Short-term outcomes of acute myocardial infarction in patients with acute kidney injury: a report from the national cardiovascular data registry

Age-Dependent Risk of Long-Term All-Cause Mortality in Patients Post-Myocardial Infarction and Acute Kidney Injury

OBJECTIVES

We aimed to investigate the association between acute kidney injury (AKI) and the risk for long-term (up to 10 years) all-cause mortality among elderly compared with younger patients following an acute myocardial infarction (AMI).

METHODS

This study was a retrospective analysis of the Soroka Acute Myocardial Infarction registry and covered the years 2002 to 2017. It included patients diagnosed with an AMI who had a baseline estimated glomerular filtration rate (eGFR) greater than 60 mL/min/1.73 m2 and serum creatinine measurements available during hospitalization. The patients were stratified by age: elderly (aged 65 years or older at admission) and younger. In each stratum, two groups were defined based on the presence of an AKI. The survival approach (Kaplan-Meier survival curves, log-rank test and Cox regressions) was utilized to estimate and compare the probability of long-term (up to 10 years) all-cause mortality in each group.

RESULTS

Among the 10,511 eligible patients, which consisted of 6132 younger patients (58.3%) and 4379 elderly (41.7%), an AKI occurred in 15.2% of cases, where the elderly patients experienced a higher incidence than the younger patients (20.9% vs. 11.2%, p < 0.001). The presence of an AKI significantly increased the risk of death in both age groups, with the association being stronger among the younger patients (AdjHR = 1.634, 95% CI: 1.363-1.959, p < 0.001) than among the elderly (AdjHR = 1.278, 95% CI: 1.154-1.415, p < 0.001, p-for-interaction = 0.020).

CONCLUSIONS

An AKI following an AMI was associated with a high risk for long-term all-cause mortality in both age groups, with a stronger association among younger patients.

Hypomagnesemia is a Risk Factor for Acute Kidney Injury in Patients Admitted With ST-Segment Elevation Myocardial Infarction: A Retrospective Observational Study

OBJECTIVES

Acute kidney injury (AKI) is prevalent in patients hospitalized with ST segment elevation myocardial infarction (STEMI) and is correlated with worse cardiovascular outcomes. Hypomagnesemia has been found to be associated with an elevated risk of AKI in various patient populations. Nonetheless, the relationship between hypomagnesemia and AKI incidence in patients with STEMI has not been fully elucidated. The study aims to investigate the association between admission serum magnesium levels and the development of AKI in patients with STEMI.

DESIGN AND METHODS

A total of 1,219 patients with STEMI were retrospectively included in this study and assigned to the hypomagnesemia and nonhypomagnesemia groups. Hypomagnesemia was defined as a serum magnesium level <0.75 mmol/L. The primary study outcome was AKI Incidence during hospitalization. Univariate and multivariate logistic regression analyses were conducted to assess the association between serum magnesium levels and AKI incidence.

RESULTS

Overall, 163 patients (13.4%) met the hypomagnesemia criteria, and 256 (21.0%) patients developed AKI. The AKI incidence was significantly higher in the hypomagnesemia group compared to the nonhypomagnesemia group (31.9% vs. 19.3%; P < .001). Multivariate logistic analysis, adjusted for demographic characteristics and other confounding variables, revealed that hypomagnesemia is a risk factor for AKI (odds ratio: 2.41, 95% confidence interval: 1.61-3.62; P < .001).

CONCLUSIONS

Hypomagnesemia at admission is an independent predictor for AKI occurrence in patients with acute STEMI. Therefore, interventions targeting serum magnesium levels to mitigate AKI risk may warrant clinical consideration.

Acute changes in kidney function and outcomes following an acute myocardial infarction: Insights from PARADISE-MI

AIMS

Pharmacologic blockade of neurohormonal pathways in patients with acute myocardial infarction (MI) can result in acute changes in biomarkers of kidney function. We evaluated the effect of sacubitril/valsartan versus ramipril on initial changes in serum creatinine and the association of these changes with longer-term outcomes among participants in PARADISE-MI.

