Trajectories of Fluid Management after Initiation of Kidney Replacement Therapy in Critically Ill Patients: Insights from the STARRT-AKI Trial
Bibliographic record
Abstract
Background: Fluid management is an essential component of renal replacement therapy (RRT) in critically ill patients. Both a positive cumulative fluid balance (CFB) and high net ultrafiltration (NUF) have been associated with adverse outcomes but fluid management trajectories remain incompletely described by previous efforts. We aimed to analyze the CFB/NUF as a trajectory over the first week after the initiation of RRT. Methods: This is a secondary analysis using fluid balance data from individuals enrolled in the standard-strategy arm of the STARRT-AKI trial who initiated RRT. Cumulative fluid balance (CFB) since RRT initiation and daily net ultrafiltration (NUF) adjusted for body weight during the first 7 days after initiation of RRT were the main variables studied. We employed multivariable joint longitudinal models to determine the association with 90-day mortality. We then modeled the trajectory of fluid parameters using spline functions and used latent class analysis methods to identify predominant trajectories to compare patients’ characteristics and outcomes. Results: We included 855 patients in the analysis. After adjustments, an association between CFB and 90-day mortality was found (HR: 1.075 (1.04; 1.11) p<0.001) but no association with net daily NUF (HR: 0.95 (CI: 0.64; 1.39) p=0.78). Using latent class analysis, we identified two distinct CFB/NUF trajectories. Class A was characterized by a slight increase in CFB and low/stable NUF after RRT initiation while class B was characterized by an increasingly negative CFB with initially higher daily NUF during the first 4 days followed by a stabilization after day 4. In adjusted analysis, individuals classified in class A were at higher risk for 90-day mortality (aOR: 2.22 CI: 1.52; 3.28) p<0.001) compared to class B. Conclusion: Beyond cumulative fluid balance and daily NUF rate, the overarching CFB/NUF trajectory should be considered when attempting to elucidate the safety of fluid balance management strategies.Predominant trajectories of A) cumulative fluid balance (CFB) in mL/kg and B) daily ultrafiltration rate (UF) in mL/kg/d.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.008 | 0.012 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.001 | 0.002 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.001 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".