Pre-operative N-terminal pro-B-type natriuretic peptide for prediction of acute kidney injury after noncardiac surgery: A retrospective cohort study

Association between the preoperative N-terminal pro-B-type natriuretic peptide and acute kidney injury in gastrointestinal surgery patients managed with enhanced recovery strategy: a retrospective cohort study

Importance Previous evidence has indicated that N-terminal pro-B-type natriuretic peptide (NT-proBNP) is associated with postoperative acute kidney injury (AKI). However, the association between preoperative NT-proBNP level and postoperative AKI in surgeries managed with enhanced recovery after surgery (ERAS) strategy requires further clarification.Objective To explore the association between preoperative NT-proBNP and the incidence of postoperative AKI in patients who underwent gastrointestinal surgeries and managed with ERAS strategy.Design A retrospective cohort study.Setting A review of documented cases of elective gastrointestinal surgeries managed with ERAS strategy occurred at Xijing Hospital from 01 May 2017 to 30 June 2022.Participants A total of 629 patients aged 18 years or older who were scheduled for elective gastrointestinal surgeries and subjected to the ERAS strategy with preoperative NT-proBNP and creatinine measurements were included in the analysis.Exposure Preoperative serum concentrations of NT-proBNP.Main outcomes and measures The primary outcome was the incidence of postoperative AKI. Preoperative NT-proBNP was divided into high- or low-level groups based on the median (165 pg/ml). Logistic regression was used to explore the association between increased preoperative NT-proBNP level and risk of AKI.Results After screening 1932 case records, 629 cases were included in the final analyses. The average age was 63.5 (15.3) years old and 197 (31.3%) of them were female. Among them, 112 (17.8%) developed postoperative AKI. The incidence of AKI was 21% in the high NT-proBNP group, and 14.6% in the low NT-proBNP group. Patients with higher preoperative NT-proBNP levels (≥ 165 pg/mL) have significant higher risk of postoperative AKI as compared to those in the lower group (adjusted OR 1.75; 95% CI 1.12 to 2.73).Conclusions and relevance Increased preoperative NT-proBNP is associated with an elevated risk of postoperative AKI in patients who underwent gastrointestinal surgery and managed with ERAS strategy.Trial registry number Clinical trial registry number: NCT06145347.

A retrospective analysis of the incidence and risk factors for amniotic fluid embolism in cesarean deliveries

BACKGROUND

Amniotic-fluid embolism (AFE) is a rare occurrence but life-threatening disease that can occur in process of delivery and postnatal women. The topic of cesarean section surgery and its associated risk factors has been neglected due to the infrequent occurrence of AFE. However, AFE significantly contribute to maternal morbidity and mortality.

PURPOSES

We aim to examine the correlation between clinical issues, prenatal complications, comorbidities, medical perioperative complications, and cesarean section surgery of AFE in the US, utilizing a Nationwide Inpatient Sample (NIS) database.

METHODS

This study conducted a retrospective cohort analysis on cesarean deliveries in the United States using data from the NIS of the Healthcare Cost and Utilization Project (HCUP) to examine the incidence and risk factors of AFE during cesarean section surgery. The analysis included the period from January 1, 2010, to December 31, 2019. We employed a multivariable logistic regression to evaluate the main outcome, which encompassed the clinical, prenatal, comorbidity, and medical perioperative AFE undergoing cesarean deliveries.

RESULTS

We identified AFE in 269 out of the 2,462,005 women whose cesarean deliveries we investigated, with an incidence rate of 0.0113%. In the AFE group, the median patient age at the cohort level was 32 years (IQR, 27-36 years). The in-hospital mortality rate for patients with AFE following cesarean delivery was significantly higher than for those without AFE (14.9% vs. 0.0%, P < 0.001). In univariable analysis, P < 0.05 served as the initial selection criterion. A multivariable analysis revealed that AFE at the time of cesarean deliveries was significantly correlated with chronic blood loss anemia, coagulopathy, congestive heart failure, other neurological disorders, fluid and electrolyte disorders, weight loss, pulmonary circulation disorders, abruptio placentae, and polyhydramnios.

