A clinical model to predict successful renal replacement therapy (RRT) discontinuation in patients with Acute Kidney Injury (AKI)

Valle, Eduardo de Oliveira; Smolentzov, Igor; Gorzoni, João Lucas Martins; Salgado, Isabela Cavalcante; Mainardes, Lorena Catelan; Gomes, Vanessa Oliveira; Mélo Júnior, Charles Hamilton; Rodrigues, Camila Eleuterio; Vieira Júnior, José Mauro

doi:10.1016/j.clinsp.2023.100280

Eduardo de Oliveira Valle

conception and design of the work

data acquisition

interpretation of data and for the draft and review of the manuscript

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0000-0002-9436-9743

Igor Smolentzov

conception and design of the work

data acquisition

interpretation of data and for the draft and review of the manuscript

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0000-0001-6286-2560

João Lucas Martins Gorzoni

data acquisition

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0009-0002-2335-7160

Isabela Cavalcante Salgado

data acquisition

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0009-0004-9794-4194

Lorena Catelan Mainardes

data acquisition

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0000-0002-2685-5299

Vanessa Oliveira Gomes

data acquisition

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0009-0009-3897-447X

Charles Hamilton Mélo Júnior

data acquisition

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

http://orcid.org/0009-0004-1592-7324

Camila Eleuterio Rodrigues ^** Corresponding author. E-mail address:camila.eleuterio@hc.fm.usp.br (C.E. Rodrigues).

conception and design of the work

statistical analysis

interpretation of data and for the draft and review of the manuscript

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

Nephrology Department, Prince of Wales Clinical School ‒ UNSW Medicine & Health, Sydney, Australia

1 These authors contributed equally to this work.

http://orcid.org/0000-0003-0562-0893

José Mauro Vieira Júnior

conception and design of the work

interpretation of data and for the draft and review of the manuscript

read and approved the final manuscript

Nephrology Department, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP, Brazil

1 These authors contributed equally to this work.

http://orcid.org/0000-0002-1944-6980

* Corresponding author. E-mail address:camila.eleuterio@hc.fm.usp.br (C.E. Rodrigues).

1
These authors contributed equally to this work.

Conflicts of interest

The authors declare no conflicts of interest.

	[ALL] n= 124	Failure n= 49	Success n= 75	p-value	N
Baseline sCr, mg/dL, median [IQR]	0.96 [0.76;1.23]	0.98 [0.69;1.22]	0.96 [0.77;1.23]	0.600	124
Baseline eGFR, mL/min/1.73m² (mean ± SD)	84.5 ± 28.1	85.2 ± 28.2	84.0 ± 28.2	0.826	124
Age, years, median [IQR]	53.5 [44.0;63.0]	57.0 [48.0;65.0]	51.0 [40.0;62.0]	0.135	124
Gender, female, n (%)	41 (33.1%)	14 (28.6%)	27 (36.0%)	0.506	124
Body mass index, Kg/m² median [IQR]	26.0 [23.8;29.2]	26.0 [23.0;29.0]	26.0 [24.0;30.4]	0.470	124
Race, n (%)				0.350	124
White	84 (67.7%)	37 75.5%)	47 (62.7%)
Black	14 (11.3%)	5 (10.2%)	9 (12.0%)
Brown	24 (19.4%)	6 (12.2%)	18 (24.0%)
Other	2 (1.61%)	1 (2.04%)	1 (1.33%)
Hypertension, n (%)	57 (46.0%)	29 (59.2%)	28 (37.3%)	0.028	124
Diabetes, n (%)	80 (35.5%)	29 (40.8%)	51 (32.0%)	0.417	124
CHF, n (%)	5 (4.03%)	2 (4.08%)	3 (4.00%)	1.000	124
PVD, n (%)	14 (11.3%)	7 (14.3%)	7 (9.33%)	0.574	124
Cirrhosis, n (%)	30 (24.2%)	13 (26.5%)	17 (22.7%)	0.782	124
SAPS, mean ± SD	66.0 ± 14.2	62.7 ± 15.4	68.1 ± 13.0	0.044	124
SOFA, median [IQR]	10.0 [7.00;13.0]	8.00 [5.00;13.0]	11.0 [8.00;13.0]	0.027	124
Main cause of AKI, n (%)				0.928	124
COVID-19	51 (41.1%)	23 (46.9%)	28 (37.3%)
Sepsis (other than COVID-19)	26 (21.0%)	10 (20.4%)	16 (21.3%)
SIRS	3 (2.42%)	1 (2.04%)	2 (2.67%)
Kidney ischaemia	29 (23.4%)	11 (22.4%)	18 (24.0%)
Presumed AIN	2 (1.61%)	0	2 (2.67%)
Other	13 (10.5%)	4 (8.2%)	9 (12%)

