The Renal Angina Index

The Renal Angina Index (RAI) combines risk and injury strata to assess patients in need of interventional therapy. Recent data has demonstrated improvements in survival and reduced ICU length of stay among survivors. Originally developed by Cincinnati Children's Hospital Medical Center (CCHMC), RAI has been studied and validated across multiple leading pediatric critical care centers^1-7.

TAKING FOCUS 2

Data has demonstrated improved sensitivity and specificity of RAI when coupled with uNGAL. This combination has led to the TAKING FOCUS 2 (TF2) study⁸ with endpoints targeting improvement in patient outcome and health economics.

Results from TF2 demonstrated both an 18.9% absolute survival rate improvement and an 11-day LOS reduction among surviving patients in the PICU who received continuous renal replacement therapy (CRRT)⁸.

The table below displays the full results from the TAKING FOCUS 2 study. Some of the persistent results worth highlighting are:

Survival Improvement: ↑18.9% (p = 0.02)
>15% Fluid Accumulation: ↓16% (p = 0.02)
PICU LOS Reduction: ↓11 days (↓46%) (p = 0.02)
CRRT Duration: ↓1.8 days (↓31%) (p = 0.06)
(2.2 days earlier initiation)
Conservative Cost Savings per CRRT Pt: $12,507

All patients who received CRRT (N=178)
Variable		Pre-TF2 (n=71)	Post-TF2 (n=107)	P-value
Pre-CRRT patient demographics and fluid status
Patient age (yrs)	Median [IQR]	8.1 [2.0, 15.1]	10.3 [2.3, 17.0]	0.37
Patient PICU admission weight (kg)	Median [IQR]	26.5 [13.3, 49.0]	30.7 [13.2, 59.0]	0.21
PRISM III score at PICU admission	Median [IQR]	12 [8.0, 16]	10 [5.0, 17]	0.23
Renal angina index at 12 hours of PICU admission	Median [IQR]	8 [6, 24]	15 [6, 40]	0.26
Time from PICU admission to CRRT initiation (d)	Median [IQR]	4.5 [2.5, 12.5]	2.3 [1.4, 5.8]	0.002
Fluid accumulation from PICU admission to CRRT initiation (%)	Median [IQR]	12.1 [4.9, 20.3]	4.1 [0.6, 12.2]	0.0008
PICU fluid accumulation >15% at CRRT initiation	Yes	26 (36.6%)	22 (20.6%)	0.02
PICU fluid accumulation >20% at CRRT initiation	Yes	18 (25.4%)	20 (18.7%)	0.35
Patient outcome measures		Pre-TF2 (n=71)	Post-TF2 (n=107)
Survival to CRRT D/C	Yes	48 (67.6%)	74 (69.2%)	0.87
Survival to PICU D/C	Yes	33 (46.5%)	70 (65.4%)	0.02
		Pre-TF2 (n=48)	Post-TF2 (n=74)
CRRT duration among CRRT survivors (d)	Median [IQR]	5.8 [2.9, 12.2]	4.0 [1.9, 9.7]	0.06
		Pre-TF2 (n=33)	Post-TF2 (n=70)
PICU LOS after CRRT D/C among PICU survivors (d)	Median [IQR]	8.6 [4.5, 13]	2.6 [0.7, 8.6]	0.002
Total PICU length of stay among PICU survivors (d)	Median [IQR]	24 [12, 39]	13 [6, 26]	0.02

Comparisons between the pre-TF2 and TF2 cohorts⁸

RAIDAR Health RAI-CDS Services

The RAIDAR Health RAI Service is a cloud-based software as a service (SaaS) that provides Clinical Decision Support (CDS) of the RAI protocol developed at CCHMC.

Primary Connections and Data Transfer for the RAI Service

Operation

The system receives ADT events via secured HL7v2/MLLP message (or equivalent REST/HTTPS)
After the time prescribed by the RAI algorithm, patient data is retrieved from the hospital's EHR via FHIR/HTTPS
The results of the RAI calculation are returned to the hospital's EHR via FHIR/HTTPS
EPIC is configured with a conditional order for uNGAL, to be triggered by a high RAI index, and confirmed by the clinician
Patient data is anonymized and kept for clinical study and reporting purposes

Customization and Maintenance

Current EPIC interactions were designed for use at CCHMC and must be customized by RAIDAR Health to adapt to the customer's IT infrastructure
The RAIDAR Health RAI Service will be monitored by RAIDAR Health, and any unexpected failure will be addressed by RAIDAR Health
Any new developments in the RAI algorithm, or improvements to the RAIDAR Health Service, will be deployed by RAIDAR Health

Software Validation & Clinical Training

Software validation to demonstrate consistent performance and security as benchmarked by CCHMC comparison
Clinical training that motivates clinical application and compliance toward predetermined endpoints

Interested?

To learn more about adopting RAI, email us at [email protected].

Goldstein, Chawla. Renal Angina, CJASN, 210;5(5):943-949.
Basu et al. Derivation and validation of the renal angina index to improve the predication of acute kidney injury in crit…, KI, 214;85:659-667
Menon et al. Urinary biomarker incorporation into the RAI early in intensive care unit admission optimizes AKI…, NDT, 216;31:586-594
Basu et al. Assessment of a RAI for prediction of severe AKI in critically ill children: a multicentre, multinational…, Lancet, 218;2:112-120
Abbasi et al. Discriminatory Precision of RAI in predicting AKI in children; a systematic review and meta-analysis…, AAEM, 220;8(1):e39
Goldstein et al. Integration of the RAI and urine neutrophil gelatinase-associated lipocalin improves severe AKI…, KIR, 222;7(8):1842-1849
Stanski et al. A risk-stratified assessment of biomarker-based acute kidney injury phenotypes in children, Ped Res, 222;Aug 6
Goldstein et al. Real-Time Acute Kidney Injury Risk Stratification - Biomarker Directed Fluid Management Improves Outcomes in Critically Ill Children and Young Adults. 223; Kidney International Reports 8:2690-270