METHODS AND RESULTS

In this randomized, double-blind, active-controlled, event-driven trial, 5661 patients with an acute MI were assigned to receive sacubitril/valsartan or ramipril, with no run-in. The frequency of an initial pre-specified increase in serum creatinine (≥26.5 or ≥44 μmol/L) from baseline to week 1 was compared between arms. Multivariable Cox regression models were fit to examine the association of acute changes in serum creatinine with the primary cardiovascular composite outcome (cardiovascular death, first heart failure hospitalization, or outpatient heart failure), all-cause mortality, and longer-term changes in estimated glomerular filtration rate (eGFR). An initial increase in serum creatinine ≥26.5 μmol/L occurred in 155 of 2604 (6.0%) patients assigned to sacubitril/valsartan and 120 of 2603 (4.6%) patients assigned to ramipril (odds ratio [OR] 1.32; 95% confidence interval [CI] 1.03-1.68). The corresponding numbers for an increase ≥44 μmol/L were 57 (2.2%) and 42 (1.6%), respectively (OR 1.37; 95% CI 0.92-2.05). A higher odds of increased serum creatinine ≥26.5 and ≥44 μmol/L for sacubitril/valsartan versus ramipril appeared to be restricted to patients who had a greater decline in systolic blood pressure over the same period (p-interaction = 0.05 and 0.001, respectively). In multivariable analyses, neither an acute increase in serum creatinine ≥26.5 or ≥44 μmol/L was associated with a higher risk of cardiovascular outcomes, all-cause mortality, or differences in longer-term eGFR slope. Findings were similar across the randomized treatment arms (p-interaction >0.6 for all).

CONCLUSIONS

Following acute MI, patients assigned to sacubitril/valsartan had a higher frequency of initial increases in serum creatinine at 1 week, compared with ramipril. In adjusted models, initial increases in serum creatinine with either treatment were not associated with adverse cardiovascular outcomes or changes in longer-term kidney function.

Recovery from Acute Kidney Injury and Long-Term Prognosis following Acute Myocardial Infarction

We investigated the recovery pattern from acute kidney injury (AKI) following acute myocardial infarction (AMI) and its association with long-term mortality. The retrospective study included AMI patients (2002-2027), who developed AKI during hospitalization. Creatinine (Cr) measurements were collected and categorized into 24 h timeframes up to 7 days from AKI diagnosis. The following groups of recovery patterns were defined: rapid (24-48 h)/no rapid and early (72-144 h)/no early recovery. Specific cut-off points for recovery at each AKI stage and timeframe were determined through receiver operating characteristic (ROC) curves. The probability of long-term (up to 10 years) mortality as a post-AKI recovery was investigated using a survival approach. Out of 17,610 AMI patients, 1069 developed AKI. For stage 1 AKI, patients with a Cr ratio <1.5 at 24 h and/or <1.45 at 48 h were defined as 'rapid recovery'; for stages 2-3 AKI, a Cr ratio <2.5 at 96 h was defined as 'early recovery'. Mortality risk in stage 1 AKI was higher among the non-rapidly recovered: AdjHR = 1.407; 95% CI: 1.086-1.824; p = 0.010. Among stages 2-3 AKI patients, the risk for long-term mortality was higher among patients who did not recover in the early period: AdjHR = 1.742; 95% CI: 1.085-2.797; p = 0.022. The absence of rapid recovery in stage 1 AKI and lack of early recovery in stages 2-3 AKI are associated with higher long-term mortality.

Differences in the incidence, characteristics, and outcomes of patients with acute kidney injury in the medical and surgical intensive care units

BACKGROUND

Though acute kidney injury (AKI) is a prevalent complication in critically ill patients, knowledge on the epidemiological differences and clinical characteristics of patients with AKI admitted to medical and surgical intensive care units (ICUs) remains limited.