CONCLUSION

This contemporaneous, nationwide investigation verified the incidence of cesarean deliveries by AFE and corroborated previously identified risk factors for AFE. Although the absolute risk of AFE is minimal, clinicians should be aware of the identified risk factors, such as chronic blood loss anemia, coagulopathy, and polyhydramnios, to enhance preparedness and optimize patient counseling, particularly in high-risk cases.

Risk factors analysis and prediction model establishment of acute kidney injury after heart valve replacement in patients with normal renal function

Background

The study aimed to develop a risk prediction model through screening preoperative risk factors for acute kidney injury (AKI) after heart valve replacement in patients with normal renal function.

Methods

A total of 608 patients with normal renal function who underwent heart valve replacement from November 2013 to June 2022 were analyzed retrospectively. The Lasso regression was used to preliminarily screen potential risk factors, which were entered into the multivariable logistic regression analysis to identify preoperative independent risk factors for postoperative AKI. Based on the results, a risk prediction model was developed, and traditional and dynamic nomograms were constructed. The risk prediction model was evaluated using receiver operating characteristic (ROC), calibration curve, and decision curve analysis (DCA).

Results

220 patients (36.2%) developed AKI after surgery. Current smoker, hypertension, heart failure, previous myocardial infarction, cerebrovascular disease, CysC, and NT-proBNP were selected as independent risk factors for AKI. A risk prediction model, a traditional and a dynamic nomogram were developed based on the above factors. The area under the curve (AUC) of the ROC for predicting the risk of postoperative AKI was 0.803 (95% CI 0.769-0.836), with sensitivity and specificity of 84.9% and 63.4%, respectively. The calibration curve slope was close to 1, and the DCA showed that the model produced better clinical benefits when the probability threshold was set at 10%-82%.

Conclusions

We developed a preoperative risk prediction model for AKI after heart valve replacement in patients with normal renal function, which demonstrated satisfactory discrimination and calibration.

Preoperative assessment of adults undergoing elective noncardiac surgery: Updated guidelines from the European Society of Anaesthesiology and Intensive Care

BACKGROUND

When considering whether a patient is fit for surgery, a comprehensive patient assessment represents the first step for an anaesthetist to evaluate the risks associated with the procedure and the patient's underlying diseases, and to optimise (whenever possible) the perioperative surgical journey. These guidelines from the European Society of Anaesthesiology and Intensive Care Medicine (ESAIC) update previous guidelines to provide new evidence on existing and emerging topics that consider the different aspects of the patient's surgical path.

DESIGN

A comprehensive literature review focused on organisation, clinical facets, optimisation and planning. The methodological quality of the studies included was evaluated using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. A Delphi process agreed on the wording of recommendations, and clinical practice statements (CPS) supported by minimal evidence. A draft version of the guidelines was published on the ESAIC website for 4 weeks, and the link was distributed to all ESAIC members, both individual and national, encompassing most European national anaesthesia societies. Feedback was gathered and incorporated into the guidelines accordingly. Following the finalisation of the draft, the Guidelines Committee and ESAIC Board officially approved the guidelines.

RESULTS

In the first phase of the guidelines update, 17 668 titles were initially identified. After removing duplicates and restricting the search period from 1 January 2018 to 3 May 2023, the number of titles was reduced to 16 774, which were then screened, yielding 414 abstracts. Among these, 267 relevant abstracts were identified from which 204 appropriate titles were selected for a comprehensive GRADE analysis. Additionally, the study considered 4 reviews, 16 meta-analyses, 9 previously published guidelines, 58 prospective cohort studies and 83 retrospective studies. The guideline provides 55 evidence-based recommendations that were voted on by a Delphi process, reaching a solid consensus (>90% agreement).

DISCUSSION

This update of the previous guidelines has covered new organisational and clinical aspects of the preoperative anaesthesia assessment to provide a more objective evaluation of patients with a high risk of postoperative complications requiring intensive care. Telemedicine and more predictive preoperative scores and biomarkers should guide the anaesthetist in selecting the appropriate preoperative blood tests, x-rays, and so forth for each patient, allowing the anaesthetist to assess the risks and suggest the most appropriate anaesthetic plan.

CONCLUSION

Each patient should have a tailored assessment of their fitness to undergo procedures requiring the involvement of an anaesthetist. The anaesthetist's role is essential in this phase to obtain a broad vision of the patient's clinical conditions, to coordinate care and to help the patient reach an informed decision.

