Simulated comparison of care pathways: biomarker-guided patient management for acute kidney injury and fluid accumulation

Population enrichment strategies for management of acute kidney injury (AKI) are now being trialed in adult and pediatric patient populations. Early evidence suggests integration of risk stratification and injury specific biomarkers in management of AKI may improve renal and patient-based outcomes. Leveraging these data, we present a theoretical side-by-side comparison of patient trajectory juxtaposing standard of care to a risk stratified biomarker-guided approach in the management of pediatric septic shock. We describe use of AKI risk prediction enrichment provided by the renal angina index to direct assessment of the distal tubule damage biomarker neutrophil gelatinase associated lipocalin for prognosis and to guide intervention opportunities for AKI and fluid balance management. This real-time comparison illustrates potential opportunities to optimize clinical interventions through an integrated risk stratification and biomarker strategy. Specifically, biomarkers may contribute to identification of appropriate time windows for prevention and timely treatment which include, but are not limited to, personalization of antibiotic dosing, mitigation of excessive fluid delivery, earlier transition from pharmacological to mechanical fluid balance strategies, and enhanced guidance for liberation from renal replacement therapy. Though a simulation, the comparison is evidence-informed and thus provides a plausible illustration of how biomarker-guided management may influence clinical decision-making and identify potential opportunities to optimize care.