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Published on: February 2, 2021
Modification of the Cardiac Renal Angina Index for Predicting Adverse Kidney Events After Pediatric Cardiac Surgery
Katherine F Melink1,2, Natalja L Stanski1, Emily Gorrell1
1Department of Pediatrics, Cincinnati Children's Hospital Medical Center University of Cincinnati College of Medicine Cincinnati OH USA.
Insights
A modified cardiac renal angina index (cRAI) effectively predicts adverse kidney events in pediatric cardiac surgery patients. Integrating urine neutrophil gelatinase-associated lipocalin further enhances prediction accuracy for these critical outcomes.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Cardiovascular surgery
Background:
- Pediatric cardiac surgery-associated acute kidney injury (AKI) is a significant clinical challenge with poor prognoses.
- Early and accurate prediction of AKI in this vulnerable population remains difficult.
- The modified cardiac renal angina index (cRAI) was developed to aid in risk stratification.
Purpose of the Study:
- To evaluate the predictive performance of the modified cRAI for adverse renal events in pediatric patients post-cardiac surgery.
- To determine if integrating urine neutrophil gelatinase-associated lipocalin (NGAL) improves the predictive accuracy of the cRAI.
- To assess the clinical utility of cRAI in identifying high-risk patients for adverse outcomes.
Main Methods:
- A prospective, 2-center observational study involving 476 children (0-18 years) undergoing cardiac surgery.
- A modified cRAI nomogram was developed using multivariable logistic regression to predict a composite outcome (postoperative AKI or prolonged mechanical ventilation).
- The predictive performance of the cRAI model was compared with a model incorporating urine NGAL.
Main Results:
- The modified cRAI demonstrated strong predictive performance (AUC 0.82) for the composite adverse renal outcome.
- Patients with a positive cRAI had significantly worse outcomes, including higher mortality and longer ICU stays.
- Integration of urine NGAL improved predictive performance (AUC 0.84), with enhanced sensitivity and specificity.
Conclusions:
- The modified cRAI is a robust tool for predicting adverse renal outcomes in pediatric cardiac surgery patients.
- A negative cRAI effectively rules out the composite adverse outcome, aiding in patient management.
- Urine NGAL integration enhances the predictive power of the cRAI, offering potential for improved risk stratification and clinical trial enrichment.
Background:
Pediatric cardiac surgery-associated acute kidney injury is common and associated with poor outcomes, but early prediction is challenging. The purpose of this study was to determine the performance of a modified cardiac renal angina index (cRAI) in predicting adverse renal events and whether biomarker integration (urine neutrophil gelatinase-associated lipocalin) enhances cRAI performance.
Methods:
This was a 2-center prospective observational study in children ages 0 to 18 years admitted to the intensive care unit after cardiac surgery. The cRAI was presented as a nomogram using multivariable logistic regression to predict a composite of (1) any postoperative day 2 to 4 acute kidney injury, or (2) mechanical ventilation ≥3 days. The performance of including urine neutrophil gelatinase-associated lipocalin into the nomogram was compared with the model constructed for cRAI alone.
Results:
Of 476 patients, 129 (27%) experienced the composite outcome, and 191 (40%) were cRAI positive. Patients who were cRAI positive were younger, had higher surgical complexity, a higher mortality rate, and longer intensive care unit length of stay. cRAI predicted the composite outcome with an optimism-corrected area under the receiver operating characteristic curve of 0.82, sensitivity of 0.81 (95% CI, 0.73-0.87), specificity of 0.75 (95% CI, 0.70-0.80), and negative predictive value of 0.91 (95% CI, 0.87-0.94). Incorporating urine neutrophil gelatinase-associated lipocalin improved predictive performance, with an area under the receiver operating characteristic curve of 0.84, sensitivity of 0.84 (95% CI, 0.77-0.90), specificity of 0.79 (95% CI, 0.74-0.83), and negative predictive value of 0.93 (95% CI, 0.90-0.96).
Conclusions:
The cRAI demonstrates strong predictive performance for adverse renal outcomes. Patients who were cRAI positive had worse outcomes, while the composite outcome was effectively ruled out in patients who were cRAI negative. Urine neutrophil gelatinase-associated lipocalin integration improved predictive performance parameters. cRAI holds potential for cardiac surgery-associated acute kidney injury risk stratification to enrich clinical trial enrollment.
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