Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA.
Section of Nephrology, Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA.
Am J Nephrol. 2023;54(7-8):281-290. doi: 10.1159/000531641. Epub 2023 Jun 23.
Novel urinary biomarkers, including tissue inhibitor metalloprotease-2 and insulin-like growth factor binding protein 7 ([TIMP-2][IGFBP7]), have been developed to identify patients at risk for acute kidney injury (AKI). We investigated the "real-world" clinical utility of [TIMP-2][IGFBP7] in preventing AKI.
We performed a before and after single-center quality improvement study of intensive care unit (ICU) patients at risk for severe (KDIGO stage 2 or 3) AKI. In the prospective cohort, ICU providers were allowed to order [TIMP-2]*[IGFBP7] for patients at their discretion, then offered AKI practice recommendations based on the results. Outcomes were compared to a historical cohort in which biomarker values were not reported to clinical teams.
There was no difference in 7-day progression to severe AKI between the prospective (n = 116) and historical cohorts (n = 63) when [TIMP-2][IGFBP7] ≥0.3 (24 [28%] versus 8 [21%], p = 0.38) despite more stage 1 AKI at time of biomarker measurement in the prospective cohort (58 [67%] versus 9 [23%], p < 0.001). In the prospective cohort, patients with higher [TIMP-2][IGFBP7] values were more likely to receive a nephrology consult. Early consultation (within 24 h of biomarker measurement, n = 20) had a nonsignificant trend toward net negative volume balance (-1,787 mL [6,716 mL] versus + 4,974 mL [15,540 mL]) and more diuretic use (19 [95%] versus 8 [80%]) and was associated with less severe AKI (9 [45%] versus 10 [100%], p = 0.004) and inpatient dialysis (2 [10%] versus 7 [70%], p = 0.002) compared to delayed consultation (n = 10).
Despite the prospective cohort having more preexisting stage 1 AKI, there were equal rates of progression to severe AKI in the prospective and historical cohorts. In the setting of [TIMP-2]*[IGFBP7] reporting, there were more nephrology consults in response to elevated biomarker levels. Early nephrology consultation resulted in improved volume balance and favorable outcomes compared to delayed consultation.
新型尿生物标志物，包括组织抑制剂金属蛋白酶-2 和胰岛素样生长因子结合蛋白 7（[TIMP-2][IGFBP7]），已被开发用于识别发生急性肾损伤（AKI）风险的患者。我们研究了 [TIMP-2][IGFBP7] 在预防 AKI 中的“真实世界”临床应用。
我们对危重病监护病房（ICU）有发生严重（KDIGO 第 2 或 3 期）AKI 风险的患者进行了前瞻性和回顾性质量改进研究。在前瞻性队列中，ICU 医生可以根据患者的情况自行决定是否为患者开具 [TIMP-2]*[IGFBP7]，然后根据结果提供 AKI 实践建议。将前瞻性队列（n = 116）和回顾性队列（n = 63）的结果进行比较，其中生物标志物值未报告给临床团队。
尽管前瞻性队列中在进行生物标志物测量时更早期 AKI 比例更高（58 [67%] 比 9 [23%]，p < 0.001），但当 [TIMP-2][IGFBP7]≥0.3 时，前瞻性队列（n = 116）和回顾性队列（n = 63）之间 7 天进展为严重 AKI 的发生率无差异（24 [28%] 比 8 [21%]，p = 0.38）。在前瞻性队列中，[TIMP-2][IGFBP7] 值较高的患者更有可能接受肾脏病学咨询。早期咨询（在生物标志物测量后 24 小时内，n = 20）的净负容量平衡（-1,787 mL [6,716 mL] 比 + 4,974 mL [15,540 mL]）和利尿剂使用量（19 [95%] 比 8 [80%]）呈无显著趋势，并且与更严重的 AKI（9 [45%] 比 10 [100%]，p = 0.004）和住院透析（2 [10%] 比 7 [70%]，p = 0.002）的发生率较低有关，与延迟咨询（n = 10）相比。
尽管前瞻性队列中已有更多的预先存在的 1 期 AKI，但前瞻性队列和回顾性队列中严重 AKI 的进展率相等。在报告 [TIMP-2]*[IGFBP7] 的情况下，生物标志物水平升高会导致更多的肾脏病学咨询。与延迟咨询相比，早期肾脏病学咨询可改善容量平衡和预后。
