Department of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio.
Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio.
JAMA. 2022 Mar 8;327(10):956-964. doi: 10.1001/jama.2022.1751.
Effective treatment of acute kidney injury (AKI) is predicated on timely diagnosis; however, the lag in the increase in serum creatinine levels after kidney injury may delay therapy initiation.
To determine the derivation and validation of predictive models for AKI after cardiac surgery.
DESIGN, SETTING, AND PARTICIPANTS: Multivariable prediction models were derived based on a retrospective observational cohort of adult patients undergoing cardiac surgery between January 2000 and December 2019 from a US academic medical center (n = 58 526) and subsequently validated on an external cohort from 3 US community hospitals (n = 4734). The date of final follow-up was January 15, 2020.
Perioperative change in serum creatinine and postoperative blood urea nitrogen, serum sodium, potassium, bicarbonate, and albumin from the first metabolic panel after cardiac surgery.
Area under the receiver-operating characteristic curve (AUC) and calibration measures for moderate to severe AKI, per Kidney Disease: Improving Global Outcomes (KDIGO), and AKI requiring dialysis prediction models within 72 hours and 14 days following surgery.
In a derivation cohort of 58 526 patients (median [IQR] age, 66 [56-74] years; 39 173 [67%] men; 51 503 [91%] White participants), the rates of moderate to severe AKI and AKIrequiring dialysis were 2674 (4.6%) and 868 (1.48%) within 72 hours and 3156 (5.4%) and 1018 (1.74%) within 14 days after surgery. The median (IQR) interval to first metabolic panel from conclusion of the surgical procedure was 10 (7-12) hours. In the derivation cohort, the metabolic panel-based models had excellent predictive discrimination for moderate to severe AKI within 72 hours (AUC, 0.876 [95% CI, 0.869-0.883]) and 14 days (AUC, 0.854 [95% CI, 0.850-0.861]) after the surgical procedure and for AKI requiring dialysis within 72 hours (AUC, 0.916 [95% CI, 0.907-0.926]) and 14 days (AUC, 0.900 [95% CI, 0.889-0.909]) after the surgical procedure. In the validation cohort of 4734 patients (median [IQR] age, 67 (60-74) years; 3361 [71%] men; 3977 [87%] White participants), the models for moderate to severe AKI after the surgical procedure showed AUCs of 0.860 (95% CI, 0.838-0.882) within 72 hours and 0.842 (95% CI, 0.820-0.865) within 14 days and the models for AKI requiring dialysis and 14 days had an AUC of 0.879 (95% CI, 0.840-0.918) within 72 hours and 0.873 (95% CI, 0.836-0.910) within 14 days after the surgical procedure. Calibration assessed by Spiegelhalter z test showed P >.05 indicating adequate calibration for both validation and derivation models.
Among patients undergoing cardiac surgery, a prediction model based on perioperative basic metabolic panel laboratory values demonstrated good predictive accuracy for moderate to severe acute kidney injury within 72 hours and 14 days after the surgical procedure. Further research is needed to determine whether use of the risk prediction tool improves clinical outcomes.
重要性：急性肾损伤（AKI）的有效治疗取决于及时诊断；然而，肾损伤后血清肌酐水平的增加滞后可能会延迟治疗的开始。
目的：确定心脏手术后 AKI 的预测模型的推导和验证。
设计、环境和参与者：基于美国学术医疗中心（n=58526）接受心脏手术的成年患者的回顾性观察队列，建立了多变量预测模型，随后在来自美国 3 家社区医院的外部队列（n=4734）中进行了验证。最终随访日期为 2020 年 1 月 15 日。
暴露：心脏手术后第一个代谢组学检测的血清肌酐和术后血尿素氮、血清钠、钾、碳酸氢盐和白蛋白的变化。
主要结果和措施：在手术后 72 小时和 14 天内，根据肾脏疾病：改善全球结果（KDIGO）中度至重度 AKI 和需要透析的 AKI 的预测模型，计算接受手术患者的接收者操作特征曲线（AUC）和校准指标。
结果：在 58526 名患者的推导队列中（中位数[IQR]年龄，66[56-74]岁；39173 名[67%]男性；51503 名[91%]白种人参与者），在手术后 72 小时内中度至重度 AKI 和需要透析的 AKI 的发生率分别为 2674 例（4.6%）和 868 例（1.48%），而在手术后 14 天内，中度至重度 AKI 和需要透析的 AKI 的发生率分别为 3156 例（5.4%）和 1018 例（1.74%）。手术结束后到第一次代谢组学检测的中位（IQR）时间间隔为 10（7-12）小时。在推导队列中，基于代谢组学的模型在手术后 72 小时和 14 天内预测中度至重度 AKI 的准确性很高（AUC，0.876[95%CI，0.869-0.883]和 0.854[95%CI，0.850-0.861]），以及手术后 72 小时和 14 天内预测需要透析的 AKI 的准确性很高（AUC，0.916[95%CI，0.907-0.926]和 0.900[95%CI，0.889-0.909]）。在 4734 名患者的验证队列中（中位数[IQR]年龄，67（60-74）岁；3361 名[71%]男性；3977 名[87%]白种人参与者），术后中度至重度 AKI 的模型在手术后 72 小时内的 AUC 为 0.860（95%CI，0.838-0.882），14 天内的 AUC 为 0.842（95%CI，0.820-0.865），而术后需要透析的 AKI 和 14 天内的模型的 AUC 为 0.879（95%CI，0.840-0.918）和 0.873（95%CI，0.836-0.910）。 Spiegelhalter z 检验评估的校准表明，验证和推导模型均通过了 P＞.05，表明具有足够的校准。
结论：在接受心脏手术的患者中，基于围手术期基本代谢组学实验室值的预测模型在手术后 72 小时和 14 天内对中度至重度急性肾损伤的预测准确性较好。需要进一步研究以确定使用风险预测工具是否可以改善临床结局。
