ArticleCritical care (London, England)2022
Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes.
Article in Critical care (London, England), 2022. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.
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Who cites it
6 citing papers in PubMed, 10 citations in OpenAlex.
- Opportunities, challenges and future perspectives for target trial emulation in critical care clinical research.Critical care (London, England) · 2025Review
- Ethical considerations on the use of big data and artificial intelligence in kidney research from the ERA ethics committee.Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association · 2025Review
- When to stop immunotherapy for advanced melanoma: the emulated target trials.EClinicalMedicine · 2024Article
- Personalizing renal replacement therapy initiation in the intensive care unit: a reinforcement learning-based strategy with external validation on the AKIKI randomized controlled trials.Journal of the American Medical Informatics Association : JAMIA · 2024Article
- The relationship between trajectories of renal oxygen saturation and acute kidney injury: a prospective cohort study with a secondary analysis.Aging clinical and experimental research · 2024Article
- Causal inference using observational intensive care unit data: a scoping review and recommendations for future practice.NPJ digital medicine · 2023Article
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Authors and funding
6 authors at 2 institutions in 2 countries.
Funding
Abstract
BACKGROUND AND
objectivesDefining the optimal moment to start renal replacement therapy (RRT) in acute kidney injury (AKI) remains challenging. Multiple randomized controlled trials (RCTs) addressed this question whilst using absolute criteria such as pH or serum potassium. However, there is a need for identification of the most optimal cut-offs of these criteria. We conducted a causal analysis on routinely collected data (RCD) to compare the impact of different pre-specified dynamic treatment regimes (DTRs) for RRT initiation based on time-updated levels of potassium, pH, and urinary output on 30-day ICU mortality. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: Patients in the ICU of Ghent University Hospital were included at the time they met KDIGO-AKI-stage ≥ 2. We applied inverse-probability-of-censoring-weighted Aalen-Johansen estimators to evaluate 30-day survival under 81 DTRs prescribing RRT initiation under different thresholds of potassium, pH, or persisting oliguria.
resultsOut of 13,403 eligible patients (60.8 ± 16.8 years, SOFA 7.0 ± 4.1), 5622 (63.4 ± 15.3 years, SOFA 8.2 ± 4.2) met KDIGO-AKI-stage ≥ 2. The DTR that delayed RRT until potassium ≥ 7 mmol/l, persisting oliguria for 24-36 h, and/or pH < 7.0 (non-oliguric) or < 7.2 (oliguric) despite maximal conservative treatment resulted in a reduced 30-day ICU mortality (from 12.7% [95% CI 11.9-13.6%] under current standard of care to 10.5% [95% CI 9.5-11.7%]; risk difference 2.2% [95% CI 1.3-3.8%]) with no increase in patients starting RRT (from 471 [95% CI 430-511] to 475 [95% CI 342-572]). The fivefold cross-validation benchmark for the optimal DTR resulted in 30-day ICU mortality of 10.7%.
conclusionsOur causal analysis of RCD to compare RRT initiation at different thresholds of refractory low pH, high potassium, and persisting oliguria identified a DTR that resulted in a decrease in 30-day ICU mortality without increase in number of RRTs. Our results suggest that the current criteria to start RRT as implemented in most RCTs may be suboptimal. However, as our analysis is hypothesis generating, this optimal DTR should ideally be validated in a multicentric RCT.
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