Patients with acute kidney injury (AKI) are at high risk of developing chronic kidney disease (CKD), but identifying those at greatest risk remains challenging. We used electronic health record (EHR) data to dynamically track AKI patients' clinical evolution and characterize AKI-to-CKD progression. Post-AKI clinical states were identified by clustering patient vectors derived from longitudinal medical codes and creatinine measurements. Transition probabilities between states and progression to CKD were estimated using multi-state modeling. After identifying common post-AKI trajectories, CKD risk factors in AKI subpopulations were identified through survival analysis. Of 20,699 patients with AKI at admission, 3,491 (17%) developed CKD. We identified fifteen distinct post-AKI states, each with different probabilities of CKD development. Most patients (75%, n=15,607) remained in a single state or made only one transition during the study period. Both established (e.g., AKI severity, diabetes, hypertension, heart failure, liver disease) and novel CKD risk factors, with their impact varying across these clinical states. This study demonstrates a data-driven approach for identifying high-risk AKI patients, supporting the development of decision-support tools for early CKD detection and intervention.

Background: Cirrhosis is a progressive liver disease with high mortality and frequent complications, notably acute kidney injury (AKI), which occurs in up to 50% of hospitalized patients and worsens outcomes. AKI stems from complex hemodynamic, inflammatory, and metabolic changes, making early detection essential. Many predictive tools lack accuracy, interpretability, and alignment with intensive care unit (ICU) workflows. This study developed an interpretable machine learning model for early AKI prediction in critically ill patients with cirrhosis. Methods: We conducted a retrospective analysis of the MIMIC-IV v2.2 database, identifying 1240 adult ICU patients with cirrhosis and excluding those with ICU stays under 48 hours or missing key data. Laboratory and physiological variables from the first 48 hours were extracted. The pipeline included preprocessing, missingness filtering, LASSO feature selection, and SMOTE class balancing. Six algorithms-LightGBM, CatBoost, XGBoost, logistic regression, naive Bayes, and neural networks-were trained and evaluated using AUROC, accuracy, F1-score, sensitivity, specificity, and predictive values. Results: LightGBM achieved the best performance (AUROC 0.808, 95% CI 0.741-0.856; accuracy 0.704; NPV 0.911). Key predictors included prolonged partial thromboplastin time, absence of outside-facility 20G placement, low pH, and altered pO2, consistent with known cirrhosis-AKI mechanisms and suggesting actionable targets. Conclusion: The LightGBM-based model enables accurate early AKI risk stratification in ICU patients with cirrhosis using routine clinical variables. Its high negative predictive value supports safe de-escalation for low-risk patients, and interpretability fosters clinician trust and targeted prevention. External validation and integration into electronic health record systems are warranted.

Background: Vancomycin, a key antibiotic for severe Gram-positive infections in ICUs, poses a high nephrotoxicity risk. Early prediction of kidney injury in critically ill patients is challenging. This study aimed to develop a machine learning model to predict vancomycin-related creatinine elevation using routine ICU data. Methods: We analyzed 10,288 ICU patients (aged 18-80) from the MIMIC-IV database who received vancomycin. Kidney injury was defined by KDIGO criteria (creatinine rise >=0.3 mg/dL within 48h or >=50% within 7d). Features were selected via SelectKBest (top 30) and Random Forest ranking (final 15). Six algorithms were tested with 5-fold cross-validation. Interpretability was evaluated using SHAP, Accumulated Local Effects (ALE), and Bayesian posterior sampling. Results: Of 10,288 patients, 2,903 (28.2%) developed creatinine elevation. CatBoost performed best (AUROC 0.818 [95% CI: 0.801-0.834], sensitivity 0.800, specificity 0.681, negative predictive value 0.900). Key predictors were phosphate, total bilirubin, magnesium, Charlson index, and APSIII. SHAP confirmed phosphate as a major risk factor. ALE showed dose-response patterns. Bayesian analysis estimated mean risk 60.5% (95% credible interval: 16.8-89.4%) in high-risk cases. Conclusions: This machine learning model predicts vancomycin-associated creatinine elevation from routine ICU data with strong accuracy and interpretability, enabling early risk detection and supporting timely interventions in critical care.

