Predicting kidney replacement therapy in critically ill patients: machine learning models versus clinician judgment

Abstract Background Acute kidney injury (AKI) is common in intensive care units (ICUs) and often leads to kidney replacement therapy (KRT). Precise prediction of KRT requirements could improve resource allocation and patient outcomes. We evaluated multiple machine learning (ML) models for their ability to predict KRT in critically ill patients with AKI, comparing their performance with experienced clinicians. Methods We conducted a single-center, retrospective study at Mohammed VI University Hospital, including adult patients (≥ 18 years) admitted between April 2023 and December 2024 who developed AKI according to Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Five ML classifiers (random forest, logistic regression, extreme gradient boosting, K -nearest neighbors, and artificial neural network) were trained on 80% of the dataset and tested on the remaining 20%. A panel of five intensivists, blinded to model outputs, independently predicted the need for KRT in the test cohort. Model performance and the clinician consensus were assessed via accuracy, recall, precision, F1-score, F1.5-score, and area under the receiver operating characteristic curve (AUROC). Results Of 2148 screened ICU admissions, 425 patients with AKI were included (22.1% required KRT). Random forest demonstrated the best balance of metrics (accuracy = 0.882; AUROC = 0.931), tied with XGBoost. The clinician consensus performed well (AUROC = 0.898; recall = 0.947; precision = 0.562), slightly below RF. Shapley additive explanations (SHAP) analysis identified serum creatinine, potassium, and blood urea nitrogen among the strongest predictors. Subgroup analysis showed no major bias by age or sex. Conclusions Machine learning models, particularly random forest, reliably predicted KRT needs in critically ill AKI patients and slightly exceeded experienced clinicians’ performance. Integrating ML outputs with clinical judgment may enhance timely decision-making, especially in resource-limited ICUs, yet external prospective validation is essential. Registration Registered on the Open Science Framework ( https://doi.org/10.17605/OSF.IO/YBQ5C ), including protocol and analytical code. Graphical abstract