Derivation and validation a risk model for acute kidney injury and subsequent adverse events after cardiac surgery: a multicenter cohort study

Abstract Background Acute Kidney Injury, a frequent complication in patients undergoing cardiac surgery, is associated with high mortality and poor quality of life. We aimed to establish a risk model for acute kidney injury and subsequent adverse events in Chinese cardiac patients. Methods This study included 11740 patients who had cardiac surgery at 14 institutions in China. Patients were randomly assigned to a derivation cohort (n = 8197) or a validation cohort (n = 3543). Variables ascertained during hospitalization were screened using least absolute shrinkage and selection operator and logistic regression to construct a nomogram model. Model performance was evaluated using C-statistic, calibration curve, and Brier score. The nomogram was further compared with the five conventional models: Mehta score, Ng score, AKICS score, SRI score, and Cleveland Clinic score. Acute kidney injury was defined according to the Kidney Disease Improving Global Outcomes criteria. Subsequent adverse events included mid-term outcomes: death from all causes and major adverse kidney events (defined as composite outcome of death from renal failure, dialysis, and advanced chronic kidney disease). Results Acute kidney injury occurred in 3237 (27.6%) patients. The model included 12 predictors. The nomogram achieved a C-statistic of 0.825 and 0.804 in the derivation and validation cohorts, respectively, and had well-fitted calibration curves. The model performance of the nomogram was better than other five conventional models. After risk stratification, moderate-risk or high-risk groups were associated with significantly higher rates of death from all causes and major adverse kidney events compared with low-risk group during 7-year follow-up. Conclusions The nomogram provided an effective tool for predicting acute kidney injury and evaluating its subsequent adverse events after cardiac surgery.

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Application of 17 Contrast-Induced Acute Kidney Injury Risk Prediction Models

Cardiorenal Medicine ◽

10.1159/000506379 ◽

2020 ◽

Vol 10 (3) ◽

pp. 162-174

Author(s):

Levent Serif ◽

George Chalikias ◽

Matthaios Didagelos ◽

Dimitrios Stakos ◽

Petros Kikas ◽

...

Keyword(s):

Acute Kidney Injury ◽

Predictive Value ◽

Injury Risk ◽

Prediction Models ◽

Risk Model ◽

Model Performance ◽

Kidney Injury ◽

Risk Scores ◽

True Negative ◽

C Statistic

Introduction: Contrast-induced acute kidney injury (CI-AKI) is a frequent complication of percutaneous coronary interventions (PCI). Various groups have developed and validated risk scores for CI-AKI. Although the majority of these risk scores achieve an adequate accuracy, their usability in clinical practice is limited and greatly debated. Objective: With the present study, we aimed to prospectively assess the diagnostic performance of recently published CI-AKI risk scores (up to 2018) in a cohort of patients undergoing PCI. Methods: We enrolled 1,247 consecutive patients (80% men, mean age 62 ± 10 years) treated with elective or urgent PCI. For each patient, we calculated the individual CI-AKI risk score based on 17 different risk models. CI-AKI was defined as an increase of ≥25% (liberal) or ≥0.5 mg/dL (strict) in pre-PCI serum creatinine 48 h after PCI. Results: CI-AKI definition and, therefore, CI-AKI incidence have a significant impact on risk model performance (median negative predictive value increased from 85 to 99%; median c-statistic increased from 0.516 to 0.603 using more strict definition criteria). All of the 17 published models were characterized by a weak-to-moderate discriminating ability mainly based on the identification of “true-negative” cases (median positive predictive value 19% with liberal criterion and 3% with strict criterion). In none of the models, c-statistic was >0.800 with either CI-AKI definition. Novel, different combinations of the >35 independent variables used in the published models either by down- or by up-scaling did not result in significant improvement in predictive performance. Conclusions: The predictive ability of all models was similar and only modest, derived mainly by identifying true-negative cases. A new approach is probably needed by adding novel markers or periprocedural characteristics.

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Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative

Nature Reviews Nephrology ◽

10.1038/s41581-021-00418-2 ◽

2021 ◽

Author(s):

John R. Prowle ◽

Lui G. Forni ◽

Max Bell ◽

Michelle S. Chew ◽

Mark Edwards ◽

...

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Adverse Outcomes ◽

Baseline Risk ◽

Major Surgery ◽

Increased Risk

AbstractPostoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.

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Risk Factors for Long-Term Mortality and Progressive Chronic Kidney Disease Associated With Acute Kidney Injury After Cardiac Surgery

Medicine ◽

10.1097/md.0000000000002025 ◽

2015 ◽

Vol 94 (45) ◽

pp. e2025 ◽

Cited By ~ 46

Author(s):

Jia-Rui Xu ◽

Jia-Ming Zhu ◽

Jun Jiang ◽

Xiao-Qiang Ding ◽

Yi Fang ◽

...

