---
title: "Early fluid accumulation predicts acute kidney injury but not mortality in critically ill children"
id: "pubmed-42895576"
canonical_url: "https://medichelpline.com/clinical-feed/pubmed-42895576"
content_type: "clinical_feed_article"
specialty: "Critical Care"
source_name: "PubMed / NCBI"
source_url: "https://pubmed.ncbi.nlm.nih.gov/42895576/"
doi: "10.1007/s00467-026-07558-2"
published_at: "2026-10-19T00:00:00.000Z"
evidence_level: "Journal Article"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Early fluid accumulation predicts acute kidney injury but not mortality in critically ill children
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/pubmed-42895576
- **Specialty:** [Critical Care](https://medichelpline.com/clinical-feed/critical-care.md)
- **Primary Source:** PubMed / NCBI
- **Source URL:** [Original Journal Publication](https://pubmed.ncbi.nlm.nih.gov/42895576/)
- **DOI:** [10.1007/s00467-026-07558-2](https://doi.org/10.1007%2Fs00467-026-07558-2)
- **Published At:** 2026-10-19T00:00:00.000Z
- **Evidence Rating:** Journal Article
## Executive GIST (TL;DR)
- Prospective cohort of 360 children (1 month–18 years) admitted ≥24 h to a tertiary PICU; investigators measured early **fluid accumulation (FA)** during the first 24 h using the Goldstein formula and dichotomised at ≥5%. - Early FA ≥5% occurred in 23.1% of patients. The cohort showed AKI in 24.7% and PICU mortality of 19.4%. - FA predicted subsequent **acute kidney injury (AKI)**: adjusted odds ratio reported by the authors was 4.45; propensity-score–matched estimate was 2.72. - The relationship between FA and AKI was non-linear, with a dose–response inflection between roughly 2% and 5% FA. - FA did not independently predict PICU mortality after adjustment. The crude mortality association disappeared when AKI and severity were considered; propensity-matched mortality OR was 1.36. - Adding FA to the **PRISM III** score minimally changed mortality discrimination (ΔAUC 0.007), indicating little incremental prognostic value for death. - AKI showed strong, stagewise associations with mortality (mortality ranged from 10.0% to 77.8% across AKI stages reported by the authors), and mediation analysis attributed FA’s small total association with death largely to AKI. - FA was associated with longer duration of mechanical ventilation and longer PICU length of stay in this cohort. - Analytic methods included multivariable regression, restricted cubic splines, propensity-score matching, interaction testing (additive/multiplicative), incremental discrimination, and exploratory mediation, all adjusted for **PRISM III** score. - The authors concluded limiting early FA could be a target to reduce AKI risk but noted interventional trials are required to confirm causality; PRISM III remains the dominant mortality prognostic tool in their data.
## Clinical Analysis & Structured Key Points
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Online ahead of print. # 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 [Akshata Angadi](https://pubmed.ncbi.nlm.nih.gov/?term=Angadi+A&cauthor_id=42895576)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#full-view-affiliation-1 "Department of Pediatrics, S Nijalingappa Medical College, Bagalkote, India."), [Maneesha Bhargava](https://pubmed.ncbi.nlm.nih.gov/?term=Bhargava+M&cauthor_id=42895576)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#full-view-affiliation-2 "Department of Paediatric Nephrology, SMS Medical College, Jaipur, India."), [Amarjeet Mehta](https://pubmed.ncbi.nlm.nih.gov/?term=Mehta+A&cauthor_id=42895576)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#full-view-affiliation-3 "Department of Pediatrics, JNU Institute for Medical Sciences and Research Centre, Jaipur, India. dramarjeetmehta@yahoo.com.") Affiliations Expand ### Affiliations * 1 Department of Pediatrics, S Nijalingappa Medical College, Bagalkote, India. * 2 Department of Paediatric Nephrology, SMS Medical College, Jaipur, India. * 3 Department of Pediatrics, JNU Institute for Medical Sciences and Research Centre, Jaipur, India. dramarjeetmehta@yahoo.com. * PMID: **42895576** * DOI: [ 10.1007/s00467-026-07558-2 ](https://doi.org/10.1007/s00467-026-07558-2) Item in Clipboard # 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 Akshata Angadi et al. Pediatr Nephrol. 2026. Show details Display options Display options Format Abstract PubMed PMID Pediatr Nephrol Actions * [ Search in PubMed ](https://pubmed.ncbi.nlm.nih.gov/?term=%22Pediatr+Nephrol%22%5Bjour%5D&sort=date&sort_order=desc) * [ Search in NLM Catalog ](https://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22Pediatr+Nephrol%22%5BTitle+Abbreviation%5D) * [ Add to Search ](https://pubmed.ncbi.nlm.nih.gov/42895576/) . 