{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T06:01:36Z","timestamp":1790834496978,"version":"4.1.0"},"reference-count":51,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,10,1]],"date-time":"2026-10-01T00:00:00Z","timestamp":1790812800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Urosepsis remains a leading cause of ICU mortality. Albumin-derived composite indices, which integrate nutritional, inflammatory, and metabolic parameters, hold prognostic promise; however, their comparative performance has not been directly assessed.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      We conducted a dual-cohort retrospective study using MIMIC-IV (\n                      <jats:italic>n<\/jats:italic>\n                      = 3,060) for derivation and the Affiliated Hospital of Guizhou Medical University (\n                      <jats:italic>n<\/jats:italic>\n                      = 353) for validation. The primary outcome was 28-day ICU mortality in a competing-risks framework with discharge alive as competing event. Six indices\u2014lactate dehydrogenase-to-albumin ratio (LDAR), anion gap-to-albumin ratio (AGAR), glucose-to-albumin ratio (GAR), red cell distribution width-to-albumin ratio (RAR), total bilirubin-to-albumin ratio (TAR), and urea nitrogen-to-albumin ratio (UAR)\u2014were compared via cause-specific Cox and Fine-Gray subdistribution hazard models, cumulative incidence functions, restricted cubic splines (RCS), Kaplan-Meier curves, and ROC\/Youden\/cNRI analyses. LASSO-selected features trained a multilayer perceptron (MLP), benchmarked against six severity scores; a parsimonious external model (events per variable \u2265 10) was also examined.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      In the derivation cohort, logLDAR, RAR, TAR, AGAR, and UAR were independently associated with 28-day ICU mortality in fully adjusted models (HRs = 1.292, 1.147, 1.136, 1.074, and 1.013, respectively; all\n                      <jats:italic>P<\/jats:italic>\n                      &amp;lt; 0.01), whereas logGAR was not. Fine-Gray models corroborated these findings (logLDAR sHR = 1.351, 95% CI: 1.238\u20131.473). RCS revealed a non-linear logLDAR\u2013mortality relationship (\n                      <jats:italic>P<\/jats:italic>\n                      non-linear = 0.040), with risk accelerating beyond logLDAR &amp;gt; 7. logLDAR yielded the highest AUC (0.638, 95% CI: 0.609\u20130.667) and cNRI (0.119). External validation confirmed the independent prognostic value of logLDAR (HR = 1.524, 95% CI: 1.225\u20131.895; Fine-Gray sHR = 1.545, 95% CI: 1.295\u20131.844), with an external AUC of 0.735 (95% CI: 0.648\u20130.808), although between-cohort differences in case definitions may partly contribute. The MLP with eight LASSO-selected features achieved an external AUC of 0.762 (95% CI: 0.687\u20130.840), comparable to SOFA plus logLDAR (AUC = 0.782; DeLong\n                      <jats:italic>P<\/jats:italic>\n                      = 0.512). SHAP analysis ranked logLDAR among the top predictors.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Among the six albumin-derived indices, logLDAR demonstrated the most consistent and generalizable prognostic performance for 28-day ICU mortality in urosepsis, reflecting both tissue hypoxia and nutritional-inflammatory depletion, and remained robust under competing-risk adjustment. logLDAR may serve as a simple bedside biomarker for early risk stratification; however, prospective studies are warranted to determine whether interventions targeting its underlying pathways can improve outcomes.<\/jats:p>\n                  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