

AU - Morgan, Catherine

AU - Alobaidi, Rashid

AU - Basu, Rajit

AU - Cooper, David

AU - Goldstein, Stuart

AU - Kaddourah, Ahmad

AU - Mottes, Theresa

AU - Terrell, Tara

AU - Arnold, Patricia

AU - Metcalf, Christina

AU - Woodley, Shalayna

AU - Bogdanović, Radovan

AU - Stajić, Natasa

AU - Kovacevic, Branko

AU - Peco-Antic, Amira

AU - Paripovic, Aleksandra

AU - Brophy, Patrick

AU - Bunchman, Timothy

AU - Williams, Duane

AU - Hoot, Michelle

AU - Chadha, Vimal

AU - Davis, Keefe

AU - Dharnidharka, Vikas

AU - Walther, Leslie

AU - Faustino, Vincent

AU - Taft, Janet

AU - Tala, Joana

AU - Gist, Katja

AU - Soranno, Danielle

AU - Ha, Il Soo

AU - Kang, Hee Gyung

AU - Hackbarth, Richard

AU - Avendt-Reeber, Mary

AU - Butler, Chloe

PY - 2018/2/1

Y1 - 2018/2/1

N2 - Background: Acute kidney injury occurs in one in four children admitted to an intensive care unit (ICU) and its severity is independently associated with increased patient morbidity and mortality. Early prediction of acute kidney injury has the potential to improve outcomes. In smaller, single-centre trial populations, we have previously derived and validated the performance of a renal angina index, a context-driven risk stratification system, to predict severe acute kidney injury in children and adolescents. Here, we tested the predictive accuracy of this index for severe acute kidney injury in a large heterogeneous population. Methods: We did a prospective, observational study (AWARE) that recruited patients in the ICUs of 32 hospitals in nine countries across Asia, Australia, Europe, and North America. All patients aged between 3 months and 25 years who were admitted to an ICU at least 48 h previously were eligible. Exclusion criteria were a history of stage 5 chronic kidney disease (ie, estimated glomerular filtration rate <15 mL/min per 1·73m2 or on maintenance dialysis) or kidney transplantation in the preceding 90 days. Patients' medical records were reviewed to collect data up to 3 months before (serum creatinine only), daily during the first 7 days, and on day 28 after ICU admission. For the assessment of the renal angina index, we included patients from the AWARE study who had full data from the day of ICU admission, day 3, and day 28, including serum creatinine concentrations and urine output measurements. The primary outcome was the presence of severe acute kidney injury (stage 2–3 acute kidney injury, according to Kidney Disease Improving Global Outcomes [KDIGO] guidelines) on the third day after ICU admission. We compared the performance of the renal angina index with changes in serum creatinine relative to baseline for prediction of the primary outcome. A score of eight points or more on the renal angina index defined fulfilment of renal angina; serum creatinine concentration relative to baseline was calculated using maximum serum creatinine concentration in the first 12 h of ICU admission). This trial is registered with ClinicalTrials.gov, number NCT01987921. Findings: Between Jan 1 and Dec 31, 2014, we obtained data for 1590 patients. 286 patients (18%) had fulfilment of renal angina. At day 3, severe acute kidney injury occurred in 121 (42%) patients positive for renal angina and 247 (19%) patients negative for renal angina (relative risk [RR] 2·23, 95% CI 1·87–2.66, p<0·0001). Of 368 (23%) patients with severe acute kidney injury, more had increased use of renal replacement and increased mortality than of the 1222 (77%) patients without severe acute kidney injury (40 [11%] vs 18 [2%], p<0.0001; and 28 [8%] vs 53 [4%], p=0·01). Fulfilment of renal angina showed better prediction for severe acute kidney injury than serum creatinine greater than baseline (RR 1.61, 95% CI 1·33–1·93; p<0·0001), which was maintained on multivariate regression (independent odds ratio for fulfilment of renal angina 3·21, 95% CI 2·20–4·67 vs serum creatinine greater than baseline 0·68, 0·49–4·94). Interpretation: Earlier and better prediction of severe acute kidney injury has the potential to improve patient outcomes associated with acute kidney injury. Compared with isolated, context-free changes in serum creatinine, renal angina risk assessment improved accuracy for prediction of severe acute kidney injury in critically ill children and young people. Funding: US National Institutes of Health.