METHODS

Electronic medical records of patients in ICUs in Pusan National University Hospital and Pusan National University Hospital Yangsan, from January 2011 to December 2020, were retrospectively analyzed. Different characteristics of AKI between patients were analyzed. The contribution of AKI to the in-hospital mortality rate was assessed using a Cox proportional hazards model.

RESULTS

A total of 7,150 patients were included in this study. AKI was more frequent in medical (48.7%) than in surgical patients (19.7%), with the severity of AKI higher in medical patients. In surgical patients, hospital-acquired AKI was more frequent (51.0% vs. 49.0%), whereas community-acquired AKI was more common in medical patients (58.5% vs. 41.5%). 16.9% and 5.9% of medical and surgical patients died in the hospital, respectively. AKI affected patient groups to different degrees. In surgical patients, AKI patients had 4.778 folds higher risk of mortality (95% confidence interval [CI], 3.577-6.382; p < 0.001) than non-AKI patients; whereas in medical AKI patients, it was 1.239 (95% CI, 1.051-1.461; p = 0.01).

CONCLUSION

While the prevalence of AKI itself is higher in medical patients, the impact of AKI on mortality was stronger in surgical patients compared to medical patients. This suggests that more attention is needed for perioperative patients to prevent and manage AKI.

Admission proteinuria predicts the incidence of acute kidney injury among patients with acute ST-segment elevation myocardial infarction: a retrospective cohort study

BACKGROUND

Proteinuria indicates renal dysfunction and is associated with the development of acute kidney injury (AKI) in several conditions, but the association between proteinuria and AKI in patients with ST-segment elevation myocardial infarction (STEMI) remains unclear. This research aims to investigate the predictive value of proteinuria for the development of AKI in STEMI patients.

METHODS

A total of 2735 STEMI patients were enrolled. The present study's endpoint was AKI incidence during hospitalization. AKI is defined according to the Kidney Disease: Improving Global Outcomes criteria. We defined proteinuria, measured with a dipstick, as mild (1+) or heavy (2+ to 4+). Multivariate logistic regression and subgroup analyses were used to testify to the association between proteinuria and AKI.

RESULTS

Overall, proteinuria was observed in 634 (23.2%) patients. Multivariate logistic regression analyses revealed that proteinuria [odds ratio (OR), 1.58; 95% confidence interval (CI), 1.25-2.00; P  < 0.001] was the independent predictive factor for AKI. Severe proteinuria was associated with a higher adjusted risk for AKI compared with the nonproteinuria group (mild proteinuria: OR, 1.35; 95% CI, 1.04-1.75; P  = 0.025; severe proteinuria: OR, 2.50; 95% CI, 1.70-3.68; P  < 0.001). The association was highly consistent across all studied subgroups. (all P for interaction >0.05).

CONCLUSION

Admission proteinuria measured using a urine dipstick is an independent risk factor for the development of AKI in STEMI patients.

Obesity is associated with acute kidney injury in ST-segment-elevation myocardial infarction undergoing percutaneous coronary intervention: A national representative cohort study

BACKGROUND

Acute kidney injury (AKI) is a frequent and potentially life-threatening complication after percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). However, the relationship between obesity and the risk of AKI in this specific patient population has not been previously examined.

METHODS

We queried the National Inpatient Sample (2016-2019) using ICD-10 codes to obtain a sample of adults with STEMI undergoing PCI. All patients were further subcategorized into obese and nonobese cohorts. The primary outcome was the incidence of AKI. Multivariate regression analysis was performed to assess the impact of obesity on AKI. The consistency of this correlation between subgroups was investigated using subgroup analysis and interaction testing.