Acute Kidney Injury Post Hip Fracture Surgery: Local Quality Improvement Project and Review of Literature

BACKGROUND

 The aim of the study is to identify the potential risk factors for postoperative AKI in hip fracture patients.

DESIGN AND METHODS

 Using our local neck of femur (NOF) registration data, patient details were selected using inclusion and exclusion criteria. Electronic records of patients were assessed retrospectively, including blood results, radiological investigations, clinical documentation, and drug charts. The time period was from the start of January 2022 to the end of June 2022.

INCLUSION CRITERIA

All patients > 50 years old with NOF fractures underwent operative management from January 2022 to June 2022.

EXCLUSION CRITERIA

1. Pathological fractures. 2. Non-operative management. 3. Died directly postoperative.

RESULTS

Two hundred and fifty patients underwent hip fracture surgery at our hospital in 6 months (January 2022-June 2022) (Cemented procedures were 133 [53%], while fixation procedures were 117 [47%]). Female patients were 174 (70%), and male patients were 76. The average age was 83.4 years, and the number of operations done over the weekend (Friday-Sunday) = 123 (49%). The incidence of postoperative AKI was 56 (22.4%). Forty-five of the fifty-six cases were stage one (80.4%), while seven cases (12.5%) were stage 2. The studied risk factors for postoperative AKI were cemented procedures (61% of postoperative AKI incidence), female gender (66%), time from admission to operation (>24 hours = 33%), day of operation (operations done Friday/Saturday/Sunday = 55%), and postoperative antibiotics (71%).

CONCLUSION

 We need strategies to reduce the incidence of postoperative AKI, like AKI alert on laboratory results, IV fluid prescription preoperatively since the arrival of patients to the ED, avoiding/stopping nephrotoxic medications on admission, regular review of postoperative renal function tests and fluid balance, especially in high-risk patients, increase nursing staff and junior doctors on wards over weekends, and we need to review our policy of giving postoperative IV antibiotics.

Diagnostic accuracy of NT-proBNP to predict the incidence of CSA-AKI: A systematic review and meta-analysis

BACKGROUND

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a severe complication following cardiac surgery. Early identification and diagnosis are critical. In this study, we aim to systematically assess the diagnostic value of N-terminal pro-B-type natriuretic peptide (NT-proBNP) for CSA-AKI.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were searched from January 1971 to October 2023 to identify prospective observational and retrospective observational studies. Data extraction and study screening were carried out independently by 2 authors. The methodological quality of the included studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2 standards, and all statistical analyses were conducted by Stata 15.0.

RESULTS

Seven studies including 37,200 patients were identified. The pooled sensitivity of 0.67 (95% credible interval [CI] = 0.56-0.77), specificity of 0.55 (95% CI = 0.45-0.64), area under the summary receiver operating characteristic curve of 0.65 (95% CI = 0.60-0.69), positive likelihood ratio of 1.5 (95% CI = 1.2-1.8), negative likelihood ratio of 0.60 (95% CI = 0.46-0.79), and diagnostic odds ratio of 2 (95% CI = 2-4) suggested that patients with higher preoperative NT-proBNP levels (pg/mL) are at higher risk of developing acute kidney injury after cardiac surgery. However, NT-proBNP lacks sufficient sensitivity and specificity to reliably predict CSA-AKI.

CONCLUSION

Our findings suggest that the diagnostic accuracy of NT-proBNP to predict the incidence of CSA-AKI is limited. However, we provide novel perspectives on the early detection of CSA-AKI biomarkers, and it is urgent to identify more precise and practical biomarkers for the early diagnosis of CSA-AKI.

Preoperative risk prediction models for acute kidney injury after noncardiac surgery: an independent external validation cohort study

BACKGROUND

Numerous models have been developed to predict acute kidney injury (AKI) after noncardiac surgery, yet there is a lack of independent validation and comparison among them.

