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Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes

Pawel Morzywolek (UGent) , Johan Steen (UGent) , Stijn Vansteelandt (UGent) , Johan Decruyenaere (UGent) , Sigrid Sterckx (UGent) and Wim Van Biesen (UGent)
(2022) CRITICAL CARE. 26(1).
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Abstract
Background and objectives : Defining 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. Results : Out 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%. Conclusions : Our 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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MLA
Morzywolek, Pawel, et al. “Timing of Dialysis in Acute Kidney Injury Using Routinely Collected Data and Dynamic Treatment Regimes.” CRITICAL CARE, vol. 26, no. 1, 2022, doi:10.1186/s13054-022-04252-1.
APA
Morzywolek, P., Steen, J., Vansteelandt, S., Decruyenaere, J., Sterckx, S., & Van Biesen, W. (2022). Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes. CRITICAL CARE, 26(1). https://doi.org/10.1186/s13054-022-04252-1
Chicago author-date
Morzywolek, Pawel, Johan Steen, Stijn Vansteelandt, Johan Decruyenaere, Sigrid Sterckx, and Wim Van Biesen. 2022. “Timing of Dialysis in Acute Kidney Injury Using Routinely Collected Data and Dynamic Treatment Regimes.” CRITICAL CARE 26 (1). https://doi.org/10.1186/s13054-022-04252-1.
Chicago author-date (all authors)
Morzywolek, Pawel, Johan Steen, Stijn Vansteelandt, Johan Decruyenaere, Sigrid Sterckx, and Wim Van Biesen. 2022. “Timing of Dialysis in Acute Kidney Injury Using Routinely Collected Data and Dynamic Treatment Regimes.” CRITICAL CARE 26 (1). doi:10.1186/s13054-022-04252-1.
Vancouver
1.
Morzywolek P, Steen J, Vansteelandt S, Decruyenaere J, Sterckx S, Van Biesen W. Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes. CRITICAL CARE. 2022;26(1).
IEEE
[1]
P. Morzywolek, J. Steen, S. Vansteelandt, J. Decruyenaere, S. Sterckx, and W. Van Biesen, “Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes,” CRITICAL CARE, vol. 26, no. 1, 2022.
@article{01GK1TGQD81XGTAN3EWKDMPHHM,
  abstract     = {{Background and objectives : Defining 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.

Results : Out 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%.

Conclusions : Our 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.}},
  articleno    = {{365}},
  author       = {{Morzywolek, Pawel and Steen, Johan and Vansteelandt, Stijn and Decruyenaere, Johan and Sterckx, Sigrid and Van Biesen, Wim}},
  issn         = {{1364-8535}},
  journal      = {{CRITICAL CARE}},
  language     = {{eng}},
  number       = {{1}},
  pages        = {{11}},
  title        = {{Timing of dialysis in acute kidney injury using routinely collected data and dynamic treatment regimes}},
  url          = {{http://dx.doi.org/10.1186/s13054-022-04252-1}},
  volume       = {{26}},
  year         = {{2022}},
}

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