Zeng Juntong, Su Xiaoting, Lin Shen, Li Zhongchen, Zhao Yan, Zheng Zhe
National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.
State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Beijing, People's Republic of China.
JACC Adv. 2024 Oct 15;3(11):101326. doi: 10.1016/j.jacadv.2024.101326. eCollection 2024 Nov.
Cardiac surgery-associated acute kidney injury (CSA-AKI) is prevalent and increasingly reported. Its diagnosis traditionally follows the Kidney Disease: Improving Global Outcomes (KDIGO) AKI criteria. However, little evidence supports its appropriateness for cardiac surgery patients, particularly regarding the subtle serum creatinine change (ΔSCr) that defines mild AKI.
The purpose of the study was to investigate the ΔSCr threshold specific to CSA-AKI and compare its impact on CSA-AKI incidence and prognosis with the KDIGO AKI criteria threshold.
A 10-year coronary surgery cohort with serial perioperative SCr measurements was retrospectively analyzed. The relationship and prognostically significant threshold of 48-hour absolute ΔSCr with 30-day mortality were explored using multivariate restricted cubic spline analysis and receiver-operating characteristic curve analysis. AKI incidence and prognostic value were compared between adopting the KDIGO or new thresholds.
Among 37,706 patients, 20,290 (53.8%) developed KDIGO-defined AKI. For stage-1 AKI (18,835, 49.9%), the majority (75.2%) were solely attributed to the KDIGO absolute criterion (48-hour ΔSCr ≥0.3 mg/dL). The 48-hour ΔSCr threshold associated with an adjusted odds ratio ≥1.00 for 30-day mortality was 0.549 mg/dL. A similar threshold (0.553 mg/dL) was also identified based on the Youden index cutoff. Applying the 0.55 mg/dL threshold to define stage 1 CSA-AKI, the overall and stage-1 CSA-AKI incidence decreased to 21.0% and 17.2%, with 27.7% of the stage-1 CSA-AKI solely attributed to the new criterion. The prognostic value for AKI defined by this new threshold was significantly higher than the KDIGO criteria.
A cardiac surgery-specific ΔSCr threshold in defining AKI was notably higher compared with the current general AKI definition.
心脏手术相关急性肾损伤（CSA-AKI）很常见，且报告越来越多。其诊断传统上遵循《改善全球肾脏病预后组织（KDIGO）急性肾损伤临床实践指南》的急性肾损伤标准。然而，几乎没有证据支持该标准适用于心脏手术患者，尤其是在定义轻度急性肾损伤的血清肌酐细微变化（ΔSCr）方面。
本研究旨在探讨CSA-AKI特有的ΔSCr阈值，并将其对CSA-AKI发病率和预后的影响与KDIGO急性肾损伤标准阈值进行比较。
对一个有围手术期连续血清肌酐测量值的10年冠状动脉手术队列进行回顾性分析。使用多变量受限立方样条分析和受试者工作特征曲线分析，探讨48小时绝对ΔSCr与30天死亡率之间的关系及预后显著阈值。比较采用KDIGO标准或新阈值时急性肾损伤的发病率和预后价值。
在37706例患者中，20290例（53.8%）发生了KDIGO定义的急性肾损伤。对于1期急性肾损伤（18835例，49.9%），大多数（75.2%）仅归因于KDIGO绝对标准（48小时ΔSCr≥0.3mg/dL）。与30天死亡率调整优势比≥1.00相关的48小时ΔSCr阈值为0.549mg/dL。基于约登指数临界值也确定了类似的阈值（0.553mg/dL）。应用0.55mg/dL阈值定义1期CSA-AKI，总体和1期CSA-AKI发病率分别降至21.0%和17.2%，其中1期CSA-AKI的27.7%仅归因于新标准。该新阈值定义的急性肾损伤的预后价值显著高于KDIGO标准。
与当前一般急性肾损伤定义相比，定义急性肾损伤的心脏手术特异性ΔSCr阈值明显更高。