METHODS

We conducted a systematic literature search to review published risk prediction models for AKI after noncardiac surgery. An independent external validation was performed using a retrospective surgical cohort at a large Chinese hospital from January 2019 to October 2022. The cohort included patients undergoing a wide range of noncardiac surgeries with perioperative creatinine measurements. Postoperative AKI was defined according to the Kidney Disease Improving Global Outcomes creatinine criteria. Model performance was assessed in terms of discrimination (area under the receiver operating characteristic curve, AUROC), calibration (calibration plot), and clinical utility (net benefit), before and after model recalibration through intercept and slope updates. A sensitivity analysis was conducted by including patients without postoperative creatinine measurements in the validation cohort and categorising them as non-AKI cases.

RESULTS

Nine prediction models were evaluated, each with varying clinical and methodological characteristics, including the types of surgical cohorts used for model development, AKI definitions, and predictors. In the validation cohort involving 13,186 patients, 650 (4.9%) developed AKI. Three models demonstrated fair discrimination (AUROC between 0.71 and 0.75); other models had poor or failed discrimination. All models exhibited some miscalibration; five of the nine models were well-calibrated after intercept and slope updates. Decision curve analysis indicated that the three models with fair discrimination consistently provided a positive net benefit after recalibration. The results were confirmed in the sensitivity analysis.

CONCLUSIONS

We identified three models with fair discrimination and potential clinical utility after recalibration for assessing the risk of acute kidney injury after noncardiac surgery.

Incidence, risk factors and outcome of postoperative acute kidney injury in China

BACKGROUND

Postoperative acute kidney injury (AKI) is a common condition after surgery, however, the available data about nationwide epidemiology of postoperative AKI in China from large and high-quality studies are limited. This study aimed to determine the incidence, risk factors and outcomes of postoperative AKI among patients undergoing surgery in China.

METHODS

This was a large, multicentre, retrospective study performed in 16 tertiary medical centres in China. Adult patients (≥18 years of age) who underwent surgical procedures from 1 January 2013 to 31 December 2019 were included. Postoperative AKI was defined by the Kidney Disease: Improving Global Outcomes creatinine criteria. The associations of AKI and in-hospital outcomes were investigated using logistic regression models adjusted for potential confounders.

RESULTS

Among 520 707 patients included in our study, 25 830 (5.0%) patients developed postoperative AKI. The incidence of postoperative AKI varied by surgery type, which was highest in cardiac (34.6%), urologic (8.7%) and general (4.2%) surgeries. A total of 89.2% of postoperative AKI cases were detected in the first 2 postoperative days. However, only 584 (2.3%) patients with postoperative AKI were diagnosed with AKI on discharge. Risk factors for postoperative AKI included older age, male sex, lower baseline kidney function, pre-surgery hospital stay ≤3 days or >7 days, hypertension, diabetes mellitus and use of proton pump inhibitors or diuretics. The risk of in-hospital death increased with the stage of AKI. In addition, patients with postoperative AKI had longer lengths of hospital stay (12 versus 19 days) and were more likely to require intensive care unit care (13.1% versus 45.0%) and renal replacement therapy (0.4% versus 7.7%).

CONCLUSIONS

Postoperative AKI was common across surgery type in China, particularly for patients undergoing cardiac surgery. Implementation and evaluation of an alarm system is important for the battle against postoperative AKI.

Prognostic Value of Natriuretic Peptide Levels for Adverse Renal Outcomes in Patients With Moderate to Severe Acute Kidney Injury With or Without Heart Failure

Background Natriuretic peptides have been recommended as biomarkers for the diagnosis and prognosis of patients with heart failure and are often elevated in the setting of acute kidney injury. We sought to demonstrate the associations between increased baseline NT-proBNP (N-terminal pro-B-type natriuretic peptide) and adverse renal outcomes in patients with moderate-to-severe acute kidney injury. Methods and Results We reviewed electronic medical records of consecutive patients with acute kidney injury stage 2 and 3 admitted to the Cleveland Clinic between September 2011 and December 2021. Patients with NT-proBNP levels collected before renal consultation or dialysis initiation were included. Adverse renal outcomes included dialysis requirement and dialysis dependence defined as patients undergoing dialysis within 72 hours before hospital discharge or in-hospital mortality. In our study cohort (n=3811), 2521 (66%) patients underwent dialysis, 1619 (42%) patients became dialysis dependent, and 1325 (35%) patients had in-hospital mortality. After adjusting for cardiorenal risk factors, compared with the lowest quartile, the highest quartile of NT-proBNP (≥18 215 pg/mL) was associated with increased likelihood of dialysis requirement (adjusted odds ratio [OR], 2.36 [95% CI, 1.87-2.99]), dialysis dependence (adjusted OR, 1.89 [95% CI, 2.53-1.34]), and in-hospital mortality (adjusted OR, 1.34 [95% CI, 1.01-1.34]). Conclusions Increased NT-proBNP was associated with an increased risk of dialysis requirement, becoming dialysis dependent, and in-hospital mortality in patients with moderate-to-severe acute kidney injury.