	[ALL] n= 124	Failure n= 49	Success n= 75	p-value	N
First RRT modality, n (%)				0.481	124
PIRRT	57 (46.0%)	26 (53.1%)	31 (41.3%)
CVVHDF	35 (28.2%)	12 (24.5%)	23 (30.7%)
CVVHD	25 (20.2%)	8 (16.3%)	17 (22.7%)
CVVH	4 (3.2%)	2 (4.1%)	2 (2.7%)
Other	3 (2.4%)	1 (2.0%)	2 (2.7%)
nrSOFA^a a At the time of RRT discontinuation , median [IQR]	5.00 [2.00;7.00]	6.00 [3.00;8.00]	4.00 [1.00;6.00]	0.008	124
ΔnrSOFA^a a At the time of RRT discontinuation , median [IQR]	3.00 [1.00;5.00]	2.00 [0.00;4.00]	4.00 [1.00;6.50]	0.024	124
Diuretic need^b b One day before RRT discontinuation. , n (%)	62 (50.0%)	30 (61.2%)	32 (42.7%)	0.066	124
Urine output^a a At the time of RRT discontinuation , mL/day median [IQR]	1500 [900;2042]	1000 [650;1600]	1700 [1375;2125]	0.001	110
Daily fluid balance^a a At the time of RRT discontinuation , mL/day median [IQR]	332 [-404.25;781]	508 [146;844]	80.5 [-550.50;641]	0.022	110
Serum urea^a a At the time of RRT discontinuation , mg/dL, median [IQR]	118 [83.0;144]	122 [102;148]	109 [71.5;138]	0.013	124
Serum potassium^a a At the time of RRT discontinuation , mEq/L, mean ± SD	4.33 ± 0.67	4.56 ± 0.55	4.18 ± 0.69	0.001	124
Blood pH^a a At the time of RRT discontinuation , median [IQR]	7.40 [7.36;7.44]	7.38 [7.35;7.40]	7.41 [7.38;7.45]	0.003	124
Blood bicarbonate^a a At the time of RRT discontinuation , mmoL/L, median [IQR]	24.0 [21.0;26.0]	23.0 [21.0;25.0]	24.0 [21.1;26.5]	0.228	124
sCr1, mg/dL, median [IQR]	1.94 [1.40;2.71]	1.96 [1.59;2.52]	1.93 [1.36;3.11]	0.904	122
sCr2, mg/dL, median [IQR]	2.72 [1.84;3.51]	2.87 [2.18;3.53]	2.40 [1.62;3.45]	0.096	124
sCr3, mg/dL, median [IQR]	2.70 [1.94;3.67]	3.32 [2.55;4.14]	2.34 [1.71;3.31]	0.001	124
ΔsCr1, mg/dL, mean ± SD	0.64 ± 0.65	0.91 ± 0.67	0.47 ± 0.58	< 0.001	122
ΔsCr2, mg/dL, median [IQR]	0.14 [-0.13;0.43]	0.39 [0.13;0.59]	0.03 [-0.21;0.21]	< 0.001	124
KeGFR1, mL/min, median [IQR]	19.3 [7.62;36.4]	11.2 [3.24;25.2]	25.7 [12.2;44.0]	< 0.001	122
KeGFR2, mL/min, median [IQR]	25.6 [16.0;42.9]	17.2 [12.8;25.9]	33.6 [22.6;49.0]	< 0.001	124
sCr ratio (day 2/day 1), median [IQR]	1.27 [1.11;1.56]	1.44 [1.15;1.72]	1.22 [1.07;1.40]	0.001	122
sCr ratio (day 3/day 1), median [IQR]	1.33 [1.08;1.79]	1.61 [1.30;1.99]	1.19 [0.93;1.57]	< 0.001	122