The performance of predictive models in clinical settings often degrades when deployed in new hospitals due to distribution shifts. This paper presents a large-scale study of causality-inspired domain generalization on heterogeneous multi-center intensive care unit (ICU) data. We apply anchor regression and introduce anchor boosting, a novel, tree-based nonlinear extension, to a large dataset comprising 400,000 patients from nine distinct ICU databases. The anchor regularization consistently improves out-of-distribution performance, particularly for the most dissimilar target domains. The methods appear robust to violations of theoretical assumptions, such as anchor exogeneity. Furthermore, we propose a novel conceptual framework to quantify the utility of large external data datasets. By evaluating performance as a function of available target-domain data, we identify three regimes: (i) a domain generalization regime, where only the external model should be used, (ii) a domain adaptation regime, where refitting the external model is optimal, and (iii) a data-rich regime, where external data provides no additional value.

Background: Hypertensive kidney disease (HKD) patients in intensive care units (ICUs) face high short-term mortality, but tailored risk prediction tools are lacking. Early identification of high-risk individuals is crucial for clinical decision-making. Methods: We developed a machine learning framework to predict 30-day in-hospital mortality among ICU patients with HKD using early clinical data from the MIMIC-IV v2.2 database. A cohort of 1,366 adults was curated with strict criteria, excluding malignancy cases. Eighteen clinical features-including vital signs, labs, comorbidities, and therapies-were selected via random forest importance and mutual information filtering. Several models were trained and compared with stratified five-fold cross-validation; CatBoost demonstrated the best performance. Results: CatBoost achieved an AUROC of 0.88 on the independent test set, with sensitivity of 0.811 and specificity of 0.798. SHAP values and Accumulated Local Effects (ALE) plots showed the model relied on meaningful predictors such as altered consciousness, vasopressor use, and coagulation status. Additionally, the DREAM algorithm was integrated to estimate patient-specific posterior risk distributions, allowing clinicians to assess both predicted mortality and its uncertainty. Conclusions: We present an interpretable machine learning pipeline for early, real-time risk assessment in ICU patients with HKD. By combining high predictive performance with uncertainty quantification, our model supports individualized triage and transparent clinical decisions. This approach shows promise for clinical deployment and merits external validation in broader critical care populations.

Traditional methods of surgical decision making heavily rely on human experience and prompt actions, which are variable. A data-driven system generating treatment recommendations based on patient states can be a substantial asset in perioperative decision-making, as in cases of intraoperative hypotension, for which suboptimal management is associated with acute kidney injury (AKI), a common and morbid postoperative complication. We developed a Reinforcement Learning (RL) model to recommend optimum dose of intravenous (IV) fluid and vasopressors during surgery to avoid intraoperative hypotension and postoperative AKI. We retrospectively analyzed 50,021 surgeries from 42,547 adult patients who underwent major surgery at a quaternary care hospital between June 2014 and September 2020. Of these, 34,186 surgeries were used for model training and 15,835 surgeries were reserved for testing. We developed a Deep Q-Networks based RL model using 16 variables including intraoperative physiologic time series, total dose of IV fluid and vasopressors extracted for every 15-minute epoch. The model replicated 69% of physician's decisions for the dosage of vasopressors and proposed higher or lower dosage of vasopressors than received in 10% and 21% of the treatments, respectively. In terms of IV fluids, the model's recommendations were within 0.05 ml/kg/15 min of the actual dose in 41% of the cases, with higher or lower doses recommended for 27% and 32% of the treatments, respectively. The model resulted in a higher estimated policy value compared to the physicians' actual treatments, as well as random and zero-drug policies. AKI prevalence was the lowest in patients receiving medication dosages that aligned with model's decisions. Our findings suggest that implementation of the model's policy has the potential to reduce postoperative AKI and improve other outcomes driven by intraoperative hypotension.

Background: Sepsis-Associated Acute Kidney Injury (SA-AKI) leads to high mortality in intensive care. This study develops machine learning models using the Medical Information Mart for Intensive Care IV (MIMIC-IV) database to predict Intensive Care Unit (ICU) mortality in SA-AKI patients. External validation is conducted using the eICU Collaborative Research Database. Methods: For 9,474 identified SA-AKI patients in MIMIC-IV, key features like lab results, vital signs, and comorbidities were selected using Variance Inflation Factor (VIF), Recursive Feature Elimination (RFE), and expert input, narrowing to 24 predictive variables. An Extreme Gradient Boosting (XGBoost) model was built for in-hospital mortality prediction, with hyperparameters optimized using GridSearch. Model interpretability was enhanced with SHapley Additive exPlanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME). External validation was conducted using the eICU database. Results: The proposed XGBoost model achieved an internal Area Under the Receiver Operating Characteristic curve (AUROC) of 0.878 (95% Confidence Interval: 0.859-0.897). SHAP identified Sequential Organ Failure Assessment (SOFA), serum lactate, and respiratory rate as key mortality predictors. LIME highlighted serum lactate, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, total urine output, and serum calcium as critical features. Conclusions: The integration of advanced techniques with the XGBoost algorithm yielded a highly accurate and interpretable model for predicting SA-AKI mortality across diverse populations. It supports early identification of high-risk patients, enhancing clinical decision-making in intensive care. Future work needs to focus on enhancing adaptability, versatility, and real-world applications.