Effect of preoperative risk on the association between intraoperative hypotension and postoperative acute kidney injury in cardiac surgery

BACKGROUND

Acute kidney injury (AKI), a common and severe complication after cardiac surgery, has been demonstrated to be associated with intraoperative hypotension (IOH). The reproducibility of this finding and whether preoperative risk modifies the association remain unclear. We hypothesised that the relationship between IOH and AKI after cardiac surgery varies by preoperative risk.

METHODS

We conducted a single-centre, retrospective cohort study to analyse the association between IOH and postoperative AKI by stratifying patients using preoperative risk factors. IOH was defined as a mean arterial pressure (MAP) of less than 65 mmHg and characterised by the cumulative duration and area under the curve (AUC).

RESULTS

Ten variables could be identified as risk factors: age, smoking status, NYHA III/Ⅳ, emergency surgery, peripheral vascular disease, cerebrovascular disease, heart failure, hypertension, previous cardiac surgery, and NT-proBNP concentration. The risk prediction model divided the patients into three equal-sized preoperative risk groups. Low-risk patients demonstrated no association between AKI and IOH of any severity, while high-risk patients demonstrated a statistically significant association between AKI and IOH with a cumulative duration greater than 104 min (adjusted odds ratio [OR]: 2.27, 95% confidence interval [CI]: 1.10-4.74; and adjusted OR: 3.63, 95% CI: 1.77-7.58) and an AUC greater than 905 mmHg min (adjusted OR: 2.08, 95% CI: 1.01-4.36; and adjusted OR: 4.00, 95% CI: 1.95-8.43).

CONCLUSION

IOH is a significant independent risk factor for AKI after cardiac surgery. Patients with higher baseline risk showed a more prominent relationship between IOH and postoperative AKI than low-risk patients.

Association of preoperative neutrophil-lymphocyte ratio with acute kidney injury in patients with non-cardiac surgery: difference among surgical types

PURPOSE

To examine the relationship between Neutrophil-Lymphocyte Ratio (NLR) and Acute Kidney Injury (AKI) in patients undergoing noncardiac surgery, and subgroup analysis was performed for different types of non-cardiac surgery.

METHODS

The present retrospective cohort study included 10,159 adult patients who underwent major noncardiac surgery at Nanfang Hospital, Southern Medical University, between 2008 and 2018. Postoperative AKI was defined as an increase in serum creatinine level of at least 0.3 mg/dl within 48 h, or 1.5 times higher than baseline within 7 days postoperatively according to the Kidney Disease Improving Global Outcome. The correlation between preoperative NLR and postoperative AKI was determined by stepwise multivariate logistic regression analysis, and the predictive value of NLR was evaluated by the receiver operating characteristics curve (ROC) analysis.

RESULTS

Four hundred and eighty-five (4.77%) patients developed AKI postoperatively. Preoperative NLR was independently associated with postoperative AKI in all patients undergoing non-cardiac surgery (Odds ratio [OR], 1.03; 95% confidence interval [CI], 1.00-1.06). The optimal cut-off value of NLR was 2.12 according ROC analysis. The OR and 95% CI of AKI for NLR > 2.12 was 1.48 (1.21-1.81) compared with NLR ≤ 2.12. In addition, the positive association was mainly shown in patients undergone digestive system surgery with a cut-off value of 2.12 but not in neurological and musculoskeletal system surgeries.

CONCLUSION

The present study confirmed the association of preoperative NLR with postoperative AKI in digestive system surgical patients. A NLR value of 2.12 may be a useful cut-off to evaluate the risk of AKI.

Incidence and predictors of postoperative acute kidney injury in older adults with hip fractures

OBJECTIVES

Main Purpose: To clarify the incidence and predictors of acute kidney injury (AKI) after hip fracture surgery; Secondary Purpose: To investigate the impact of AKI on the length of stay (LOS) and mortality of patients.

