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Improving the Prediction of Cardiac Surgery-Associated Acute Kidney Injury.

ABSTRACT: Introduction:Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction. Methods:To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cleveland Clinic Score, CCS) for the prediction of cardiac surgery-associated AKI, we conducted a prospective cohort study in 289 consecutive elective cardiac surgery patients at a tertiary care center. We compared the area under the receiver operator characteristic curve (AUC) of a base model including only the CCS with models containing additional selected intraoperative variables including mean arterial pressure, hematocrit, duration of procedure, blood transfusions, and fluid balance. AKI was defined by the Kidney Disease Improving Global Outcomes 2012 criteria. Results:The CCS alone gave an AUC of 0.72 (95% confidence interval, 0.62-0.82) for postoperative AKI. Nadir intraoperative hematocrit was the only variable that improved AUC for postoperative AKI when added to the CCS (AUC = 0.78; 95% confidence interval, 0.70-0.87; P = 0.002). In the subcohort of patients without preexisting chronic kidney disease (n = 214), where the CCS underperformed (AUC, 0.60 [0.43-0.76]), the improvement with the addition of nadir hematocrit was more marked (AUC, 0.74 [0.62-0.86]). Other variables did not improve discrimination. Discussion:Nadir intraoperative hematocrit is useful in improving discrimination of clinical risk scores for AKI, and may provide a target for intervention.

SUBMITTER: Crosina J

PROVIDER: S-EPMC5678656 | biostudies-literature | 2017 Mar

REPOSITORIES: biostudies-literature

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Improving the Prediction of Cardiac Surgery-Associated Acute Kidney Injury.

Crosina Jordan J Lerner Jordyn J Ho Julie J Tangri Navdeep N Komenda Paul P Hiebert Brett B Choi Nora N Arora Rakesh C RC Rigatto Claudio C

Kidney international reports 20161021 2

<h4>Introduction</h4>Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction.<h4>Methods</h4>To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cl ...[more]

PMID: 29142955

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Project description:Background: The recent integration of genomic data with electronic health records has enabled large scale genomic studies on a variety of perioperative complications, yet genome-wide association studies on acute kidney injury have been limited in size or confounded by composite outcomes. Genome-wide association studies can be leveraged to create a polygenic risk score which can then be integrated with traditional clinical risk factors to better predict postoperative complications, like acute kidney injury. Methods: Using integrated genetic data from two academic biorepositories, we conduct a genome-wide association study on cardiac surgery-associated acute kidney injury. Next, we develop a polygenic risk score and test the predictive utility within regressions controlling for age, gender, principal components, preoperative serum creatinine, and a range of patient, clinical, and procedural risk factors. Finally, we estimate additive variant heritability using genetic mixed models. Results: Among 1,014 qualifying procedures at Vanderbilt University Medical Center and 478 at Michigan Medicine, 348 (34.3%) and 121 (25.3%) developed AKI, respectively. No variants exceeded genome-wide significance (p < 5 × 10-8) threshold, however, six previously unreported variants exceeded the suggestive threshold (p < 1 × 10-6). Notable variants detected include: 1) rs74637005, located in the exonic region of NFU1 and 2) rs17438465, located between EVX1 and HIBADH. We failed to replicate variants from prior unbiased studies of post-surgical acute kidney injury. Polygenic risk was not significantly associated with post-surgical acute kidney injury in any of the models, however, case duration (aOR = 1.002, 95% CI 1.000-1.003, p = 0.013), diabetes mellitus (aOR = 2.025, 95% CI 1.320-3.103, p = 0.001), and valvular disease (aOR = 0.558, 95% CI 0.372-0.835, p = 0.005) were significant in the full model. Conclusion: Polygenic risk score was not significantly associated with cardiac surgery-associated acute kidney injury and acute kidney injury may have a low heritability in this population. These results suggest that susceptibility is only minimally influenced by baseline genetic predisposition and that clinical risk factors, some of which are modifiable, may play a more influential role in predicting this complication. The overall impact of genetics in overall risk for cardiac surgery-associated acute kidney injury may be small compared to clinical risk factors.

Project description:Objective: We aimed to: (1) explore the risk factors that affect the prognosis of cardiac surgery-associated acute kidney injury (CS-AKI) in patients undergoing renal replacement therapy (RRT) and (2) investigate the predictive value of the Acute Physiology and Chronic Health Evaluation (APACHE) III score, Sequential Organ Failure Assessment (SOFA) score, and Vasoactive-Inotropic Score (VIS) for mortality risk in patients undergoing RRT. Methods: Data from patients who underwent cardiac surgery from January 2015 through February 2021 were retrospectively reviewed to calculate the APACHE III score, SOFA score, and VIS on the first postoperative day and at the start of RRT. Various risk factors influencing the prognosis of the patients during treatment were evaluated; the area under the receiver operating characteristics curve (AUCROC) was used to measure the predictive ability of the three scores. Independent risk factors influencing mortality were analyzed using multivariable binary logistic regression. Results: A total of 90 patients were included in the study, using 90-day survival as the end point. Of those patients, 36 patients survived, and 54 patients died; the mortality rate reached 60%. At the start of RRT, the AUCROC of the APACHE III score was 0.866 (95% CI: 0.795-0.937), the VIS was 0.796 (95% CI: 0.700-0.892), and the SOFA score was 0.732 (95% CI: 0.623-0.842). The AUCROC-value of the APACHE III score on the first postoperative day was 0.790 (95% CI: 0.694-0.885). After analyzing multiple factors, we obtained the final logistic regression model with five independent risk factors at the start of RRT: a high APACHE III score (OR: 1.228, 95% CI: 1.079-1.397), high VIS (OR: 1.147, 95% CI: 1.021-1.290), low mean arterial pressure (MAP) (OR: 1.170, 95% CI: 1.050-1.303), high lactate value (OR: 1.552, 95% CI: 1.032-2.333), and long time from AKI to initiation of RRT (OR: 1.014, 95% CI: 1.002-1.027). Conclusion: In this study, we showed that at the start of RRT, the APACHE III score and the VIS can accurately predict the risk of death in patients undergoing continuous RRT for CS-AKI. The APACHE III score on the first postoperative day allows early prediction of patient mortality risk. Predictors influencing patient mortality at the initiation of RRT were high APACHE III score, high VIS, low MAP, high lactate value, and long time from AKI to the start of RRT.

Dataset Information

Improving the Prediction of Cardiac Surgery-Associated Acute Kidney Injury.

Publications

Improving the Prediction of Cardiac Surgery-Associated Acute Kidney Injury.

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