Sepsis is a severe condition that causes the body to respond incorrectly to an infection. This reaction can subsequently cause organ failure, a major one being acute kidney injury (AKI). For septic patients, approximately 50% develop AKI, with a mortality rate above 40%. Creating models that can accurately predict AKI based on specific qualities of septic patients is crucial for early detection and intervention. Using medical data from septic patients during intensive care unit (ICU) admission from the Medical Information Mart for Intensive Care 3 (MIMIC-III) database, we extracted 3301 patients with sepsis, with 73% of patients developing AKI. The data was randomly divided into a training set (n = 1980, 40%), a test set (n = 661, 10%), and a validation set (n = 660, 50%). The proposed model was logistic regression, and it was compared against five baseline models: XGBoost, K Nearest Neighbors (KNN), Support Vector Machines (SVM), Random Forest (RF), and LightGBM. Area Under the Curve (AUC), Accuracy, F1-Score, and Recall were calculated for each model. After analysis, we were able to select 23 features to include in our model, the top features being urine output, maximum bilirubin, minimum bilirubin, weight, maximum blood urea nitrogen, and minimum estimated glomerular filtration rate. The logistic regression model performed the best, achieving an AUC score of 0.887 (95% CI: [0.861-0.915]), an accuracy of 0.817, an F1 score of 0.866, a recall score of 0.827, and a Brier score of 0.13. Compared to the best existing literature in this field, our model achieved an 8.57% improvement in AUC while using 13 fewer variables, showcasing its effectiveness in determining AKI in septic patients. While the features selected for predicting AKI in septic patients are similar to previous literature, the top features that influenced our model's performance differ.

Artificial Intelligence (AI) has become essential in modern healthcare, with large language models (LLMs) offering promising advances in clinical decision-making. Traditional model-based approaches, including those leveraging in-context demonstrations and those with specialized medical fine-tuning, have demonstrated strong performance in medical language processing but struggle with real-time adaptability, multi-step reasoning, and handling complex medical tasks. Agent-based AI systems address these limitations by incorporating reasoning traces, tool selection based on context, knowledge retrieval, and both short- and long-term memory. These additional features enable the medical AI agent to handle complex medical scenarios where decision-making should be built on real-time interaction with the environment. Therefore, unlike conventional model-based approaches that treat medical queries as isolated questions, medical AI agents approach them as complex tasks and behave more like human doctors. In this paper, we study the choice of the backbone LLM for medical AI agents, which is the foundation for the agent's overall reasoning and action generation. In particular, we consider the emergent o1 model and examine its impact on agents' reasoning, tool-use adaptability, and real-time information retrieval across diverse clinical scenarios, including high-stakes settings such as intensive care units (ICUs). Our findings demonstrate o1's ability to enhance diagnostic accuracy and consistency, paving the way for smarter, more responsive AI tools that support better patient outcomes and decision-making efficacy in clinical practice.

For severely affected COVID-19 patients, it is crucial to identify high-risk patients and predict survival and need for intensive care (ICU). Most of the proposed models are not well reported making them less reproducible and prone to high risk of bias particularly in presence of imbalance data/class. In this study, the performances of nine machine and deep learning algorithms in combination with two widely used feature selection methods were investigated to predict last status representing mortality, ICU requirement, and ventilation days. Fivefold cross-validation was used for training and validation purposes. To minimize bias, the training and testing sets were split maintaining similar distributions. Only 10 out of 122 features were found to be useful in prediction modelling with Acute kidney injury during hospitalization feature being the most important one. The algorithms performances depend on feature numbers and data pre-processing techniques. LSTM performs the best in predicting last status and ICU requirement with 90%, 92%, 86% and 95% accuracy, sensitivity, specificity, and AUC respectively. DNN performs the best in predicting Ventilation days with 88% accuracy. Considering all the factors and limitations including absence of exact time point of clinical onset, LSTM with carefully selected features can accurately predict last status and ICU requirement. DNN performs the best in predicting Ventilation days. Appropriate machine learning algorithm with carefully selected features and balance data can accurately predict mortality, ICU requirement and ventilation support. Such model can be very useful in emergency and pandemic where prompt and precise