Dataset Information

Multistate Modeling of Clinical Trajectories and Outcomes in the ICU: A Proof-of-Concept Evaluation of Acute Kidney Injury Among Critically Ill Patients With COVID-19.

ABSTRACT: Multistate models yield high-fidelity analyses of the dynamic state transition and temporal dimensions of a clinical condition's natural history, offering superiority over aggregate modeling techniques for addressing these types of problems.

Objectives

To demonstrate the utility of these models in critical care, we examined acute kidney injury (AKI) development, progression, and outcomes in COVID-19 critical illness through multistate analyses.

Design setting and participants

Retrospective cohort study at an urban tertiary-care academic hospital in the United States. All patients greater than or equal to 18 years in an ICU with COVID-19 in 2020, excluding patients with preexisting end-stage renal disease.

Main outcomes and measures

Using electronic health record data, we determined AKI presence/stage in discrete 12-hour time windows and fit multistate models to determine longitudinal transitions and outcomes.

Results

Of 367 encounters, 241 (66%) experienced AKI (maximal stages: 88 stage-1, 49 stage-2, 104 stage-3 AKI [51 received renal replacement therapy (RRT), 53 did not]). Patients receiving RRT overwhelmingly received invasive mechanical ventilation (IMV) (n = 60, 95%) compared with the AKI-without-RRT (n = 98, 53%) and no-AKI groups (n = 39, 32%; p < 0.001), with similar mortality patterns (RRT: n = 36, 57%; AKI: n = 74, 40%; non-AKI: n = 23, 19%; p < 0.001). After 24 hours in the ICU, almost half the cohort had AKI (44.9%; 95% CI, 41.6-48.2%). At 7 days after stage-1 AKI, 74.0% (63.6-84.4) were AKI-free or discharged. By contrast, fewer patients experiencing stage-3 AKI were recovered (30.0% [24.1-35.8%]) or discharged (7.9% [5.2-10.7%]) after 7 days. Early AKI occurred with similar frequency in patients receiving and not receiving IMV: after 24 hours in the ICU, 20.9% of patients (18.3-23.6%) had AKI and IMV, while 23.4% (20.6-26.2%) had AKI without IMV.

Conclusions and relevance

In a multistate analysis of critically ill patients with COVID-19, AKI occurred early and heterogeneously in the course of critical illness. Multistate methods are useful and underused in ICU care delivery science as tools for understanding trajectories, prognoses, and resource needs.

SUBMITTER: Lyons PG

PROVIDER: S-EPMC9722556 | biostudies-literature | 2022 Dec

REPOSITORIES: biostudies-literature

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Publications

Multistate Modeling of Clinical Trajectories and Outcomes in the ICU: A Proof-of-Concept Evaluation of Acute Kidney Injury Among Critically Ill Patients With COVID-19.

Lyons Patrick G PG Mody Aaloke A Bewley Alice F AF Schoer Morgan M Neelam Raju Bharat B Geng Elvin E Payne Philip R O PRO Sinha Pratik P Vijayan Anitha A

Critical care explorations 20221201 12

Multistate models yield high-fidelity analyses of the dynamic state transition and temporal dimensions of a clinical condition's natural history, offering superiority over aggregate modeling techniques for addressing these types of problems.<h4>Objectives</h4>To demonstrate the utility of these models in critical care, we examined acute kidney injury (AKI) development, progression, and outcomes in COVID-19 critical illness through multistate analyses.<h4>Design setting and participants</h4>Retro ...[more]

PMID: 36479445

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Project description:ObjectivesAcute kidney injury is common among the critically ill. However, the incidence, medication use, and outcomes of acute kidney injury have been variably described. We conducted a single-center, retrospective cohort study to examine the risk factors and correlates associated with acute kidney injury in critically ill adults with a particular focus on medication class usage.MethodsWe reviewed the electronic medical records of all adult patients admitted to an intensive care unit between 1 February and 30 August 2020. Acute kidney injury was defined by the 2012 Kidney Disease: Improving Global Outcomes guidelines. Data included were demographics, comorbidities, symptoms, laboratory parameters, interventions, and outcomes. The primary outcome was acute kidney injury incidence. A Least Absolute Shrinkage and Selection Operator regression model was used to determine risk factors associated with acute kidney injury. Secondary outcomes including acute kidney injury recovery and intensive care unit mortality were analyzed using a Cox regression model.ResultsAmong 226 admitted patients, 108 (47.8%) experienced acute kidney injury. 37 (34.3%), 39 (36.1%), and 32 patients (29.6%) were classified as acute kidney injury stages I-III, respectively. Among the recovery and mortality cohorts, analgesics/sedatives, anti-infectives, and intravenous fluids were significant (p-value < 0.05). The medication classes IV-fluid electrolytes nutrition (96.7%), gastrointestinal (90.2%), and anti-infectives (81.5%) were associated with an increased odds of developing acute kidney injury, odd ratios: 1.27, 1.71, and 1.70, respectively. Cox regression analyses revealed a significantly increased time-varying mortality risk for acute kidney injury-stage III, hazard ratio: 4.72 (95% confidence interval: 1-22.33). In the recovery cohort, time to acute kidney injury recovery was significantly faster in stage I, hazard ratio: 9.14 (95% confidence interval: 2.14-39.06) cohort when compared to the stage III cohort.ConclusionEvaluation of vital signs, laboratory, and medication use data may be useful to determine acute kidney injury risk stratification. The influence of particular medication classes further impacts the risk of developing acute kidney injury, necessitating the importance of examining pharmacotherapeutic regimens for early recognition of renal impairment and prevention.

