Calibration, Uncertainty Communication, and Deployment Readiness in CKD Risk Prediction: A Framework Evaluation Study

Clinical language models (LMs) are increasingly applied to support clinical risk prediction from free-text notes, yet their uncertainty estimates often remain poorly calibrated and clinically unreliable. In this work, we propose Clinical Uncertainty Risk Alignment (CURA), a framework that aligns clinical LM-based risk estimates and uncertainty with both individual error likelihoods and cohort-level ambiguities. CURA first fine-tunes domain-specific clinical LMs to obtain task-adapted patient embeddings, and then performs uncertainty fine-tuning of a multi-head classifier using a bi-level uncertainty objective. Specifically, an individual-level calibration term aligns predictive uncertainty with each patient's likelihood of error, while a cohort-aware regularizer pulls risk estimates toward event rates in their local neighborhoods in the embedding space and places extra weight on ambiguous cohorts near the decision boundary. We further show that this cohort-aware term can be interpreted as a cross-entropy loss with neighborhood-informed soft labels, providing a label-smoothing view of our method. Extensive experiments on MIMIC-IV clinical risk prediction tasks across various clinical LMs show that CURA consistently improves calibration metrics without substantially compromising discrimination. Further analysis illustrates that CURA reduces overconfident false reassurance and yields more trustworthy uncertainty estimates for downstream clinical decision support.

Recent work has argued normatively, on synthetic data, that evaluating survival models by discrimination alone (concordance index) yields systematically misleading model comparisons, because the metric ignores calibration and time-dependent accuracy. Whether this matters for real, published, non-clinical models has not been tested. We reproduce three published survival-ML models across three structurally distinct domains -- hard-drive failure prediction, peer-to-peer credit default, and user disengagement on digital platforms -- validate our instrument against the anchor paper's own synthetic experiment, and test five pre-registered hypotheses under a Holm-corrected family-wise error rate. Three of five reject (though one pre-registered threshold clears by a narrow margin). A model reproducing the published literature's discrimination almost exactly (C = 0.9595 vs. 0.958 reported) fails a formal calibration test at p < 0.001; a broad feature-ablation search finds no single attribute responsible for its discrimination, so the calibration failure is not a trivial shortcut artifact. A lender's estimated default risk is biased upward by roughly two percentage points, growing to nearly four in the riskiest segment, when loan prepayment is treated as non-informative censoring rather than a competing risk. A platform's churn model shows probability estimates that degrade with the horizon even as global discrimination stays within the pre-registered C-index band. A direct test of whether metric choice inverts model preference does not reject, though with limited power given two to three models per domain; the failure mode we document is better characterized as misplaced confidence in a chosen model than as choosing the wrong one. We release a pre-registered evaluation harness with full code and an annotated notebook, so these results can be verified independently and the audit extended.

The early detection of Chronic Kidney Disease using machine learning has attracted significant interest in healthcare-related computer science. Despite rapid advancements in this field, many reported studies remain inconsistent and potentially misleading. A significant drawback is the lack of organized evaluation regarding methodological concerns. Key issues include data leakage, limited access to temporal patient records and inconsistency in reported clinical indicators. This research offers a systematic literature review of existing CKD prediction studies using interpretable machine learning techniques, where nineteen relevant studies were selected via systematic searches across major academic databases. To assess methodological reliability, this study introduces a structured taxonomy of information leakage and a quantitative leakage scoring framework to systematically evaluate reliability across CKD prediction studies. The analysis reveals a strong relationship between leakage and inflated performance. Here, High leakage-studies report an average accuracy of 95.48%, compared to 80.2% for leakage-free studies, reflecting an increase of approximately 15.28%. Furthermore, a cross-study feature stability analysis shows that only a small subset of predictors is consistently reproducible, with over 80% lacking reliability. Overall, the findings suggest that many reported performance improvements stem from methodological limitations rather than true predictive capability.