Renal angina index predicts fluid overload in critically ill children: an observational cohort study

Background Fluid overload and acute kidney injury are common and associated with poor outcomes among critically ill children. The prodrome of renal angina stratifies patients by risk for severe acute kidney injury, but the predictive discrimination for fluid overload is unknown. Methods Post-hoc analysis of patients admitted to a tertiary care pediatric intensive care unit (PICU). The primary outcome was the performance of renal angina fulfillment on day of ICU admission to predict fluid overload ≥15% on Day 3. Results 77/139 children (55%) fulfilled renal angina (RA+). After adjusting for covariates, RA+ was associated with increased odds of fluid overload on Day 3 (adjusted odds ratio (aOR) 5.1, 95% CI 1.23–21.2, p = 0.025, versus RA-). RA- resulted in a 90% negative predictive value for fluid overload on Day 3. Median fluid overload was significantly higher in RA+ patients with severe acute kidney injury compared to RA+ patients without severe acute kidney injury (% fluid overload on Day 3: 8.8% vs. 0.73%, p = 0.002). Conclusion Among critically ill children, fulfillment of renal angina was associated with increased odds of fluid overload versus the absence of renal angina and a higher fluid overload among patients who developed acute kidney injury. Renal angina directed risk classification may identify patients at highest risk for fluid accumulation. Expanded study in larger populations is warranted.

Re-evaluating Renal Angina Index: An Authentic, Evidence-Based Instrument for Acute Kidney Injury Assessment: Critical Appraisal

Background/Introduction: Renal angina index (RAI) used to calculate and accurately predict risk for the development of acute kidney injury (AKI) has been heavily explored. AKI is traditionally diagnosed by an increase in serum creatinine (SCr) concentration or oliguria, both of which are neither specific nor sensitive, especially among children. An RAI score may be calculated by combining objective signs of kidney dysfunction (such as SCr) and patient context, such as AKI risk factors, thus potentially serving as a more accurate indicator for AKI.Objective: Due to the propitious and novel nature of RAI, this editorial commentary aims to analyze the current literature on RAI and determine how well RAI serves as a predictor of AKI outcomes.Method: A comprehensive literature search was conducted in PubMed/Medline and Google Scholar between January 2012 and July 2020. Literature included the prognostic aspect of early prediction of AKI in the pediatric and adult population via RAI.Results: The initial literature search included 149 studies, and a total of 10 studies reporting the outcomes of interest were included. The overall sample size across these studies was 11,026. The predictive ability of RAI had a pooled (95% CI) sensitivity of 79.21%, specificity of 73.22%, and negative predictive value of 94.83%.Conclusion: RAI shows benefit in the prediction of AKI among adult and pediatric populations. However, there is a lack of sufficient data, and further prospective studies are needed in pediatric populations to use RAI as a principal AKI indicator among clinicians.

Acute kidney injury in children with COVID-19: a retrospective study

Background Acute kidney injury (AKI) is a complication of coronavirus disease 2019 (COVID-19). The reported incidence of AKI, however, varies among studies. We aimed to evaluate the incidence of AKI and its association with mortality and morbidity in children infected with severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) who required hospital admission. Methods This was a multicenter retrospective cohort study from three tertiary centers, which included children with confirmed COVID-19. All children were evaluated for AKI using the Kidney Disease Improving Global Outcomes (KDIGO) definition and staging. Results Of 89 children included, 19 (21 %) developed AKI (52.6 % stage I). A high renal angina index score was correlated with severity of AKI. Also, multisystem inflammatory syndrome in children (MIS-C) was increased in children with AKI compared to those with normal kidney function (15 % vs. 1.5 %). Patients with AKI had significantly more pediatric intensive care admissions (PICU) (32 % vs. 2.8 %, p < 0.001) and mortality (42 % vs. 0 %, p < 0.001). However, AKI was not associated with prolonged hospitalization (58 % vs. 40 %, p = 0.163) or development of MIS-C (10.5 % vs. 1.4 %, p = 0.051). No patient in the AKI group required renal replacement therapy. Residual renal impairment at discharge occurred in 9 % of patients. This was significantly influenced by the presence of comorbidities, hypotension, hypoxia, heart failure, acute respiratory distress, hypernatremia, abnormal liver profile, high C-reactive protein, and positive blood culture. Conclusions AKI occurred in one-fifth of children with SARS-CoV-2 infection requiring hospital admission, with one-third of those requiring PICU. AKI was associated with increased morbidity and mortality, and residual renal impairment at time of discharge.

MO401RENAL ANGINA INDEX IN ADULT CRITICAL CARE PATIENTS IN A POPULATION FROM BOGOTÁ – COLOMBIA

Background and Aims Clinical outcomes of Acute Kidney Injury (AKI) in ICU mainly depend on opportune preventive strategies. Thus, early identification of AKI is mandatory, and alternative diagnostic strategies become plausible: one of them, Renal Angina Index (RAI), described by Matsuura1, predicts the development of AKI KDIGO 2-3, at 7th day after admission to the intensive care unit according to a cut-off point &gt;6 on a scale with a “creatinine score” (determined by the difference in serum creatinine between that at ICU admission and the first 24 hours in the ICU) and the impact of the patients medical history. 1Kidney Int Rep (2018) 3, 677-683. Our aim is to describe predictive capacity of the Renal Angina Index (RAI) in adult critical care patients in our population. Method We retrospectively selected from our Critical Care Nephrology database adult patients admitted in any of our hospital`s ICU between February to August 2020, excluding those at admission with diagnosis of AKI, serum creatinine &gt; 2.5 mg/dl, or those receiving dialysis (acute or chronic) or kidney transplantation. We defined AKI according to KDIGO criteria. The RAI score was defined as the worst condition score multiplied by the creatinine score. The performance of the RAI score was assessed by Receiver Operating Characteristic (ROC) analysis power to detect a difference of 0.2 between the area under the curve (AUC), under the null hypothesis of AUC = 0.5 (no diagnostic accuracy). The optimal cut point was estimated with the Youden method. Results From 1204 new ICU patients, we included 372 patients (women 40.3%), with mean age 60.9 (18-98) (table 1). Main indication for ICU admission was medical conditions. Mean APACHE II was 22.9, hemodinamic support was required in 41,1% patients, mechanical ventilation in 58.6% patients and diabetes mellitus was present in 21.5% patients. AKI KDIGO 2-3 developed in 26.8% of patients. Mean creatinine at admission was statistically different in patients with AKI (CI 0.95 –0.51 - --0.15 mg/dl, p=0.0004). The requirement of hemodynamic (p = 0.003) and ventilatory support (p = 0.009), sepsis (p = 0.003), and COVID-19 (p = 0.03) were more frequent in patients who developed AKI. Renal replacement therapy was required in 39 (60%) of patients with severe AKI (incidence 10,5%). RAI cutt-off point determined by Youden method in the overall sample was 24, being significantly higher in patients who developed AKI (16.54 Vs 7.47, CI 0.95 –13.5--4.99, p &lt;0.001). A cut-off point of 24 was required for the Best predictive capacity for severe AKI, with sensitivity, specificity, positive and negative likelihood ratio of 34%, 94%, 5.5 and 0.7 respectively. Conclusion In our population, RAI score requires a cutoff point much higher than that originally described to predict the development of severe AKI. Losing its discriminatory capacity.