Dataset Information

Development and Validation of a Model for Predicting the Risk of Acute Kidney Injury Associated With Contrast Volume Levels During Percutaneous Coronary Intervention.

ABSTRACT: Importance:Determining the association of contrast volume during percutaneous coronary intervention (PCI) with the risk of acute kidney injury (AKI) is important for optimizing PCI safety. Objective:To quantify how the risk of AKI is associated with contrast volume, accounting for the possibility of nonlinearity and heterogeneity among different baseline risks. Design, Setting, and Participants:This prognostic study used data from the American College of Cardiology National Cardiovascular Data Registry CathPCI Registry for 1694 US hospitals. Derivation analysis included 2?076?694 individuals who underwent PCI from July 1, 2011, to June 30, 2015. Validation analysis included 961?863 individuals who underwent PCI from July 1, 2015, to March 31, 2017. Data analysis took place from July 2018 to May 2019. Exposure:Contrast volume during PCI. Main Outcomes and Measures:Acute kidney injury was defined using 3 thresholds for preprocedure to postprocedure creatinine level increase (ie, ?0.3 mg/dL, ?0.5 mg/dL, and ?1.0 mg/dL). A model quantifying the association of contrast volume with AKI was developed, and the existence of nonlinearity and heterogeneity were examined by likelihood ratio tests. The model was derived in the training set (a random 50% of the derivation cohort), and performance was evaluated in the test set (the remaining 50% of the derivation cohort) and an independent validation set by area under the receiver operating characteristic curve (AUC) and calibration slope of observed vs predicted risks. Results:The 2?076?694 patients in the derivation set had a mean (SD) age of 65.1 (12.1) years, and 662?525 (31.9%) were women; 133?306 (6.4%) had creatinine level increases of at least 0.3 mg/dL, 66?626 (3.2%) had creatinine level increases of at least 0.5 mg/dL, and 28?378 (1.4%) had creatinine level increases of at least 1.0 mg/dL. In the validation set of 961?843 patients (mean [SD] age, 65.7 [12.1] years; 305?577 [31.8%] women), these rates were 62?913 (6.5%), 34?229 (3.6%), and 15?555 (1.6%), respectively. The association of contrast volume and AKI risk was nonlinear (?226?=?1436.2; P?

SUBMITTER: Huang C

PROVIDER: S-EPMC6902830 | biostudies-literature | 2019 Nov

REPOSITORIES: biostudies-literature

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Development and Validation of a Model for Predicting the Risk of Acute Kidney Injury Associated With Contrast Volume Levels During Percutaneous Coronary Intervention.

Huang Chenxi C Li Shu-Xia SX Mahajan Shiwani S Testani Jeffrey M JM Wilson Francis P FP Mena Carlos I CI Masoudi Frederick A FA Rumsfeld John S JS Spertus John A JA Mortazavi Bobak J BJ Krumholz Harlan M HM

JAMA network open 20191101 11

<h4>Importance</h4>Determining the association of contrast volume during percutaneous coronary intervention (PCI) with the risk of acute kidney injury (AKI) is important for optimizing PCI safety.<h4>Objective</h4>To quantify how the risk of AKI is associated with contrast volume, accounting for the possibility of nonlinearity and heterogeneity among different baseline risks.<h4>Design, setting, and participants</h4>This prognostic study used data from the American College of Cardiology National ...[more]

