Recalibration of the Renal Angina Index for Pediatric Septic Shock

Natalja L Stanski; Hector R Wong; Rajit K Basu; Natalie Z Cvijanovich; Julie C Fitzgerald; Scott L Weiss; Michael T Bigham; Parag N Jain; Adam Schwarz; Riad Lutfi; Jeffrey Nowak; Geoffrey L Allen; Neal J Thomas; Jocelyn R Grunwell; Michael Quasney; Bereketeab Haileselassie; Lakhmir S Chawla; Stuart L Goldstein

doi:10.1016/j.ekir.2021.04.022

Recalibration of the Renal Angina Index for Pediatric Septic Shock

Kidney Int Rep. 2021 May 1;6(7):1858-1867. doi: 10.1016/j.ekir.2021.04.022. eCollection 2021 Jul.

Authors

Natalja L Stanski^{1

2}, Hector R Wong^{1

2}, Rajit K Basu³, Natalie Z Cvijanovich⁴, Julie C Fitzgerald⁵, Scott L Weiss⁵, Michael T Bigham⁶, Parag N Jain⁷, Adam Schwarz⁸, Riad Lutfi⁹, Jeffrey Nowak¹⁰, Geoffrey L Allen¹¹, Neal J Thomas¹², Jocelyn R Grunwell³, Michael Quasney¹³, Bereketeab Haileselassie¹⁴, Lakhmir S Chawla¹⁵, Stuart L Goldstein^{1

2}

Affiliations

¹ Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.
² Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.
³ Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA.
⁴ UCSF Benioff Children's Hospital Oakland, Oakland, California, USA.
⁵ The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
⁶ Akron Children's Hospital, Akron, Ohio, USA.
⁷ Texas Children's Hospital and Baylor College of Medicine, Houston, Texas, USA.
⁸ Children's Hospital of Orange County, Orange, California, USA.
⁹ Riley Hospital for Children, Indianapolis, Indiana, USA.
¹⁰ Children's Hospital and Clinics of Minnesota, Minneapolis, Minnesota, USA.
¹¹ Children's Mercy Hospital, Kansas City, Missouri, USA.
¹² Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA.
¹³ CS Mott Children's Hospital at the University of Michigan, Ann Arbor, Michigan, USA.
¹⁴ Lucile Packard Children's Hospital Stanford, Palo Alto, California, USA.
¹⁵ Veterans Affairs Medical Center, San Diego, California, USA.

Abstract

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.

Keywords: acute kidney injury; precision medicine; prediction; septic shock.

Grants and funding

K23 DK119463/DK/NIDDK NIH HHS/United States