Keyword(s):

Risk Factors ◽

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury ◽

Long Term Mortality

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Use of Both Serum Cystatin C and Creatinine as Diagnostic Criteria for Cardiac Surgery-Associated Acute Kidney Injury and Its Correlation with Long-Term Major Adverse Events

Kidney & Blood Pressure Research ◽

10.1159/000499647 ◽

2019 ◽

Vol 44 (3) ◽

pp. 415-425

Author(s):

Miaolin Che ◽

Xudong Wang ◽

Bo Xie ◽

Ritai Huang ◽

Shang Liu ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Adverse Events ◽

Predictive Value ◽

Kidney Injury ◽

Serum Cystatin C ◽

Serum Cystatin ◽

Single Marker ◽

Major Adverse Events

Background/Aims: Cardiac surgery-associated acute kidney injury (CSA-AKI) was traditionally defined as an increase in serum creatinine (sCr) after cardiac surgery. Recently, serum cystatin C (sCyC) has been proposed to be a better biomarker in the prediction of AKI. The clinical utility and performance of combining sCyC and sCr in patients with AKI, particularly for the prediction of long-term outcomes, remain unknown. Methods: We measured sCyC together with sCr in 628 patients undergoing cardiac surgery. sCyC and sCr were assessed at baseline and 24 and 48 h after surgery. CSA-AKI determined by sCr (CSA-AKIsCr) was defined as an sCr increase greater than 0.3 mg/dL or 50% from baseline. Major adverse events (MAEs; including death of any cause and dialysis) at 3 years were assessed. Results: CSA-AKIsCr developed in 178 patients (28.3%). Three-year follow-up was available for 621 patients; MAEs occurred in 42 patients (6.8%). An increase in sCyC concentration ≥30% within 48 h after surgery was detected in 228 patients (36.3%). This was the best sCyC cutoff for CSA-AKIsCr detection (negative predictive value = 88.8%, positive predictive value = 58.3%). To evaluate the use of both sCyC and sCr as CSA-AKI diagnostic criteria, we stratified patients into 3 groups: non-CSA-AKI, CSA-AKI detected by a single marker, and CSA-AKI detected by both markers. By multivariable logistic regression analysis, the independent predictors of MAEs at 3 years were group 2 (non-CSA-AKI group as the reference, CSA-AKI detected by a single marker: odds ratio [OR] = 3.48, 95% confidence interval [CI]: 1.27–9.58, p = 0.016), group 3 (CSA-AKI detected by both markers: OR = 5.12, 95% CI: 2.01–13.09; p = 0.001), and baseline glomerular filtration rate (OR = 2.24; 95% CI: 1.27–3.95; p = 0.005). Conclusion: Combining sCyC and sCr to diagnose CSA-AKI would be beneficial for risk stratification and prognosis in patients after cardiac surgery.

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Establishment of a risk model for acute kidney injury after cardiac surgery

General Thoracic and Cardiovascular Surgery ◽

10.1007/s11748-020-01355-w ◽

2020 ◽

Vol 68 (12) ◽

pp. 1603-1604

Author(s):

Fu-Kun Liu ◽

Fu-Shan Xue ◽

Shao-Hua Liu

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Risk Model ◽

Kidney Injury

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Acute kidney injury in renal transplant recipients undergoing cardiac surgery

Nephrology Dialysis Transplantation ◽

10.1093/ndt/gfaa063 ◽

2020 ◽

Vol 36 (1) ◽

pp. 185-196

Author(s):

Gregory L Hundemer ◽

Anand Srivastava ◽

Kirolos A Jacob ◽

Neeraja Krishnasamudram ◽

Salman Ahmed ◽

...

Keyword(s):

Risk Factors ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Risk Factor ◽

Renal Transplant ◽

Kidney Disease ◽

Kidney Injury ◽

Renal Transplant Recipients ◽

Transplant Recipients ◽

Trough Levels

Abstract Background Acute kidney injury (AKI) is a key risk factor for chronic kidney disease in the general population, but has not been investigated in detail among renal transplant recipients (RTRs). We investigated the incidence, severity and risk factors for AKI following cardiac surgery among RTRs compared with non-RTRs with otherwise similar clinical characteristics. Methods We conducted a retrospective cohort study of RTRs (n = 83) and non-RTRs (n = 83) who underwent cardiac surgery at two major academic medical centers. Non-RTRs were matched 1:1 to RTRs by age, preoperative (preop) estimated glomerular filtration rate and type of cardiac surgery. We defined AKI according to Kidney Disease: Improving Global Outcomes criteria. Results RTRs had a higher rate of AKI following cardiac surgery compared with non-RTRs [46% versus 28%; adjusted odds ratio 2.77 (95% confidence interval 1.36–5.64)]. Among RTRs, deceased donor (DD) versus living donor (LD) status, as well as higher versus lower preop calcineurin inhibitor (CNI) trough levels, were associated with higher rates of AKI (57% versus 33% among DD-RTRs versus LD-RTRs; P = 0.047; 73% versus 36% among RTRs with higher versus lower CNI trough levels, P = 0.02). The combination of both risk factors (DD status and higher CNI trough level) had an additive effect (88% AKI incidence among patients with both risk factors versus 25% incidence among RTRs with neither risk factor, P = 0.004). Conclusions RTRs have a higher risk of AKI following cardiac surgery compared with non-RTRs with otherwise similar characteristics. Among RTRs, DD-RTRs and those with higher preop CNI trough levels are at the highest risk.