RESULTS

A total of 62,599 (weighted national estimate of 529,016) patients were identified, of which 9.80% (n = 6137) had AKI. Obesity comprised 19.78% (n = 1214) of the AKI cohort. Obese patients were on average younger, male, white, and had more comorbidities. Additionally, there was a significant positive association between obesity and AKI incidence (adjusted odds ratio [aOR]: 1.24, 95% confidence interval [CI]: 1.15-1.34), which was more pronounced in female patients (aOR: 1.56, 95% CI: 1.33-1.82, p < 0.001, p-interaction = 0.008). The AKI incidence in these patients increased steadily during the 4-year study period, and it was consistently higher in obese patients than in nonobese patients (p-trend < 0.001 for all).

CONCLUSIONS

Obesity was independently associated with a greater risk of AKI among adults with STEMI undergoing PCI, particularly in female patients.

Analyzing predictors of in-hospital mortality in patients with acute ST-segment elevation myocardial infarction using an evolved machine learning approach

Acute ST-segment elevation myocardial infarction (STEMI) is a severe cardiac ailment characterized by the sudden complete blockage of a portion of the coronary artery, leading to the interruption of blood supply to the myocardium. This study examines the medical records of 3205 STEMI patients admitted to the coronary care unit of the First Affiliated Hospital of Wenzhou Medical University from January 2014 to December 2021. In this research, a novel predictive framework for STEMI is proposed, incorporating evolutionary computational methods and machine learning techniques. A variant algorithm, AGCOSCA, is introduced by integrating crossover operation and observation bee strategy into the original Sine Cosine Algorithm (SCA). The effectiveness of AGCOSCA is initially validated using IEEE CEC 2017 benchmark functions, demonstrating its ability to mitigate the deficiency in local mining after SCA random perturbation. Building upon this foundation, the AGCOSCA approach has been paired with Support Vector Machine (SVM) to forge the predictive framework referred to as AGCOSCA-SVM. Specifically, AGCOSCA is employed to refine the selection of predictors from a substantial feature set before SVM is utilized to forecast the occurrence of STEMI. In our analysis, we observed that SVM excels at managing nonlinear data relationships, a strength that becomes particularly prominent in smaller datasets of STEMI patients. To assess the effectiveness of AGCOSCA-SVM, diagnostic experiments were conducted based on the STEMI sample data. Results indicate that AGCOSCA-SVM outperforms traditional machine learning methods, achieving superior Accuracy, Sensitivity, and Specificity values of 97.83 %, 93.75 %, and 96.67 %, respectively. The selected features, such as acute kidney injury (AKI) stage, fibrinogen, mean platelet volume (MPV), free triiodothyronine (FT3), diuretics, and Killip class during hospitalization, are identified as crucial for predicting STEMI. In conclusion, AGCOSCA-SVM emerges as a promising model framework for supporting the diagnostic process of STEMI, showcasing potential applications in clinical settings.

Serum total bilirubin level is associated with contrast induced nephropathy after primary percutaneous coronary intervention

Contrast Induced Nephropathy (CIN) is a major complication of angiographic procedures. Primary percutaneous coronary intervention (pPCI) is the preferred treatment for ST-segment elevation myocardial infarction (STEMI) but is associated with a risk of CIN. Oxidative stress and free radical damage play a role in the pathogenesis of CIN. Bilirubin has anti-inflammatory and antioxidant activity and has been shown to have a protective effect on endothelial cells. The present study aimed to assess the association between serum bilirubin level and development of CIN after pPCI. Sequential STEMI patients (n = 595) who underwent pPCI between January 2021 and December 2022 were enrolled. Among the participants, 116 (19.5%) developed CIN. Serum total bilirubin level was significantly lower in the CIN group (P = .001). In multivariate logistic regression analysis, serum bilirubin level was found as an independent predictor of CIN. Age, gender, contrast volume, and white blood cell count were other independent predictors of CIN. A higher serum bilirubin level is associated with a lower risk of CIN in the present study. In STEMI patients undergoing pPCI, serum bilirubin level may be helpful to predict the risk of CIN and may help ensure early initiation of preventive treatment and careful follow-up.

