{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T08:25:19Z","timestamp":1786955119969,"version":"build-2736575974"},"reference-count":43,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Med Inform"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n Sepsis-associated acute kidney injury (SA-AKI) is a frequent and life-threatening complication of sepsis. While the static lactate-to-albumin ratio (LAR) has prognostic value, its dynamic temporal evolution during early resuscitation and its utility for guiding clinical risk stratification remain underexplored.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n The aim of the study is to identify distinct dynamic trajectories of LAR, evaluate their independent associations with adverse clinical outcomes, and construct a practical prognostic nomogram for patients with SA-AKI.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n Data were extracted from the Medical Information Mart for Intensive Care IV database, including adult patients with SA-AKI and \u2265 3 lactate and albumin measurements within the first 72 hours of intensive care unit admission. A multicenter external validation cohort was assembled from 5 tertiary hospitals in Beijing, China. Group-based trajectory modeling identified distinct LAR trajectories. The primary outcome was 28-day mortality; secondary outcomes included 90-day mortality and continuous renal replacement therapy initiation. Trajectory-outcome associations were assessed using multivariable Cox and logistic regression models. Robustness was examined using restricted cubic splines, inverse probability of treatment weighting, weight truncation, doubly robust estimation, and subgroup analyses. Incremental predictive value beyond single baseline LAR was quantified, and a trajectory-integrated nomogram was developed and externally validated.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Among the 615 patients in the primary cohort, 3 LAR trajectories were identified: trajectory 1 (low-stable type), trajectory 2 (rapid-clearance type), and trajectory 3 (delayed-clearance type). In adjusted multivariable models, trajectory 3 (vs trajectory 1) was independently associated with increased 28-day mortality risk (hazard ratio 1.63, 95% CI 1.00\u20102.64;\n P<\/jats:italic>\n =.0496), 90-day mortality (hazard ratio 1.72, 95% CI 1.14\u20102.60;\n P<\/jats:italic>\n =.01), and continuous renal replacement therapy initiation (odds ratio 3.40, 95% CI 1.64\u20107.15;\n P<\/jats:italic>\n =.001). Conversely, the mortality risk for trajectory 2 did not differ significantly from trajectory 1. Sensitivity analyses supported these findings, although trajectory 3 associations attenuated in inverse probability of treatment weighting\u2013weighted analyses. Incorporating trajectories improved predictive accuracy over single baseline LAR (continuous net reclassification improvement 0.170, integrated discrimination improvement 0.023; both\n P<\/jats:italic>\n =.01). In the external validation cohort (n=508), 3 analogous trajectories were identified. Trajectory 3 consistently conferred a higher mortality risk across both cohorts, whereas trajectory 2 was significantly associated with 28-day mortality only in validation. The nomogram exhibited modest discrimination in the external cohort (concordance index=0.612), acceptable calibration, and potential utility as a supplementary bedside risk stratification tool.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n Dynamic LAR trajectories are independently associated with 28- and 90-day mortality in SA-AKI. The delayed-clearance trajectory identifies a specific high-risk phenotype, suggesting that longitudinal LAR monitoring and the constructed nomogram may support early risk stratification and inform clinical decision-making.<\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/92838","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T07:51:22Z","timestamp":1786953082000},"page":"e92838-e92838","source":"Crossref","is-referenced-by-count":0,"title":["Dynamic Lactate-to-Albumin Ratio Trajectories and Outcomes in Sepsis-Associated Acute Kidney Injury: Evidence From MIMIC-IV and a Multicenter Chinese 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