Pediatric nephrology (Berlin, Germany) · 2026
Differential associations of early fluid accumulation with acute kidney injury and mortality in critically ill children: a prospective cohort study with mediation and propensity-score analyses.
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Angadi Akshata, Bhargava Maneesha, Mehta Amarjeet
Аннотация
BACKGROUND: Cumulative fluid accumulation (FA), historically termed fluid overload, is reported to increase mortality in critically ill children, but whether its associations differ across renal and mortality outcomes-and whether any mortality association reflects a direct pathway, confounding, or mediation via acute kidney injury (AKI)-is unresolved. We applied convergent causal-inference methods.
METHODS: In a prospective cohort of 360 children (1 month-18 years) admitted ≥24 h to a tertiary paediatric intensive care unit, early fluid accumulation (first 24 h, Goldstein formula; historically termed fluid overload) was dichotomised at ≥5%.
PRIMARY OUTCOME: AKI (AKI Network criteria); secondary outcomes: PICU mortality, mechanical ventilation duration, length of stay.
ANALYSES: sequential multivariable regression, restricted cubic splines, propensity score matching, additive/multiplicative interaction, incremental discrimination, and exploratory mediation, all adjusted for the Paediatric Risk of Mortality III (PRISM III) score.
RESULTS: FA ≥ 5% occurred in 23.1%, AKI in 24.7%, mortality 19.4%. FA predicted AKI (adjusted OR 4.45; propensity-matched 2.72), with a non-linear dose-response inflecting at 2-5%. FA did not predict mortality: the crude association disappeared on AKI adjustment, the adjusted spline was flat, the matched estimate was null (OR 1.36), and FA added negligibly to PRISM III discrimination (ΔAUC 0.007). AKI dominated mortality (10.0% to 77.8% stagewise); the FA×AKI interaction was sub-additive; mediation attributed FA's small total association to AKI. FA was associated with longer PICU stay and ventilation.
CONCLUSIONS: Early FA shows differential associations: a potentially modifiable risk marker for AKI, associated with longer intensive care, but not independently associated with death once severity and AKI are considered. Limiting early FA may be a reasonable target for AKI prevention, although this requires interventional confirmation; PRISM III remains the mortality-prognostic tool.
METHODS: In a prospective cohort of 360 children (1 month-18 years) admitted ≥24 h to a tertiary paediatric intensive care unit, early fluid accumulation (first 24 h, Goldstein formula; historically termed fluid overload) was dichotomised at ≥5%.
PRIMARY OUTCOME: AKI (AKI Network criteria); secondary outcomes: PICU mortality, mechanical ventilation duration, length of stay.
ANALYSES: sequential multivariable regression, restricted cubic splines, propensity score matching, additive/multiplicative interaction, incremental discrimination, and exploratory mediation, all adjusted for the Paediatric Risk of Mortality III (PRISM III) score.
RESULTS: FA ≥ 5% occurred in 23.1%, AKI in 24.7%, mortality 19.4%. FA predicted AKI (adjusted OR 4.45; propensity-matched 2.72), with a non-linear dose-response inflecting at 2-5%. FA did not predict mortality: the crude association disappeared on AKI adjustment, the adjusted spline was flat, the matched estimate was null (OR 1.36), and FA added negligibly to PRISM III discrimination (ΔAUC 0.007). AKI dominated mortality (10.0% to 77.8% stagewise); the FA×AKI interaction was sub-additive; mediation attributed FA's small total association to AKI. FA was associated with longer PICU stay and ventilation.
CONCLUSIONS: Early FA shows differential associations: a potentially modifiable risk marker for AKI, associated with longer intensive care, but not independently associated with death once severity and AKI are considered. Limiting early FA may be a reasonable target for AKI prevention, although this requires interventional confirmation; PRISM III remains the mortality-prognostic tool.