Risk factor	OR (95% CI)	p-value	c-statistic
Baseline sCr	1.29 (0.56; 3.17)	0.56	0.53
Baseline eGFR	0.998 (0.99; 1.01)	0.82	0.51
Age	0.98 (0.95; 1.005)	0.13	0.58
Gender	0.71 (0.32; 1.53)	0.39	0.54
BMI	1.01 (0.94; 1.08)	0.86	0.54
Race	Black: 1.42 (0.44; 4.59)	0.37	0.57
	Brown: 2.36 (0.85; 6.55)
	Other: 0.79 (0.05; 13.01)
Hypertension	0.41 (0.19; 0.85)	0.02	0.61
Diabetes	0.68 (0.321; 1.45)	0.32	0.54
CHF	0.98 (0.16; 7.64)	0.98	0.50
PVD	0.62 (0.20; 1.88)	0.40	0.52
Cirrhosis	0.81 (0.35; 1.87)	0.62	0.52
SAPS	1.03 (1.002; 1.06)	0.04	0.60
Main cause of AKI	Meaningless	0.99	0.57
First RRT modality	CVVHDF: 1.61 (0.68; 3.92)	0.99	0.56
	CVVHD: 1.78 (0.68; 4.98)
	CVVH: 0.84 (0.09; 7.39)
nrSOFA^a a At the time of RRT discontinuation	0.86 (0.77; 0.97)	0.01	0.64
Δ nrSOFA^a a At the time of RRT discontinuation	1.13 (1.03; 1.26)	0.01	0.62
Diuretic need^b b One day before RRT discontinuation.	0.47 (0.22; 0.97)	0.044	0.59
Urine output^a a At the time of RRT discontinuation	1.0007 (1.000; 1.001)	0.005	0.69
Daily fluid balance^a a At the time of RRT discontinuation	0.9995 (0.9990; 0.9999)	0.04	0.63
Serum urea^a a At the time of RRT discontinuation	0.99 (0.98; 0.999)	0.04	0.63
Serum potassium^a a At the time of RRT discontinuation	0.39 (0.20; 0.70)	0.002	0.68
Blood pH^a a At the time of RRT discontinuation	2094 (9.04; 1079089)	0.01	0.66
Blood bicarbonate^a a At the time of RRT discontinuation	1.06 (0.96; 1.18)	0.23	0.56
sCr1	1.13 (0.84; 1.57)	0.41	0.51
sCr2	0.94 (0.76; 1.18)	0.61	0.59
sCr3	0.79 (0.62; 0.99)	0.05	0.68
ΔsCr1	0.31 (0.15; 0.58)	0.0005	0.69
ΔsCr2	0.10 (0.03; 0.25)	0.00002	0.77
KeGFR1	1.03 (1.01; 1.06)	0.002	0.69
KeGFR2	1.05 (1.03; 1.09)	0.0001	0.76
sCr ratio (day 2/day 1)	0.15 (0.04; 0.43)	0.001	0.67
sCr ratio (day 3/day 1)	0.16 (0.06; 0.38)	0.00006	0.73

