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Recalibration of the Renal Angina Index for Pediatric Septic Shock
Natalja L Stanski1,2, Hector R Wong1,2, Rajit K Basu3
1Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
Insights
The Renal Angina Index (RAI) effectively predicts severe acute kidney injury (AKI) in children with septic shock. A recalibrated RAI incorporating platelet count and a higher threshold improves prediction accuracy for pediatric sepsis-AKI.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Pediatric Sepsis Research
Background:
- Sepsis-associated acute kidney injury (AKI) in children presents significant challenges due to poor outcomes.
- Early identification of children at risk for severe AKI is crucial, given limited therapeutic options.
- The Renal Angina Index (RAI) is validated for predicting severe AKI in critically ill children, but its performance in septic shock is unestablished.
Purpose of the Study:
- To evaluate the predictive ability of the Renal Angina Index (RAI) for severe AKI in children with septic shock.
- To assess the need for recalibrating the RAI for this specific pediatric population.
Main Methods:
- Secondary analysis of a multicenter, prospective, observational study involving 379 children with septic shock.
- Determination of the RAI's capability to predict severe AKI at day 3.
- Assessment of RAI recalibration using a higher threshold and inclusion of platelet count.
Main Results:
- The original RAI (cutoff ≥8) showed high sensitivity (95%) but moderate specificity (54%) for predicting day 3 severe AKI (AUROC 0.90).
- An optimized cutoff (≥20) improved specificity (80%) but reduced sensitivity (83%).
- Day 1 platelet count <150 × 10³ /μl was an independent predictor of severe AKI (aOR 3.2). Recalibration with a higher threshold and platelet count improved specificity to 69% while maintaining 95% sensitivity.
Conclusions:
- The RAI is a sensitive and reliable tool for predicting severe AKI in pediatric septic shock.
- A recalibrated, sepsis-specific RAI utilizing a higher cutoff and incorporating platelet count may enhance predictive accuracy in this cohort.
Introduction:
Sepsis-associated acute kidney injury (AKI) is a common diagnosis in children that is associated with poor outcomes. The lack of therapeutic options once present makes early identification of at-risk patients essential. The renal angina index (RAI) has been previously validated to predict severe AKI in heterogeneous populations of critically ill children. The performance of this score specifically in children with septic shock is unknown.
Methods:
A secondary analysis of a multicenter, prospective, observational study of 379 children with septic shock to determine the ability of the RAI to predict severe AKI at day 3, and to assess for the potential need for recalibration of the RAI in this unique subset of patients.
Results:
At the original cutoff of ≥8, the RAI predicted day 3 severe AKI with an area under the receiving operating characteristic (AUROC) curve 0.90 (95% confidence interval [CI]: 0.86 to 93), 95% sensitivity, and 54% specificity. A Youden's index identified a higher optimal cutoff of ≥20 (sensitivity 83%, specificity 80%), and day 1 platelet count <150 × 103/μl was an independent predictor of severe AKI (adjusted odds ratio: 3.2; 95% CI: 1.7 to 6.3; P < 0.001). Recalibration of the RAI to include platelet count and this new threshold restored the sensitivity of the original ≥8 threshold (95%), while improving its specificity (69%).
Conclusions:
The RAI appears to be a sensitive and reliable tool for prediction of severe AKI in children with septic shock, although the use of a recalibrated sepsis-specific RAI using a higher cutoff and platelet count may be beneficial.
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