AB - Background: Acute kidney injury occurs in one in four children admitted to an intensive care unit (ICU) and its severity is independently associated with increased patient morbidity and mortality. Early prediction of acute kidney injury has the potential to improve outcomes. In smaller, single-centre trial populations, we have previously derived and validated the performance of a renal angina index, a context-driven risk stratification system, to predict severe acute kidney injury in children and adolescents. Here, we tested the predictive accuracy of this index for severe acute kidney injury in a large heterogeneous population. Methods: We did a prospective, observational study (AWARE) that recruited patients in the ICUs of 32 hospitals in nine countries across Asia, Australia, Europe, and North America. All patients aged between 3 months and 25 years who were admitted to an ICU at least 48 h previously were eligible. Exclusion criteria were a history of stage 5 chronic kidney disease (ie, estimated glomerular filtration rate <15 mL/min per 1·73m2 or on maintenance dialysis) or kidney transplantation in the preceding 90 days. Patients' medical records were reviewed to collect data up to 3 months before (serum creatinine only), daily during the first 7 days, and on day 28 after ICU admission. For the assessment of the renal angina index, we included patients from the AWARE study who had full data from the day of ICU admission, day 3, and day 28, including serum creatinine concentrations and urine output measurements. The primary outcome was the presence of severe acute kidney injury (stage 2–3 acute kidney injury, according to Kidney Disease Improving Global Outcomes [KDIGO] guidelines) on the third day after ICU admission. We compared the performance of the renal angina index with changes in serum creatinine relative to baseline for prediction of the primary outcome. A score of eight points or more on the renal angina index defined fulfilment of renal angina; serum creatinine concentration relative to baseline was calculated using maximum serum creatinine concentration in the first 12 h of ICU admission). This trial is registered with ClinicalTrials.gov, number NCT01987921. Findings: Between Jan 1 and Dec 31, 2014, we obtained data for 1590 patients. 286 patients (18%) had fulfilment of renal angina. At day 3, severe acute kidney injury occurred in 121 (42%) patients positive for renal angina and 247 (19%) patients negative for renal angina (relative risk [RR] 2·23, 95% CI 1·87–2.66, p<0·0001). Of 368 (23%) patients with severe acute kidney injury, more had increased use of renal replacement and increased mortality than of the 1222 (77%) patients without severe acute kidney injury (40 [11%] vs 18 [2%], p<0.0001; and 28 [8%] vs 53 [4%], p=0·01). Fulfilment of renal angina showed better prediction for severe acute kidney injury than serum creatinine greater than baseline (RR 1.61, 95% CI 1·33–1·93; p<0·0001), which was maintained on multivariate regression (independent odds ratio for fulfilment of renal angina 3·21, 95% CI 2·20–4·67 vs serum creatinine greater than baseline 0·68, 0·49–4·94). Interpretation: Earlier and better prediction of severe acute kidney injury has the potential to improve patient outcomes associated with acute kidney injury. Compared with isolated, context-free changes in serum creatinine, renal angina risk assessment improved accuracy for prediction of severe acute kidney injury in critically ill children and young people. Funding: US National Institutes of Health.

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U2 - 10.1016/S2352-4642(17)30181-5

DO - 10.1016/S2352-4642(17)30181-5

M3 - Article

C2 - 30035208

AN - SCOPUS:85041562868

VL - 2

JO - The Lancet Child and Adolescent Health

JF - The Lancet Child and Adolescent Health

SN - 2352-4642

IS - 2

ER -