Risk factor	Model 1 - c-statistic 0.786		Model 2 - c-statistic 0.804		Model 3 - c-statistic 0.798		Model 4 - c-statistic 0.812
	OR (95% CI)	p-value	OR (95% CI)	p-value	OR (95% CI)	p-value	OR (95% CI)	p-value
nrSOFA^a a At the time of RRT discontinuation.	0.85 (0.73; 0.99)	0.04	0.87 (0.74; 1.01)	0.06	0.88 (0.75; 1.03)	0.11	0.83 (0.71; 0.98)	0.02
UO^a a At the time of RRT discontinuation.	1.00 (1.00; 1.00)	0.12	1.00 (1.00; 1.00)	0.08	1.00 (1.00; 1.00)	0.09	1.00 (1.00; 1.00)	0.23
Daily FB^a a At the time of RRT discontinuation.	1.00 (1.00; 1.00)	0.36	1.00 (1.00; 1.00)	0.39	1.00 (1.00; 1.00)	0.50	1.00 (1.00; 1.00)	0.25
Serum U^a a At the time of RRT discontinuation.	1.00 (0.99; 1.01)	0.76	1.00 (0.98; 1.01)	0.61	0.99 (0.98; 1.00)	0.26	1.00 (0.99; 1.01)	0.69
Serum K^a a At the time of RRT discontinuation.	0.39 (0.16; 0.96)	0.04	0.40 (0.16; 0.96)	0.03	0.42 (0.17; 1.02)	0.05	0.40 (0.16; 0.99)	0.04
Blood pH^a a At the time of RRT discontinuation.	57.67 (0.04; 86826.6)	0.28	84.24 (0.05; 133270.3)	0.22	152.98 (0.09; 269551.6)	0.17	32.87 (0.02; 67337.7)	0.36
KeGFR1	1.03 (1.00; 1.05)	0.04
ΔsCr1			0.36 (0.15; 0.85)	0.01
sCr ratio (day 2/day 1)					0.20 (0.05; 0.85)	0.02
KeGFR2							1.04 (1.01; 1.08)	< 0.01
ΔsCr2
sCr ratio (day 3/day 1)
Risk factor	Model 5 - c-statistic 0.839		Model 6 - c-statistic 0.812
	OR (95% CI)	p-value	OR (95% CI)	p-value
nrSOFA^a a At the time of RRT discontinuation.	0.84 (0.71; 1.00)	0.04	0.89 (0.75; 1.04)	0.14
UO^a a At the time of RRT discontinuation.	1.00 (1.00; 1.00)	0.15	1.00 (1.00; 1.00)	0.13
Daily FB^a a At the time of RRT discontinuation.	1.00 (1.00; 1.00)	0.50	1.00 (1.00; 1.00)	0.54
Serum U^a a At the time of RRT discontinuation.	0.99 (0.98; 1.00)	0.07	0.99 (0.98; 1.00)	0.15
Serum K^a a At the time of RRT discontinuation.	0.49 (0.20; 1.20)	0.11	0.40 (0.16; 0.99)	0.04
Blood pH^a a At the time of RRT discontinuation.	188.74 (0.05; 685805.7)	0.20	263.54 (0.10; 672343.4)	0.14
KeGFR1
ΔsCr1
sCr ratio (day 2/day 1)
KeGFR 2
ΔsCr2	0.08 (0.02; 0.35)	< 0.01
sCr ratio (day 3/day 1)			0.16 (0.05; 0.55)	< 0.01

c-statistic: 0.88	OR (95% CI)	p-value	score
Urine output > 1350 mL/day	4.50 (1.46; 13.90)	0.01	4
nrSOFA ≤ 4	3.56 (1.18; 10.75)	0.02	4
Fluid balance ≤ 86 mL/day	2.93 (0.93; 9.24)	0.07	3
Serum urea ≤ 91 mg/dL	7.58 (1.69; 33.93)	0.01	8
pH > 7.40	1.81 (0.58; 5.63)	0.30	2
Serum K ≤ 4.3	4.84 (1.53; 15.27)	0.01	5
ΔsCr1 ≤ 0.87mg/dL	2.71 (0.85; 8.66)	0.09	3
Final complete score			29

Score	Likelihood of success
0	4.9%
5	18.1%
10	48.4%
15	80.0%
18	90.5%
20	94.4%
25	98.6%

[1] * Corresponding author. E-mail address:camila.eleuterio@hc.fm.usp.br (C.E. Rodrigues).

Brasil

Brasil

A clinical model to predict successful renal replacement therapy (RRT) discontinuation in patients with Acute Kidney Injury (AKI)

Highlights

Abstract

Introduction

Methods

Results

Conclusion