A new marker for the prediction of contrast induced-acute kidney injury following primary percutaneous coronary intervention: logarithm of haemoglobin-albumin product

BACKGROUND

Contrast-induced acute kidney injury (CI-AKI) is a disorder that adversely affects the prognosis of STEMI. The study aimed to assess the predictive value of a new marker, logarithm of haemoglobin and albumin product (LHAP) on the risk of CI-AKI development after primary percutaneous coronary intervention (p-pcı).

METHOD

We retrospectively enrolled 3057 patients with ST-elevation acute myocardial infarction who were treated with p-PCI. The primary outcome was CI-AKI, defined as >25% or >0.5 mg/dl increase of baseline creatinine values during post-procedural 48 h.

RESULTS

First, a baseline model was produced to determine the predictors of CI-AKI, then haemoglobin, albumin and LHAP were included in the base model and the performances of all models were compared. The predictive accuracy (Likelihood ratio χ2 and R2) and discrimination (ROC-AUC) of the model including LHAP were significantly higher than that of models including both albumin and Hgb. LHAP best cut-off value for the development of CI-AKI was 9.26 (sensitivity 68% and specificity 66%).

CONCLUSION

LHAP values were the most important predictor of CI-AKI, followed by creatinine value and Killip class. LHAP values are significantly associated with CI-AKI after p-PCI.

Soluble interleukin-2 receptor predicts acute kidney injury and in-hospital mortality in patients with acute myocardial infarction

BACKGROUND

Acute kidney injury (AKI) is the most common and critical complication in patients with acute myocardial infarction (AMI). This study aims to evaluate the significance of elevated soluble interleukin 2 receptor (sIL-2R) levels in predicting AKI and mortality.

METHODS

A total of 446 patients with AMI were enrolled between January 2020 and July 2022, including 58 patients with AKI and 388 without AKI. The sIL-2R levels were measured using a commercially available chemiluminescence enzyme immunoassay. Logistic regression analysis was used to examine the risk factors for AKI. Discrimination was assessed based on the area under the receiver operating characteristic curve. The model was internally validated using 10-fold cross-validation.

RESULTS

During hospitalization, 13% of patients developed AKI following AMI, with higher sIL-2R levels (0.61 ± 0.27 U/L vs. 0.42 ± 0.19 U/L, p = 0.003) and in-hospital all-cause mortality (12.1% vs. 2.6%, P < 0.001). The sIL-2R levels emerged as an independent risk factor for both AKI (OR = 5.08, 95% CI (1.04-24.84, p < 0.045) and in-hospital all-cause mortality (OR = 73.57,95% CI 10.24-528.41, p < 0.001) in AMI patients. The sIL-2R levels were found to be useful biomarkers in prediction of AKI and in-hospital all-cause mortality in patients with AMI (AUC: 0.771 and 0.894, respectively). The respective cutoff values for sIL-2R levels in predicting AKI and in-hospital all-cause mortality were determined to be 0.423 U/L and 0.615 U/L.

CONCLUSIONS

The level of sIL-2R was an independent risk factor and predictor for both AKI and in-hospital all-cause mortality in patients with AMI. These findings highlight the potential of sIL-2R as a valuable tool for identifying high-risk patients regarding AKI and in-hospital mortality.

Predictive Value of Systemic Inflammation Score for Contrast-Associated Acute Kidney Injury and Adverse Outcomes Among Patients Undergoing Elective Percutaneous Coronary Intervention

Purpose

Prior research has demonstrated a key role of systemic inflammatory state in the pathogenesis and progression of contrast-associated acute kidney injury (CA-AKI). Recently, the systemic inflammation score (SIS) has been introduced to evaluate the inflammatory status, utilizing the lymphocyte-to-monocyte ratio (LMR) and albumin. The primary objective of this study was to determine whether the SIS can predict CA-AKI and long-term prognosis in patients undergoing elective percutaneous coronary intervention (PCI).