2026 Oct 19. doi: 10.1007/s00467-026-07558-2. Online ahead of print. ### Authors [Akshata Angadi](https://pubmed.ncbi.nlm.nih.gov/?term=Angadi+A&cauthor_id=42895576)[ 1 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#short-view-affiliation-1 "Department of Pediatrics, S Nijalingappa Medical College, Bagalkote, India."), [Maneesha Bhargava](https://pubmed.ncbi.nlm.nih.gov/?term=Bhargava+M&cauthor_id=42895576)[ 2 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#short-view-affiliation-2 "Department of Paediatric Nephrology, SMS Medical College, Jaipur, India."), [Amarjeet Mehta](https://pubmed.ncbi.nlm.nih.gov/?term=Mehta+A&cauthor_id=42895576)[ 3 ](https://pubmed.ncbi.nlm.nih.gov/42895576/#short-view-affiliation-3 "Department of Pediatrics, JNU Institute for Medical Sciences and Research Centre, Jaipur, India. dramarjeetmehta@yahoo.com.") ### Affiliations * 1 Department of Pediatrics, S Nijalingappa Medical College, Bagalkote, India. * 2 Department of Paediatric Nephrology, SMS Medical College, Jaipur, India. * 3 Department of Pediatrics, JNU Institute for Medical Sciences and Research Centre, Jaipur, India. dramarjeetmehta@yahoo.com. * PMID: **42895576** * DOI: [ 10.1007/s00467-026-07558-2 ](https://doi.org/10.1007/s00467-026-07558-2) Item in Clipboard Cite Display options Display options Format Abstract PubMed PMID Linked Discoveries ## Abstract **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. **Keywords:** Acute kidney injury; Fluid accumulation; Fluid overload; Mortality; PRISM III; Paediatric intensive care. © 2026. The Author(s), under exclusive licence to International Pediatric Nephrology Association. [PubMed Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) ## Conflict of interest statement Declarations. Ethical approval: This study was approved by the Institutional Ethics Committee of SMS Medical College and attached hospitals, Jaipur, India (Ref. 388/MC/EC/2021; approved 13 February 2021, certificate issued 25 March 2021). The study was conducted in accordance with the principles of the Declaration of Helsinki. Consent for publication: Not applicable. The manuscript does not contain any individual person’s data in any form (including individual details, images or videos). Consent to participate: Written informed consent was obtained from the parents or legal guardians of all enrolled children prior to study participation. Conflict of interest: The authors declare no competing interests. Clinical trial number: Not applicable. ## References 1. 1. Lintz VC, Vieira RA, Carioca FL et al (2024) Fluid accumulation in critically ill children: a systematic review and meta-analysis. EClinicalMedicine 74:102714. - [DOI](https://doi.org/10.1016/j.eclinm.2024.102714) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/39070177/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/11278930/) 2. 1. Alobaidi R, Morgan C, Basu RK et al (2018) Association between fluid balance and outcomes in critically ill children: a systematic review and meta-analysis. JAMA Pediatr 172:257–268. - [DOI](https://doi.org/10.1001/jamapediatrics.2017.4540) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/29356810/) - [PMC](https://pmc.ncbi.nlm.nih.gov/articles/5885847/) 3. 1. Matsushita FY, Krebs VLJ, de Carvalho WB (2022) Association between fluid overload and mortality in newborns: a systematic review and meta-analysis. Pediatr Nephrol 37:983–992. - [DOI](https://doi.org/10.1007/s00467-021-05281-8) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/34727245/) 4. 1. Wong JJM, Ho SX, Lee AOCJ et al (2019) Positive fluid balance is associated with poor clinical outcomes in paediatric severe sepsis and septic shock. Ann Acad Med Singap 48:290–297 - [DOI](https://doi.org/10.47102/annals-acadmedsg.v48n9p290) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/31737894/) 5. 1. Soulages Arrese N, Green ML (2023) Fluid management of the critically ill child. Curr Opin Pediatr 35:239–244. - [DOI](https://doi.org/10.1097/mop.0000000000001210) - [PubMed](https://pubmed.ncbi.nlm.nih.gov/36472133/) Show all 27 references [x] Cite Copy Download .nbib .nbib Format: AMA APA MLA NLM **Send To** * [Clipboard](https://pubmed.ncbi.nlm.nih.gov/42895576/) * [Email](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42895576%2F%23open-email-panel) * [Save](https://pubmed.ncbi.nlm.nih.gov/42895576/) * [My Bibliography](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42895576%2F%23open-bibliography-panel) * [Collections](https://account.ncbi.nlm.nih.gov/?back_url=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F42895576%2F%23open-collections-panel) * [Citation Manager](https://pubmed.ncbi.nlm.nih.gov/42895576/) [x] NCBI Literature Resources [MeSH](https://www.ncbi.nlm.nih.gov/mesh/) [PMC](https://www.ncbi.nlm.nih.gov/pmc/) [Bookshelf](https://www.ncbi.nlm.nih.gov/books) [Disclaimer](https://pubmed.ncbi.nlm.nih.gov/disclaimer/) The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 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