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Zappalà S, Alfieri F, Ancona A, Taccone FS, Maviglia R, Cauda V, Finazzi S, Dell'Anna AM. Development and external validation of a machine learning model for the prediction of persistent acute kidney injury stage 3 in multi-centric, multi-national intensive care cohorts. Crit Care 2024; 28:189. [PMID: 38834995 DOI: 10.1186/s13054-024-04954-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/14/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND The aim of this retrospective cohort study was to develop and validate on multiple international datasets a real-time machine learning model able to accurately predict persistent acute kidney injury (AKI) in the intensive care unit (ICU). METHODS We selected adult patients admitted to ICU classified as AKI stage 2 or 3 as defined by the "Kidney Disease: Improving Global Outcomes" criteria. The primary endpoint was the ability to predict AKI stage 3 lasting for at least 72 h while in the ICU. An explainable tree regressor was trained and calibrated on two tertiary, urban, academic, single-center databases and externally validated on two multi-centers databases. RESULTS A total of 7759 ICU patients were enrolled for analysis. The incidence of persistent stage 3 AKI varied from 11 to 6% in the development and internal validation cohorts, respectively and 19% in external validation cohorts. The model achieved area under the receiver operating characteristic curve of 0.94 (95% CI 0.92-0.95) in the US external validation cohort and 0.85 (95% CI 0.83-0.88) in the Italian external validation cohort. CONCLUSIONS A machine learning approach fed with the proper data pipeline can accurately predict onset of Persistent AKI Stage 3 during ICU patient stay in retrospective, multi-centric and international datasets. This model has the potential to improve management of AKI episodes in ICU if implemented in clinical practice.
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Affiliation(s)
- Simone Zappalà
- U-Care Medical srl, Corso Castelfidardo 30A, 10129, Turin, Italy
| | | | - Andrea Ancona
- U-Care Medical srl, Corso Castelfidardo 30A, 10129, Turin, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Riccardo Maviglia
- Department of Anesthesia, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy
| | - Valentina Cauda
- U-Care Medical srl, Corso Castelfidardo 30A, 10129, Turin, Italy
- Department of Applied Science and Technology, Politecnico di Torino, C.so Duca degli Abruzzi 24, 10129, Turin, Italy
| | - Stefano Finazzi
- Clinical Data Science Laboratory, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via Stezzano 87, 24126, Bergamo, BG, Italy
| | - Antonio Maria Dell'Anna
- Department of Anesthesia, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168, Rome, Italy.
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Liu Y, Joly R, Reading Turchioe M, Benda N, Hermann A, Beecy A, Pathak J, Zhang Y. Preparing for the bedside-optimizing a postpartum depression risk prediction model for clinical implementation in a health system. J Am Med Inform Assoc 2024; 31:1258-1267. [PMID: 38531676 PMCID: PMC11105144 DOI: 10.1093/jamia/ocae056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 02/23/2024] [Accepted: 03/04/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE We developed and externally validated a machine-learning model to predict postpartum depression (PPD) using data from electronic health records (EHRs). Effort is under way to implement the PPD prediction model within the EHR system for clinical decision support. We describe the pre-implementation evaluation process that considered model performance, fairness, and clinical appropriateness. MATERIALS AND METHODS We used EHR data from an academic medical center (AMC) and a clinical research network database from 2014 to 2020 to evaluate the predictive performance and net benefit of the PPD risk model. We used area under the curve and sensitivity as predictive performance and conducted a decision curve analysis. In assessing model fairness, we employed metrics such as disparate impact, equal opportunity, and predictive parity with the White race being the privileged value. The model was also reviewed by multidisciplinary experts for clinical appropriateness. Lastly, we debiased the model by comparing 5 different debiasing approaches of fairness through blindness and reweighing. RESULTS We determined the classification threshold through a performance evaluation that prioritized sensitivity and decision curve analysis. The baseline PPD model exhibited some unfairness in the AMC data but had a fair performance in the clinical research network data. We revised the model by fairness through blindness, a debiasing approach that yielded the best overall performance and fairness, while considering clinical appropriateness suggested by the expert reviewers. DISCUSSION AND CONCLUSION The findings emphasize the need for a thorough evaluation of intervention-specific models, considering predictive performance, fairness, and appropriateness before clinical implementation.