Patients and Methods

A total of 5726 patients who underwent elective PCI were included from January 2012 to December 2018. The primary outcome was CA-AKI, defined as an increase in serum creatinine (SCr) ≥0.3 mg/dl or ≥50% than baseline SCr within 48 h after the PCI procedure. The secondary outcome was long-term mortality. All patients were classified into low- and high-SIS groups.

Results

During hospitalization, 349 (6.1%) patients developed CA-AKI. Multivariate logistic regression analysis showed that patients in the high SIS group had a 1.47-fold higher risk of developing CA-AKI than those in the low SIS group [odds ratio (OR): 1.50, 95% confidence interval (CI): 1.12-2.01, P =0.006]. Furthermore, the SIS showed the greatest prediction performance for CA-AKI compared with other inflammatory hematological ratios. In the multivariate Cox regression analysis, the high SIS group was found to be closely associated with long-term mortality [hazard ratio (HR): 1.58, 95% CI: 1.26-1.97, P <0.001, vs low SIS group]. The Kaplan-Meier curve analysis also demonstrated a difference in long-term mortality between the two groups (Log rank test, P <0.001).

Conclusion

The SIS was closely associated with CA-AKI and long-term mortality in patients after elective PCI. Thus, more attention should be paid to exploring the potential benefits of anti-inflammatory strategies in preventing CA-AKI and improving the prognosis of patients undergoing PCI.

Venous excess ultrasound score and acute kidney injury in patients with acute coronary syndrome

AIMS

Systemic venous congestion is associated with an increased risk of acute kidney injury (AKI) in critically ill patients. Venous Excess Ultrasound Score (VExUS) has been proposed as a non-invasive score to assess systemic venous congestion. We aimed to evaluate the association between VExUS and AKI in patients with acute coronary syndrome (ACS).

METHODS AND RESULTS

This is a prospective study including patients with the diagnosis of ACS (both ST elevation and non-ST elevation ACS). VExUS was performed during the first 24 h of hospital stay. Patients were classified according to the presence of systemic congestion (VExUS 0/≥1). The primary objective of the study was to determine the occurrence of AKI, defined by KDIGO criteria. A total of 77 patients were included. After ultrasound assessment, 31 (40.2%) patients were categorized as VExUS ≥1. VExUS ≥1 was more frequently found in inferior vs. anterior myocardial infarction/non-ST-segment elevation acute myocardial infarction (48.3 vs. 25.8 and 22.5%, P = 0.031). At each increasing degree of VExUS, a higher proportion of patients developed AKI: VExUS = 0 (10.8%), VExUS = 1 (23.8%), VExUS = 2 (75.0%), and VExUS = 3 (100%; P < 0.001). A significant association between VExUS ≥1 and AKI was found [odds ratio (OR): 6.75, 95% confidence interval (CI): 2.21-23.7, P = 0.001]. After multivariable analysis, only VExUS ≥1 (OR: 6.15; 95% CI: 1.26-29.94, P = 0.02) remained significantly associated with AKI.

CONCLUSION

In patients hospitalized with ACS, VExUS is associated with the occurrence of AKI. Further studies are needed to clarify the role of VExUS assessment in patients with ACS.

Establishment and assessment of a preclinical model of acute kidney injury induced by contrast media combined acute myocardial ischemia reperfusion surgery

Acute kidney injury (AKI) is a common complication after acute myocardial infarction (AMI) in clinical practice, and the majority of previous preclinical models were induced by a single factor. The objective of the present study was to establish a stable preclinic model of AKI induced by contrast media (CM) with acute myocardial ischemia reperfusion surgery and to identify the effect of oxidative stress on kidney injury. Rats were treated individually or with CM or myocardial ischemia reperfusion surgery. Renal baseline and AKI parameters, the level of oxidative stress and histopathological images were examined along with AKI biomarkers. Results showed the incidence of AKI in the CM group and ischemia reperfusion injury (IRI) group was 40%, χ² test (P<0.05 vs. CM-IRI) and 35%, χ² test (P<0.05 vs. CM-IRI) and the combination group had the highest incidence rate 75%. IRI surgery combined with CM diminished kidney function and induced oxidative stress by increasing creatinine, blood urea nitrogen and reactive oxygen species levels. Western blotting showed that the early AKI biomarker of NGAL and KIM-1 increased and that the combination group had the highest value. Pathology damage exhibited severe kidney damage in the combination group compared with other control groups. The present research established a reliable preclinic model of post-AMI AKI with a stable and high postoperative AKI rate. Additionally, CM was demonstrated to exacerbate AKI caused by acute myocardial infarction through oxidative stress and, thus, oxidative stress may be a potential therapeutic target.