METHODS

We retrospectively evaluated data from 644 hip fracture patients at Peking University First Hospital from 2015 to 2021, and divided the patients into AKI and Non-AKI groups according to whether AKI occurred after surgery. Logistic regression was used to clarify the risk factors for AKI, draw ROC curves, and analyze the odds ratio (OR) for LOS and death at 30 days, 3 months, and 1 year for patients with AKI.

RESULTS

The prevalence of AKI after hip fracture was 12.1%. Age, BMI, and postoperative brain natriuretic peptide (BNP) levels were risk factors for AKI after hip fracture surgery. The risk of AKI in underweight patients, overweight patients and obese patients was 2.24, 1.89, and 2.58 times. Compared to patients with BNP levels <800 pg/ml, the risk of AKI was 22.34-fold for postoperative BNP levels>1500 pg/ml. The risk of a one-grade increase in LOS was 2.84 times higher in the AKI group and the mortality of patients with AKI were higher.

CONCLUSION

The incidence of AKI after hip fracture surgery was 12.1%. Advanced age, low BMI, and postoperative high level BNP were risk factors for AKI. Surgeons need to pay more attention to patients with older age, low BMI and high postoperative BNP levels in order to proactively prevent the development of postoperative AKI.

Serum N-terminal pro-B-type natriuretic peptide and cystatin C for acute kidney injury detection in critically ill adults in China: a prospective, observational study

OBJECTIVE

Serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and cystatin C (sCysC) are available clinically and beneficial in diagnosing acute kidney injury (AKI). Our purpose is to identify the performance of their combined diagnosis for AKI in critically ill patients.

DESIGN

A prospectively recruited, observational study was performed.

SETTING

Adults admitted to the intensive care unit of a tertiary hospital in China.

PARTICIPANTS

A total of 1222 critically ill patients were enrolled in the study.

MAIN OUTCOME MEASURES

To identify the performance of the combined diagnosis of serum NT-proBNP and sCysC for AKI in critically ill patients. The area under the receiver operating characteristic curve (AUC-ROC), category-free net reclassification index (NRI) and incremental discrimination improvement (IDI) were utilised for comparing the discriminative powers of a combined and single biomarker adjusted model of clinical variables enriched with NT-proBNP and sCysC for AKI.

RESULTS

AKI was detected in 256 out of 1222 included patients (20.9%). AUC-ROC for NT-proBNP and sCysC to detect AKI had a significantly higher accuracy than any individual biomarker (p<0.05). After multivariate adjustment, a level of serum NT-proBNP ≥204 pg/mL was associated with 3.5-fold higher odds for AKI compared with those below the cut-off value. Similar results were obtained for sCysC levels (p<0.001). To detect AKI, adding NT-proBNP and sCysC to a clinical model further increased the AUC-ROC to 0.859 beyond that of the clinical model with or without sCysC (p<0.05). Moreover, the addition of these two to the clinical model significantly improved risk reclassification of AKI beyond that of the clinical model alone or with single biomarker (p<0.05), as measured by NRI and IDI.

CONCLUSIONS

In critically ill individuals, serum NT-proBNP, sCysC and clinical risk factors combination improve the discriminative power for diagnosing AKI.

Predicting mortality in acute kidney injury patients undergoing continuous renal replacement therapy using a visualization model: A retrospective study

Background: Patients with severe acute kidney injury (AKI) require continuous renal replacement therapy (CRRT) when hemodynamically unstable. We aimed to identify prognostic factors and develop a nomogram that could predict mortality in patients with AKI undergoing CRRT. Methods: Data were extracted from the Dryad Digital Repository. We enrolled 1,002 participants and grouped them randomly into training (n = 670) and verification (n = 332) datasets based on a 2:1 proportion. Based on Cox proportional modeling of the training set, we created a web-based dynamic nomogram to estimate all-cause mortality. Results: The model incorporated phosphate, Charlson comorbidity index, body mass index, mean arterial pressure, levels of creatinine and albumin, and sequential organ failure assessment scores as independent predictive indicators. Model calibration and discrimination were satisfactory. In the training dataset, the area under the curves (AUCs) for estimating the 28-, 56-, and 84-day all-cause mortality were 0.779, 0.780, and 0.787, respectively. The model exhibited excellent calibration and discrimination in the validation dataset, with AUC values of 0.791, 0.778, and 0.806 for estimating 28-, 56-, and 84-day all-cause mortality, respectively. The calibration curves exhibited the consistency of the model between the two cohorts. To visualize the results, we created a web-based calculator. Conclusion: We created a web-based calculator for assessing fatality risk in patients with AKI receiving CRRT, which may help rationalize clinical decision-making and personalized therapy.

