Researchers Integrate AKI Risk Stratification System into Clinical Care

Pediatric nephrologist Stuart Goldstein, MD, led a team of researchers at Cincinnati Children’s to create a risk stratification system that can strongly predict whether a patient will develop severe acute kidney injury (AKI) within the first three days of admission to the pediatric intensive care unit (PICU).

The risk stratification system, called the Renal Angina Index, assigns points for various AKI risk factors, such as PICU admission (one point), transplantation status (three points) and intubation and vasoactive medication administration (five points). The total number of points is multiplied by a factor that represents changes in creatinine over baseline or fluid accumulation during the first 12 hours of a PICU admission. Results allow clinicians to initiate therapy in a timely manner for patients who are likely to develop severe AKI (which Dr. Goldstein and colleagues have shown is associated with mortality), and avoid unnecessary treatment for those who are not.

In 2018, thanks in part to a grant from the National Institutes of Health-funded P50 Center of Excellence in Nephrology, the Renal Angina Index was fully integrated into the Epic™ electronic medical record at Cincinnati Children’s. Goldstein presented the preliminary results from this initiative at the National Institutes of Health in April 2019, showing that the index improves prediction of AKI in the PICU. Previously, Goldstein and his team validated the Renal Angina Index in a prospective observational study that included a multinational cohort of 5,000 patients at five pediatric institutions.

Patients who score less than eight on the index have only a two percent chance of developing severe AKI. Patients who score eight or higher are tested for the urinary biomarker neutrophil gelatinase-associated lipocalin (NGAL). If there is a concentration greater than 150 ng/mL, their chance of developing severe AKI within 72 hours of PICU admission increases dramatically. Previous research at Cincinnati Children’s demonstrated that NGAL is present prior to serum creatinine changes in many PICU patients. But on its own, without clinical context, NGAL is not predictive of severe AKI, Goldstein says.

“The index provides real-time data for clinical decision support,” Goldstein says. “Our intensivists say that it takes the guesswork out of the decision to identify and support patients with AKI. They are initiating dialysis or renal replacement therapy, or altering fluid management earlier in a PICU stay than they did before in a standardized way.”

Goldstein says he hopes to make the Renal Angina Index universally available so that clinicians everywhere can provide effective, personalized care for children who are likely to develop severe AKI. Meanwhile, he is working with colleagues at Cincinnati Children’s and elsewhere to leverage the risk stratification system to study interventions that may lower acute AKI and mortality or progression to chronic kidney disease.

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