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Affiliation(s)
- Yifan Liu
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
| | - Rochelle Joly
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY 10065, United States
| | | | - Natalie Benda
- Columbia University School of Nursing, New York, NY, United States
| | - Alison Hermann
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065, United States
| | - Ashley Beecy
- Department of Medicine, Weill Cornell Medicine, New York, NY 10065, United States
- NewYork-Presbyterian Hospital, New York, NY 10065, United States
| | - Jyotishman Pathak
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
- Department of Psychiatry, Weill Cornell Medicine, New York, NY 10065, United States
| | - Yiye Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, United States
- NewYork-Presbyterian Hospital, New York, NY 10065, United States
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Barea Mendoza JA, Valiente Fernandez M, Pardo Fernandez A, Gómez Álvarez J. Current perspectives on the use of artificial intelligence in critical patient safety. Med Intensiva 2024:S2173-5727(24)00080-8. [PMID: 38677902 DOI: 10.1016/j.medine.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/11/2024] [Indexed: 04/29/2024]
Abstract
Intensive Care Units (ICUs) have undergone enhancements in patient safety, and artificial intelligence (AI) emerges as a disruptive technology offering novel opportunities. While the published evidence is limited and presents methodological issues, certain areas show promise, such as decision support systems, detection of adverse events, and prescription error identification. The application of AI in safety may pursue predictive or diagnostic objectives. Implementing AI-based systems necessitates procedures to ensure secure assistance, addressing challenges including trust in such systems, biases, data quality, scalability, and ethical and confidentiality considerations. The development and application of AI demand thorough testing, encompassing retrospective data assessments, real-time validation with prospective cohorts, and efficacy demonstration in clinical trials. Algorithmic transparency and explainability are essential, with active involvement of clinical professionals being crucial in the implementation process.
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Affiliation(s)
- Jesús Abelardo Barea Mendoza
- UCI de Trauma y Emergencias. Servicio de Medicina Intensiva. Hospital Universitario 12 de Octubre. Instituto de Investigación Hospital 12 de Octubre, Spain.
| | - Marcos Valiente Fernandez
- UCI de Trauma y Emergencias. Servicio de Medicina Intensiva. Hospital Universitario 12 de Octubre. Instituto de Investigación Hospital 12 de Octubre, Spain
| | | | - Josep Gómez Álvarez
- Hospital Universitari de Tarragona Joan XXIII. Universitat Rovira i Virgili. Institut d'Investigació Sanitària Pere i Virgili, Tarragona, Spain
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Perschinka F, Peer A, Joannidis M. [Artificial intelligence and acute kidney injury]. Med Klin Intensivmed Notfmed 2024; 119:199-207. [PMID: 38396124 PMCID: PMC10995052 DOI: 10.1007/s00063-024-01111-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/17/2024] [Indexed: 02/25/2024]
Abstract
Digitalization is increasingly finding its way into intensive care units and with it artificial intelligence (AI) for critically ill patients. One promising area for the use of AI is in the field of acute kidney injury (AKI). The use of AI is primarily focused on the prediction of AKI, but further approaches are also being used to classify existing AKI into different phenotypes. Different AI models are used for prediction. The area under the receiver operating characteristic curve values (AUROC) achieved with these models vary and are influenced by several factors, such as the prediction time and the definition of AKI. Most models have an AUROC between 0.650 and 0.900, with lower values for predictions further into the future and when applying Acute Kidney Injury Network (AKIN) instead of KDIGO criteria. Classification into phenotypes already makes it possible to categorize patients into groups with different risks of mortality or requirement of renal replacement therapy (RRT), but the etiologies or therapeutic consequences derived from this are still lacking. However, all the models suffer from AI-specific shortcomings. The use of large databases does not make it possible to promptly include recent changes in therapy and the implementation of new biomarkers in a relevant proportion. For this reason, serum creatinine and urinary output, with their known limitations, dominate current AI models for prediction impairing the performance of the current models. On the other hand, the increasingly complex models no longer allow physicians to understand the basis on which the warning of a threatening AKI is calculated and subsequent initiation of therapy should take place. The successful use of AIs in routine clinical practice will be highly determined by the trust of the physicians in the systems and overcoming the aforementioned weaknesses. However, the clinician will remain irreplaceable as the decisive authority for critically ill patients by combining measurable and nonmeasurable parameters.
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Affiliation(s)
| | | | - Michael Joannidis
- Gemeinsame Einrichtung für Internistische Notfall- und Intensivmedizin, Department Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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Baumgart A, Beck G, Ghezel-Ahmadi D. [Artificial intelligence in intensive care medicine]. Med Klin Intensivmed Notfmed 2024; 119:189-198. [PMID: 38546864 DOI: 10.1007/s00063-024-01117-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 01/29/2024] [Accepted: 02/05/2024] [Indexed: 04/05/2024]
Abstract
The integration of artificial intelligence (AI) into intensive care medicine has made considerable progress in recent studies, particularly in the areas of predictive analytics, early detection of complications, and the development of decision support systems. The main challenges remain availability and quality of data, reduction of bias and the need for explainable results from algorithms and models. Methods to explain these systems are essential to increase trust, understanding, and ethical considerations among healthcare professionals and patients. Proper training of healthcare professionals in AI principles, terminology, ethical considerations, and practical application is crucial for the successful use of AI. Careful assessment of the impact of AI on patient autonomy and data protection is essential for its responsible use in intensive care medicine. A balance between ethical and practical considerations must be maintained to ensure patient-centered care while complying with data protection regulations. Synergistic collaboration between clinicians, AI engineers, and regulators is critical to realizing the full potential of AI in intensive care medicine and maximizing its positive impact on patient care. Future research and development efforts should focus on improving AI models for real-time predictions, increasing the accuracy and utility of AI-based closed-loop systems, and overcoming ethical, technical, and regulatory challenges, especially in generative AI systems.