Project description:Critically ill patients with COVID-19 are prone to develop severe acute kidney injury (AKI), defined as KDIGO (Kidney Disease Improving Global Outcomes) stages 2 or 3. However, data are limited in these patients. We aimed to report the incidence, risk factors, and prognostic impact of severe AKI in critically ill patients with COVID-19 admitted to the intensive care unit (ICU) for acute respiratory failure. A retrospective monocenter study including adult patients with laboratory-confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection admitted to the ICU for acute respiratory failure. The primary outcome was to identify the incidence and risk factors associated with severe AKI (KDIGO stages 2 or 3). Overall, 110 COVID-19 patients were admitted. Among them, 77 (70%) required invasive mechanical ventilation (IMV), 66 (60%) received vasopressor support, and 9 (8.2%) needed extracorporeal membrane oxygenation (ECMO). Severe AKI occurred in 50 patients (45.4%). In multivariable logistic regression analysis, severe AKI was independently associated with age (odds ratio (OR) = 1.08 (95% CI (confidence interval): 1.03-1.14), p = 0.003), IMV (OR = 33.44 (95% CI: 2.20-507.77), p = 0.011), creatinine level on admission (OR = 1.04 (95% CI: 1.008-1.065), p = 0.012), and ECMO (OR = 11.42 (95% CI: 1.95-66.70), p = 0.007). Inflammatory (interleukin-6, C-reactive protein, and ferritin) or thrombotic (D-dimer and fibrinogen) markers were not associated with severe AKI after adjustment for potential confounders. Severe AKI was independently associated with hospital mortality (OR = 29.73 (95% CI: 4.10-215.77), p = 0.001) and longer hospital length of stay (subhazard ratio = 0.26 (95% CI: 0.14-0.51), p < 0.001). At the time of hospital discharge, 74.1% of patients with severe AKI who were discharged alive from the hospital recovered normal or baseline renal function. Severe AKI was common in critically ill patients with COVID-19 and was not associated with inflammatory or thrombotic markers. Severe AKI was an independent risk factor of hospital mortality and hospital length of stay, and it should be rapidly recognized during SARS-CoV-2 infection.

Project description:BackgroundAcute kidney injury (AKI) is a common complication of COVID-19. While the exact mechanisms remain unclear, direct viral infection of renal tubular epithelial cells is hypothesized. Given the pH-dependent entry of coronaviruses into host cells, urine alkalinization was proposed as a potential preventive strategy.MethodsThis was a proof-of-concept prospective, randomized clinical trial in critically ill patients with COVID-19. Patients were randomized to urine alkalinization versus usual care. The intervention group received intravenous 8.4% sodium bicarbonate to achieve a urine pH ≥ 7.5 up to 10 days after randomization. The primary outcome was the proportion of patients achieving target urine pH. Secondary outcomes included changes in urine tissue inhibitor of metalloproteinases-2 (TIMP-2) and insulin-like growth factor-binding protein 7 (IGFBP7), AKI development, renal replacement therapy, and adverse effects.ResultsThe trial was terminated early due to slow recruitment and the end of the COVID-19 pandemic. Sixteen patients were enrolled (median age 48 years old, 75% male). More patients in the intervention group achieved target urine pH than in the control group (75% vs 37.5%, P = 0.315). There was a separation of urine pH between both groups throughout 10 days (P = 0.097 for interaction). However, the intervention did not significantly impact urine [TIMP-2]x[IGFBP7] concentrations (P = 0.813 for interaction) or clinical outcomes, including AKI occurrence (risk ratio 0.6 (95% confidence interval 0.21, 1.70), P = 0.619). More patients in the intervention group experienced hypernatremia and metabolic alkalosis. Notably, patients with elevated urine [TIMP-2]x[IGFBP7] concentrations and AKI had higher ICU and 60-day mortality.ConclusionsWhile urine alkalinization is feasible and can increase urine pH, we could not demonstrate differences in AKI rates or changes in urine [TIMP-2]x[IGFBP7] concentrations in critically ill COVID-19 patients.

Dataset Information

Multistate Modeling of Clinical Trajectories and Outcomes in the ICU: A Proof-of-Concept Evaluation of Acute Kidney Injury Among Critically Ill Patients With COVID-19.

Objectives

Design setting and participants

Main outcomes and measures

Results

Conclusions and relevance

Publications

Multistate Modeling of Clinical Trajectories and Outcomes in the ICU: A Proof-of-Concept Evaluation of Acute Kidney Injury Among Critically Ill Patients With COVID-19.

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