Using preoperative N-terminal pro-B-type natriuretic peptide levels for predicting major adverse cardiovascular events and myocardial injury after noncardiac surgery in Chinese advanced-age patients

BACKGROUND

N-terminal pro-B-type natriuretic peptide (NT-proBNP) is often viewed as an indicator for heart failure. However, the prognostic association and the predictive utility of NT-proBNP for postoperative major adverse cardiovascular events (MACEs) and myocardial injury after noncardiac surgery (MINS) among older patients are unclear.

METHODS

In this study, we included 5033 patients aged 65 years or older who underwent noncardiac surgery with preoperative NT-proBNP recorded. Logistic regression was adopted to model the associations between preoperative NT-proBNP and the risk of MACEs and MINS. The receiver operating characteristic curve was used to determine the predictive value of NT-proBNP.

RESULTS

A total of 5033 patients were enrolled, 63 patients (1.25%) and 525 patients (10.43%) had incident postoperative MACEs and MINS, respectively. Analysis of the receiver operating characteristic curve indicated that the cutoff values of ln (NT-proBNP) for MACEs and MINS were 5.16 (174 pg/mL) and 5.30 (200 pg/mL), respectively. Adding preoperative ln (NT-proBNP) to the Revised Cardiac Risk Index score and the Cardiac and Stroke Risk Model boosted the area under the receiver operating characteristic curves from 0.682 to 0.726 and 0.787 to 0.804, respectively. The inclusion of preoperative NT-proBNP in the prediction models significantly increased the reclassification and discrimination.

CONCLUSIONS

Increased preoperative NT-proBNP was associated with a higher risk of postoperative MACEs and MINS. The inclusion of NT-proBNP enhances the predictive ability of the preexisting models.

Preoperative NT-proBNP and LVEF for the prediction of acute kidney injury after noncardiac surgery: a single-centre retrospective study

BACKGROUND

Acute kidney injury (AKI) is one of the most common postoperative complications in noncardiac surgical patients, has an important impact on prognosis and is difficult to predict. Whether preoperative N-terminal pro-brain natriuretic peptide (NT-proBNP) concentrations and left ventricular ejection fraction (LVEF) levels can predict postoperative AKI in noncardiac surgical patients is unclear.

METHODS

We included 3,314 patients who underwent noncardiac surgery and had measurements of preoperative NT-proBNP concentrations and LVEF levels at a tertiary academic hospital in China between 2008 and 2018. Multiple logistic regression analysis was used to construct a postoperative AKI risk prediction model for this cohort. Then, NT-proBNP concentrations and LVEF levels were included in the abovementioned model as independent variables, and the predictive ability of these two models was compared.

RESULTS

Postoperative AKI occurred in 223 (6.72%) patients within 1 week after surgery. Preoperative NT-proBNP concentrations and LVEF levels were independent predictors of AKI after adjustment for clinical variables. The area under the receiver operating characteristic curve (AUROC) of the AKI risk predictive model established with clinical baseline variables was 0.767 (95% CI: 0.732, 0.802). When NT-proBNP concentrations and LVEF levels were added to the base model, the AUROC was 0.811 (95% CI: 0.779, 0.843). The addition of NT-proBNP concentrations and LVEF levels improved reclassification by 22.9% (95% CI 10.5-34.4%) for patients who developed postoperative AKI and by 36.3% (95% CI 29.5-43.9%) for those who did not, resulting in a significant overall improvement in net reclassification (NRI: 0.591, 95% CI 0.437-0.752, P < 0.000). The integral discrimination improvement was 0.100 (95% CI: 0.075, 0.125, P < 0.000).The final postoperative AKI prediction model was constructed, and had a good discriminative ability and fitted to the dataset.

