Department of Nephrology, The Affiliated Hospital of Qingdao University, 16 Jiangsu Road, Qingdao, 266003, China.
J Nephrol. 2019 Dec;32(6):937-945. doi: 10.1007/s40620-019-00624-z. Epub 2019 Jun 26.
Cardiac surgery-associated acute kidney injury (CSA-AKI), one of the most severe complications in patients with cardiac surgery, is associated with considerable morbidity, mortality and high costs thus placing a heavy burden to society. Therefore, we aimed to build a predictive model based on preoperative features in order to early recognize and intervene for patients with high risk of CSA-AKI.
In this retrospective cohort study, baseline perioperative hospitalization information of patients who underwent cardiac surgery from October 2012 to October 2017 were screened. After multivariate logistic regression, identified independent predictive factors associated with CSA-AKI were incorporated into the nomogram and the discriminative ability and predictive accuracy of the model was assessed by concordance index (C-Index). Additionally, internal validation was performed by using bootstrapping technology with 1000 resamples to reduce the over-fit bias.
In all 4395 patients with cardiac surgery October 2012-October 2017, no patients were excluded for the continuous renal replacement therapy (CRRT) before surgery while 2495 patients were excluded due to only one or less than one Scr assay post-surgery. In the end, a total of 1900 patients were enrolled in the study, of which 698 patients (74.89%) developed AKI stage 1, 158 (16.96%) AKI stage 2 and 76 (8.15%) AKI stage 3. After multivariate logistic regression, age, perioperative estimated glomerular filtration rate (eGFR), lactate dehydrogenase (LDH), prothrombin time (PT), with a history of surgery, transfusion, cardiac arrhythmia, coronary heart disease (CHD), or chronic kidney disease (CKD), using calcium channel blocker (CCB), proton pump inhibitors (PPI), non-steroidal anti-inflammatory drugs (NSAID), antibiotic or statin before surgery were predictive factors of CSA-AKI. In addition, the nomogram demonstrated a good accuracy in estimating CSA-AKI, with an C-Index and a bootstrap-corrected one of 0.796 (SD = 0.018, 95% CI 0.795-0.797) and 0.789 (SD = 0.015, 95% CI 0.788-0.790), respectively. Moreover, calibration plots showed an optimal consistency with the actual presence of CSA-AKI.
The novel predictive nomogram achieved a good preoperative prediction of CSA-AKI within the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Though the model, the risk of an individual patient with "subclinical AKI" undergoing cardiac surgery could be determined earlier and such application was helpful for timely intervention in order to improve patient's prognosis.
心脏手术后并发急性肾损伤（CSA-AKI）是心脏手术后最严重的并发症之一，与相当高的发病率、死亡率和高成本相关，从而给社会带来沉重负担。因此，我们旨在建立一个基于术前特征的预测模型，以便早期识别和干预具有 CSA-AKI 高风险的患者。
在这项回顾性队列研究中，筛选了 2012 年 10 月至 2017 年 10 月期间接受心脏手术的患者的基线围手术期住院信息。经过多变量逻辑回归，确定与 CSA-AKI 相关的独立预测因素，并将其纳入列线图，通过一致性指数（C-指数）评估模型的判别能力和预测准确性。此外，使用 1000 次重采样的 bootstrap 技术进行内部验证，以减少过度拟合偏差。
在 2012 年 10 月至 2017 年 10 月期间接受心脏手术的 4395 例患者中，没有因术前连续肾脏替代治疗（CRRT）而被排除的患者，但有 2495 例患者因术后只有一次或少于一次 Scr 检测而被排除。最终，共有 1900 例患者入组研究，其中 698 例（74.89%）发生 AKI 1 期，158 例（16.96%）发生 AKI 2 期，76 例（8.15%）发生 AKI 3 期。多变量逻辑回归后，年龄、围手术期估算肾小球滤过率（eGFR）、乳酸脱氢酶（LDH）、凝血酶原时间（PT）、手术史、输血史、心律失常、冠心病（CHD）或慢性肾脏病（CKD）、术前使用钙通道阻滞剂（CCB）、质子泵抑制剂（PPI）、非甾体抗炎药（NSAID）、抗生素或他汀类药物是 CSA-AKI 的预测因素。此外，列线图在估计 CSA-AKI 方面表现出良好的准确性，C-指数和 bootstrap 校正后的 C-指数分别为 0.796（SD=0.018，95%CI 0.795-0.797）和 0.789（SD=0.015，95%CI 0.788-0.790）。此外，校准图显示与 CSA-AKI 的实际存在具有最佳一致性。
该新的预测列线图在肾脏病：改善全球结局（KDIGO）标准下实现了对 CSA-AKI 的良好术前预测。通过该模型，可以更早地确定“亚临床 AKI”的个体患者接受心脏手术的风险，并且这种应用有助于及时干预，从而改善患者的预后。