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Acute Kidney Injury and Chronic Kidney Disease After Cardiac Surgery

Advances in Chronic Kidney Disease ◽

10.1053/j.ackd.2008.04.006 ◽

2008 ◽

Vol 15 (3) ◽

pp. 257-277 ◽

Cited By ~ 44

Author(s):

Mark Stafford-Smith ◽

Uptal D. Patel ◽

Barbara G. Phillips-Bute ◽

Andrew D. Shaw ◽

Madhav Swaminathan

Keyword(s):

Chronic Kidney Disease ◽

Acute Kidney Injury ◽

Cardiac Surgery ◽

Kidney Disease ◽

Kidney Injury

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Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients

Anesthesiology ◽

10.1097/aln.0000000000001598 ◽

2017 ◽

Vol 126 (5) ◽

pp. 787-798 ◽

Cited By ~ 33

Author(s):

Alexander Zarbock ◽

John A. Kellum ◽

Hugo Van Aken ◽

Christoph Schmidt ◽

Mira Küllmar ◽

...

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

High Risk ◽

Renal Dysfunction ◽

Ischemic Preconditioning ◽

Absolute Risk ◽

Kidney Injury ◽

Absolute Risk Reduction ◽

Remote Ischemic Preconditioning ◽

Major Adverse Kidney Events

Abstract Background In a multicenter, randomized trial, the authors enrolled patients at high-risk for acute kidney injury as identified by a Cleveland Clinic Foundation score of 6 or more. The authors enrolled 240 patients at four hospitals and randomized them to remote ischemic preconditioning or control. The authors found that remote ischemic preconditioning reduced acute kidney injury in high-risk patients undergoing cardiac surgery. The authors now report on the effects of remote ischemic preconditioning on 90-day outcomes. Methods In this follow-up study of the RenalRIP trial, the authors examined the effect of remote ischemic preconditioning on the composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction at 90 days. Secondary outcomes were persistent renal dysfunction and dialysis dependence in patients with acute kidney injury. Results Remote ischemic preconditioning significantly reduced the occurrence of major adverse kidney events at 90 days (17 of 120 [14.2%]) versus control (30 of 120 [25.0%]; absolute risk reduction, 10.8%; 95% CI, 0.9 to 20.8%; P = 0.034). In those patients who developed acute kidney injury after cardiac surgery, 2 of 38 subjects in the remote ischemic preconditioning group (5.3%) and 13 of 56 subjects in the control group (23.2%) failed to recover renal function at 90 days (absolute risk reduction, 17.9%; 95% CI, 4.8 to 31.1%; P = 0.020). Acute kidney injury biomarkers were also increased in patients reaching the major adverse kidney event endpoint compared to patients who did not. Conclusions Remote ischemic preconditioning significantly reduced the 3-month incidence of a composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction in high-risk patients undergoing cardiac surgery. Furthermore, remote ischemic preconditioning enhanced renal recovery in patients with acute kidney injury.

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Diagnosis of Cardiac Surgery-Associated Acute Kidney Injury

Journal of Clinical Medicine ◽

10.3390/jcm10163664 ◽

2021 ◽

Vol 10 (16) ◽

pp. 3664

Author(s):

Christina Massoth ◽

Alexander Zarbock

Keyword(s):

Acute Kidney Injury ◽

Cardiac Surgery ◽

Clinical Practice ◽

Kidney Disease ◽

Conceptual Framework ◽

Diagnostic Criteria ◽

Kidney Injury ◽

Comprehensive Diagnosis

Acute kidney injury after cardiac surgery is characterized by specific patterns of damage and recovery that are important to consider for management and outcome. The Kidney Disease: Improving Global Outcomes (KDIGO) classification covers only part of the conceptual framework and is thus insufficient for a comprehensive diagnosis. This review highlights the strengths and limitations of the recent criteria and provides an overview of biomarkers of cardiac surgery-associated acute kidney injury (CSA-AKI). The evolving understanding of CSA-AKI as a time-sensitive condition has increased the demand to enhance the diagnostic criteria and translate biomarkers into clinical practice.

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