Libório Alexandre Braga, Macedo Etienne, de Queiroz Rafaela Elizabeth Bayas, Leite Tacyano Tavares, Rocha Inessa Carvalho Queiroz, Freitas Ingrid Alves, Correa Larissa Chagas, Campelo Camila Pontes Bessa, Araújo Fabrícia Souza, de Albuquerque Cláudio Alves, Arnaud Frederico Carlos de Sousa, de Sousa Francisco Daniel, Neves Fernanda Macedo de Oliveira
Internal Medicine Department, Faculdade de Medicina, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil.
Nephrol Dial Transplant. 2013 Nov;28(11):2779-87. doi: 10.1093/ndt/gft375. Epub 2013 Sep 5.
It has been recently mathematically demonstrated that the percentage increase in serum creatinine (SCr) can delay acute kidney injury (AKI) diagnosis in patients with previous chronic kidney disease (CKD). Based on creatinine (Cr) kinetics, it was suggested a new AKI classification using absolute increase in SCr elevation over specified time periods. However, this classification has not been evaluated in clinical studies.
A prospective cohort study evaluated myocardial infarction patients during the first 7 days of hospital stay with daily SCr measurements. They were classified using Kidney Disease Improving Global Outcomes (KDIGO) and Cr kinetics systems. Both classifications were compared by net reclassification improvement (NRI) and area under the receiver operator characteristic (AuROC) curve regarding hospital mortality.
A total of 584 patients were included, of which 34.1% had previous CKD. Patients had more AKI by KDIGO than by Cr kinetics criteria (25.7 versus 18.0%, P < 0.001) and 81 patients (13.9%) had different AKI severity classification. Patients with AKI by KDIGO criteria and non-AKI by Cr kinetics had higher hospital mortality rates than patients with non-AKI using both classifications [adjusted mortality odds ratios (ORs): 4.753; 95% confidence interval (CI): 1.119-9.023, P = 0.014]. In patients with previous CKD, NRI analysis was 6.2% favoring Cr kinetics criteria. However, there was no difference using the AuROC curve analysis. In patients with no previous CKD, NRI analysis was 33.0%, favoring KDIGO, and this was in accordance with a better AuROC curve (0.828 versus 0.664, P < 0.05).
AKI classification proposed by a Cr kinetics model can be superior when diagnosing patients with previous CKD. However, KDIGO had a better performance in patients with no previous CKD.
最近有数学研究表明，血清肌酐（SCr）升高百分比会延迟既往慢性肾脏病（CKD）患者急性肾损伤（AKI）的诊断。基于肌酐（Cr）动力学，有人提出一种新的AKI分类方法，即根据特定时间段内SCr升高的绝对数值进行分类。然而，该分类方法尚未在临床研究中得到评估。
一项前瞻性队列研究对心肌梗死患者在住院的前7天内每日测量SCr。使用改善全球肾脏病预后组织（KDIGO）和Cr动力学系统对患者进行分类。通过净重新分类改善（NRI）和受试者工作特征曲线下面积（AuROC）曲线比较两种分类方法对医院死亡率的预测情况。
共纳入584例患者，其中34.1%既往有CKD。KDIGO标准诊断的AKI患者比Cr动力学标准诊断的更多（25.7%对18.0%，P<0.001），81例患者（13.9%）的AKI严重程度分类不同。KDIGO标准诊断为AKI而Cr动力学标准诊断为非AKI的患者，其医院死亡率高于两种分类方法均诊断为非AKI的患者[调整后死亡率比值比（OR）：4.753；95%置信区间（CI）：1.119 - 9.023，P = 0.014]。在既往有CKD的患者中，NRI分析显示Cr动力学标准有6.2%的优势。然而，AuROC曲线分析无差异。在既往无CKD的患者中，NRI分析显示KDIGO有33.0%的优势，且与更好的AuROC曲线一致（0.828对0.664，P<0.05）。
Cr动力学模型提出的AKI分类方法在诊断既往有CKD的患者时可能更具优势。然而，KDIGO在既往无CKD的患者中表现更好。