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Affiliation(s)
- André Baumgart
- Zentrum für Präventivmedizin und Digitale Gesundheit, Medizinische Fakultät Mannheim der Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
| | - Grietje Beck
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerzmedizin, Universitätsmedizin Mannheim gGmbH, Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Deutschland
| | - David Ghezel-Ahmadi
- Abteilung für Anästhesiologie, Intensivmedizin und Schmerzmedizin, Universitätsmedizin Mannheim gGmbH, Medizinische Fakultät Mannheim der Universität Heidelberg, Mannheim, Deutschland
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Hu J, Xu J, Li M, Jiang Z, Mao J, Feng L, Miao K, Li H, Chen J, Bai Z, Li X, Lu G, Li Y. Identification and validation of an explainable prediction model of acute kidney injury with prognostic implications in critically ill children: a prospective multicenter cohort study. EClinicalMedicine 2024; 68:102409. [PMID: 38273888 PMCID: PMC10809096 DOI: 10.1016/j.eclinm.2023.102409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 12/19/2023] [Accepted: 12/19/2023] [Indexed: 01/27/2024] Open
Abstract
Background Acute kidney injury (AKI) is a common and serious organ dysfunction in critically ill children. Early identification and prediction of AKI are of great significance. However, current AKI criteria are insufficiently sensitive and specific, and AKI heterogeneity limits the clinical value of AKI biomarkers. This study aimed to establish and validate an explainable prediction model based on the machine learning (ML) approach for AKI, and assess its prognostic implications in children admitted to the pediatric intensive care unit (PICU). Methods This multicenter prospective study in China was conducted on critically ill children for the derivation and validation of the prediction model. The derivation cohort, consisting of 957 children admitted to four independent PICUs from September 2020 to January 2021, was separated for training and internal validation, and an external data set of 866 children admitted from February 2021 to February 2022 was employed for external validation. AKI was defined based on serum creatinine and urine output using the Kidney Disease: Improving Global Outcome (KDIGO) criteria. With 33 medical characteristics easily obtained or evaluated during the first 24 h after PICU admission, 11 ML algorithms were used to construct prediction models. Several evaluation indexes, including the area under the receiver-operating-characteristic curve (AUC), were used to compare the predictive performance. The SHapley Additive exPlanation method was used to rank the feature importance and explain the final model. A probability threshold for the final model was identified for AKI prediction and subgrouping. Clinical outcomes were evaluated in various subgroups determined by a combination of the final model and KDIGO criteria. Findings The random forest (RF) model performed best in discriminative ability among the 11 ML models. After reducing features according to feature importance rank, an explainable final RF model was established with 8 features. The final model could accurately predict AKI in both internal (AUC = 0.929) and external (AUC = 0.910) validations, and has been translated into a convenient tool to facilitate its utility in clinical settings. Critically ill children with a probability exceeding or equal to the threshold in the final model had a higher risk of death and multiple organ dysfunctions, regardless of whether they met the KDIGO criteria for AKI. Interpretation Our explainable ML model was not only successfully developed to accurately predict AKI but was also highly relevant to adverse outcomes in individual children at an early stage of PICU admission, and it mitigated the concern of the "black-box" issue with an undirect interpretation of the ML technique. Funding The National Natural Science Foundation of China, Jiangsu Province Science and Technology Support Program, Key talent of women's and children's health of Jiangsu Province, and Postgraduate Research & Practice Innovation Program of Jiangsu Province.
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Affiliation(s)
- Junlong Hu
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Jing Xu
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Min Li
- Pediatric Intensive Care Unit, Anhui Provincial Children’s Hospital, Hefei, Anhui province, China
| | - Zhen Jiang
- Pediatric Intensive Care Unit, Xuzhou Children’s Hospital, Xuzhou, Jiangsu province, China
| | - Jie Mao
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Lian Feng
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Kexin Miao
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Huiwen Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Jiao Chen
- Pediatric Intensive Care Unit, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Zhenjiang Bai
- Pediatric Intensive Care Unit, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Xiaozhong Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
| | - Guoping Lu
- Pediatric Intensive Care Unit, Children’s Hospital of Fudan University, Shanghai, China
| | - Yanhong Li
- Department of Nephrology and Immunology, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
- Institute of Pediatric Research, Children’s Hospital of Soochow University, Suzhou, Jiangsu province, China
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