CONCLUSIONS

Preoperative NT-proBNP concentrations and LVEF levels were independently associated with the risk of AKI after noncardiac surgery, and they could improve the predictive ability of logistic regression models based on conventional clinical risk factors.

TRIAL REGISTRATION

The protocol was preregistered in the Chinese Clinical Trial Registry ( ChiCTR1900024056 ).

The Predictive Value of Pre-operative N-Terminal Pro-B-Type Natriuretic Peptide in the Risk of Acute Kidney Injury After Non-cardiac Surgery

Objective

To evaluate the association between N-terminal pro-B-type natriuretic peptide (NT-proBNP) and risk of post-operative acute kidney injury (PO-AKI).

Methods

The electronic medical records and laboratory results were obtained from 3,949 adult patients (≥18 years) undergoing non-cardiac surgery performed between 1 October 2012 to 1 October 2019 at the Third Xiangya Hospital, Central South University, China. Collected data were analyzed retrospectively.

Results

In all, 5.3% (209 of 3,949) of patients developed PO-AKI. Pre-operative NT-proBNP was an independent predictor of PO-AKI. After adjustment for significant variables, OR for AKI of highest and lowest NT-proBNP quintiles was 1.96 (95% CI, 1.04–3.68, P = 0.008), OR per 1-unit increment in natural log transformed NT-proBNP was 1.20 (95% CI, 1.09–1.32, P < 0.001). Compared with clinical variables alone, the addition of NT-proBNP modestly improved the discrimination [change in area under the curve(AUC) from 0.82 to 0.83, ΔAUC=0.01, P = 0.024] and the reclassification (continuous net reclassification improvement 0.15, 95% CI, 0.01–0.29, P = 0.034, improved integrated discrimination 0.01, 95% CI, 0.002–0.02, P = 0.017) of AKI and non-AKI cases.

Conclusions

Results from our retrospective cohort study showed that the addition of pre-operative NT-proBNP concentrations could better predict post-operative AKI in a cohort of non-cardiac surgery patients and achieve higher net benefit in decision curve analysis.

Development and Validation of a Prediction Model for Survival in Diabetic Patients With Acute Kidney Injury

OBJECTIVE

We aimed to analyze the risk factors affecting all-cause mortality in diabetic patients with acute kidney injury (AKI) and to develop and validate a nomogram for predicting the 90-day survival rate of patients.

METHODS

Clinical data of diabetic patients with AKI who were diagnosed at The First Affiliated Hospital of Guangxi Medical University from April 30, 2011, to April 30, 2021, were collected. A total of 1,042 patients were randomly divided into a development cohort and a validation cohort at a ratio of 7:3. The primary study endpoint was all-cause death within 90 days of AKI diagnosis. Clinical parameters and demographic characteristics were analyzed using Cox regression to develop a prediction model for survival in diabetic patients with AKI, and a nomogram was then constructed. The concordance index (C-index), receiver operating characteristic curve, and calibration plot were used to evaluate the prediction model.

RESULTS

The development cohort enrolled 730 patients with a median follow-up time of 87 (40-98) days, and 86 patients (11.8%) died during follow-up. The 90-day survival rate was 88.2% (644/730), and the recovery rate for renal function in survivors was 32.9% (212/644). Multivariate analysis showed that advanced age (HR = 1.064, 95% CI = 1.043-1.085), lower pulse pressure (HR = 0.964, 95% CI = 0.951-0.977), stage 3 AKI (HR = 4.803, 95% CI = 1.678-13.750), lower 25-hydroxyvitamin D3 (HR = 0.944, 95% CI = 0.930-0.960), and multiple organ dysfunction syndrome (HR = 2.056, 95% CI = 1.287-3.286) were independent risk factors affecting the all-cause death of diabetic patients with AKI (all p < 0.01). The C-indices of the prediction cohort and the validation cohort were 0.880 (95% CI = 0.839-0.921) and 0.798 (95% CI = 0.720-0.876), respectively. The calibration plot of the model showed excellent consistency between the prediction probability and the actual probability.

CONCLUSION

We developed a new prediction model that has been internally verified to have good discrimination, calibration, and clinical value for predicting the 90-day survival rate of diabetic patients with AKI.