国家手术质量改进计划低估了轻度和中度术后急性肾损伤相关的风险。
National surgical quality improvement program underestimates the risk associated with mild and moderate postoperative acute kidney injury.
机构信息
1Department of Anesthesiology, University of Florida, Gainesville, FL. 2Department of Surgery, University of Florida, Gainesville, FL. 3Department of Medicine, University of Florida, Gainesville, FL. 4Department of Surgery, North Florida South Georgia Veterans Affairs Medical Center, Gainesville, FL.
出版信息
Crit Care Med. 2013 Nov;41(11):2570-83. doi: 10.1097/CCM.0b013e31829860fc.
OBJECTIVES
In a single-center cohort of surgical patients, we assessed the association between postoperative change in serum creatinine and adverse outcomes and compared the American College of Surgeons National Surgical Quality Improvement Program's definition for acute kidney injury with consensus risk, injury, failure, loss, and end-stage kidney and Kidney Disease: Improving Global Outcomes definitions.
DESIGN
Retrospective single-center cohort.
SETTING
Academic tertiary medical center.
PATIENTS
Twenty-seven thousand eight hundred forty-one adult patients with no previous history of chronic kidney disease undergoing major surgery.
INTERVENTIONS
Risk, injury, failure, loss, and end-stage kidney defines acute kidney injury as change in serum creatinine greater than or equal to 50% while Kidney Disease: Improving Global Outcomes uses 0.3 mg/dL change from the reference serum creatinine. Since National Surgical Quality Improvement Program defines acute kidney injury as serum creatinine change greater than 2 mg/dL, it may underestimate the risk associated with less severe acute kidney injury.
MEASUREMENTS AND MAIN RESULTS
The optimal discrimination limits for both percent and absolute serum creatinine changes were calculated by maximizing sensitivity and specificity along the receiver operating characteristic curves for postoperative complications and mortality. Although prevalence of risk, injury, failure, loss, and end-stage kidney-acute kidney injury was 37%, only 7% of risk, injury, failure, loss, and end-stage kidney-acute kidney injury patients would be diagnosed with acute kidney injury using the National Surgical Quality Improvement Program definition. In multivariable logistic models, patients with risk, injury, failure, loss, and end-stage kidney or Kidney Disease: Improving Global Outcomes-acute kidney injury had a 10 times higher odds of dying compared to patients without acute kidney injury. The optimal discrimination limits for change in serum creatinine associated with adverse postoperative outcomes were as low as 0.2 mg/dL while the National Surgical Quality Improvement Program discrimination limit of 2.0 mg/dL had low sensitivity (0.05-0.28).
CONCLUSIONS
Current American College of Surgeons National Surgical Quality Improvement Program definition underestimates the risk associated with mild and moderate acute kidney injury otherwise captured by the consensus risk, injury, failure, loss, and end-stage kidney and Kidney Disease: Improving Global Outcomes criteria.
目的
在一项单中心外科患者队列研究中，我们评估了术后血清肌酐变化与不良结局之间的关联，并比较了美国外科医师学院国家外科质量改进计划（ACS NSQIP）对急性肾损伤的定义与共识风险、损伤、衰竭、丧失和终末期肾脏以及改善全球肾脏病预后组织（KDIGO）定义。
设计
回顾性单中心队列研究。
地点
学术三级医疗中心。
患者
27841 例无慢性肾脏病既往史的成年患者，行大手术。
干预措施
共识风险、损伤、衰竭、丧失和终末期肾脏将急性肾损伤定义为血清肌酐增加大于等于 50%，而 KDIGO 则使用与参考血清肌酐相比增加 0.3mg/dL。由于 ACS NSQIP 将急性肾损伤定义为血清肌酐变化大于 2mg/dL，因此它可能低估了与较轻的急性肾损伤相关的风险。
测量和主要结果
通过最大化受试者工作特征曲线的敏感性和特异性，计算了术后并发症和死亡率的最佳百分比和绝对血清肌酐变化的区分界限。尽管共识风险、损伤、衰竭、丧失和终末期肾脏-急性肾损伤的患病率为 37%，但只有 7%的共识风险、损伤、衰竭、丧失和终末期肾脏-急性肾损伤患者会被诊断为急性肾损伤使用 ACS NSQIP 定义。在多变量逻辑模型中，与无急性肾损伤患者相比，有共识风险、损伤、衰竭、丧失和终末期肾脏或 KDIGO-急性肾损伤的患者死亡风险高 10 倍。与不良术后结局相关的血清肌酐变化的最佳区分界限低至 0.2mg/dL，而 ACS NSQIP 区分界限为 2.0mg/dL，敏感性较低（0.05-0.28）。
结论
目前的 ACS NSQIP 定义低估了轻度和中度急性肾损伤的风险，而这些风险通常被共识风险、损伤、衰竭、丧失和终末期肾脏以及 KDIGO 标准所捕获。
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