PMID: 31755952

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Project description:ImportanceAcute kidney injury (AKI) after percutaneous coronary intervention (PCI) is common, morbid, and costly; increases patients' mortality risk; and can be mitigated by limiting contrast use.ObjectiveTo examine the national variation in AKI incidence and contrast use among US physicians and the variation's association with patients' risk of developing AKI after PCI.Design, setting, and participantsThis cross-sectional study used the American College of Cardiology National Cardiovascular Data Registry (NCDR) CathPCI Registry to identify in-hospital care for PCI in the United States. Participants included 1?349?612 patients who underwent PCI performed by 5973 physicians in 1338 hospitals between June 1, 2009, and June 30, 2012. Data analysis was performed from July 1, 2014, to August 31, 2016.Main outcomes and measuresThe primary outcome was AKI, defined according to the Acute Kidney Injury Network criteria as an absolute increase of 0.3 mg/dL or more or a relative increase of 50% or more from preprocedural to peak creatinine. A secondary outcome was the mean contrast volume as reported in the NCDR CathPCI Registry. Physicians who performed more than 50 PCIs per year were the main exposure variable of interest. Hierarchical regression with adjustment for patients' AKI risk was used to identify the variation in AKI rates, the variation in contrast use, and the association of contrast volume with patients' predicted AKI risk.ResultsOf the 1?349?612 patients who underwent PCI, the mean (SD) age was 64.9 (12.2) years, 908 318 (67.3%) were men, and 441 294 (32.7%) were women. Acute kidney injury occurred in 94?584 patients (7%). A large variation in AKI rates was observed among individual physicians ranging from 0% to 30% (unadjusted), with a mean adjusted 43% excess likelihood of AKI (median odds ratio, 1.43; 95% CI, 1.41-1.44) for statistically identical patients presenting to 2 random physicians. A large variation in physicians' mean contrast volume, ranging from 79 mL to 487 mL with an intraclass correlation coefficient of 0.23 (interquartile range, 0.21-0.25), was also observed, implying a 23% variation in contrast volume among physicians after adjustment. There was minimal correlation between contrast use and patients' AKI risk (r?=?-0.054). Sensitivity analysis after excluding complex cases showed that the physician variation in AKI remained unchanged.Conclusions and relevanceAcute kidney injury rates vary greatly among physicians, who also vary markedly in their use of contrast and do not use substantially less contrast in patients with higher risk for AKI. These findings suggest an important opportunity to reduce AKI by reducing the variation in contrast volumes across physicians and lowering its use in higher-risk patients.

Project description:BackgroundContrast volume used during percutaneous coronary intervention has a direct relationship with contrast-associated acute kidney injury. While several models estimate the risk of contrast-associated acute kidney injury, only the strategy of limiting contrast volume to 3 × estimated glomerular filtration rate (eGFR) gives actionable estimates of safe contrast volume doses. However, this method does not consider other patient characteristics associated with risk, such as age, diabetes or heart failure.MethodsUsing the National Cardiovascular Data Registry acute kidney injury risk model, we developed a novel strategy to define safe contrast limits by entering a contrast term into the model and using it to meet specific (eg, 10%) relative risk reductions. We then estimated acute kidney injury rates when our patient-centered model-derived thresholds were and were not exceeded using data from CathPCI version 5 between April 2018 and June 2019. We repeated the same analysis in a sub-set of patients who received ≤3 × eGFR contrast.ResultsAfter excluding patients on hemodialysis, below average risk (<7%), missing data and multiple percutaneous coronary interventions, our final analytical cohort included 141,133 patients at high risk for acute kidney injury. The rate of acute kidney injury was 10.0% when the contrast thresholds derived from our patient-centered model were met and 18.2% when they were exceeded (P < .001). In patients who received contrast ≤3 × eGFR (n = 82,318), contrast-associated acute kidney injury rate was 9.8% when the contrast thresholds derived from our patient centered model were met and 14.5% when they were exceeded (P < .001).ConclusionsA novel strategy for developing personalized contrast volume thresholds, provides actionable information for providers that could decrease rates of contrast-associated acute kidney injury. This strategy needs further prospective testing to assess efficacy in improving patient outcomes.

Dataset Information

Development and Validation of a Model for Predicting the Risk of Acute Kidney Injury Associated With Contrast Volume Levels During Percutaneous Coronary Intervention.

Publications

Development and Validation of a Model for Predicting the Risk of Acute Kidney Injury Associated With Contrast Volume Levels During Percutaneous Coronary Intervention.

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