Clinical Outcomes for Acute Kidney Injury in Acute Myocardial Infarction Patients after Intra-Aortic Balloon Pump Implantation: A Single-Center Observational Study

Background

Acute kidney injury (AKI) is common after cardiac interventional procedures. The prevalence and clinical outcome of AKI in patients with acute myocardial infarction (AMI) after undergoing intra-aortic balloon pump (IABP) implantation remains unknown. The aim of this study was to investigate the incidence, risk factors, and prognosis of AKI in specific patient populations.

Methods

We retrospectively reviewed 319 patients with AMI between January 2017 and December 2021 and who had successfully received IABP implantation. The diagnostic and staging criteria used for AKI were based on guidelines from "Kidney Disease Improving Global Outcomes". The composite endpoint included all-cause mortality, recurrent myocardial infarction, rehospitalization for heart failure, and target vessel revascularization.

Results

A total of 139 patients (43.6%) developed AKI after receiving IABP implantation. These patients showed a higher incidence of major adverse cardiovascular events (hazard ratio [HR]: 1.55, 95% confidence interval [CI]: 1.06-2.26, p = 0.022) and an increased risk of all-cause mortality (HR: 1.62, 95% CI: 1.07-2.44, p = 0.019). Multivariable regression models found that antibiotic use (odds ratio [OR]: 2.07, 95% CI: 1.14-3.74, p = 0.016), duration of IABP use (OR: 1.24, 95% CI: 1.11-1.39, p < 0.001) and initial serum creatinine (SCr) (OR: 1.01, 95% CI: 1.0-1.01, p = 0.01) were independent risk factors for AKI, whereas emergency percutaneous coronary intervention was a protective factor (OR: 0.35, 95% CI: 0.18-0.69, p = 0.003).

Conclusions

AMI patients who received IABP implantation are at high risk of AKI. Close monitoring of these patients is critical, including the assessment of renal function before and after IABP implantation. Additional preventive measures are needed to reduce the risk of AKI in these patients.

Major cardiovascular events and subsequent risk of kidney failure with replacement therapy: a CKD Prognosis Consortium study

AIMS

Chronic kidney disease (CKD) increases risk of cardiovascular disease (CVD). Less is known about how CVD associates with future risk of kidney failure with replacement therapy (KFRT).

METHODS AND RESULTS

The study included 25 903 761 individuals from the CKD Prognosis Consortium with known baseline estimated glomerular filtration rate (eGFR) and evaluated the impact of prevalent and incident coronary heart disease (CHD), stroke, heart failure (HF), and atrial fibrillation (AF) events as time-varying exposures on KFRT outcomes. Mean age was 53 (standard deviation 17) years and mean eGFR was 89 mL/min/1.73 m2, 15% had diabetes and 8.4% had urinary albumin-to-creatinine ratio (ACR) available (median 13 mg/g); 9.5% had prevalent CHD, 3.2% prior stroke, 3.3% HF, and 4.4% prior AF. During follow-up, there were 269 142 CHD, 311 021 stroke, 712 556 HF, and 605 596 AF incident events and 101 044 (0.4%) patients experienced KFRT. Both prevalent and incident CVD were associated with subsequent KFRT with adjusted hazard ratios (HRs) of 3.1 [95% confidence interval (CI): 2.9-3.3], 2.0 (1.9-2.1), 4.5 (4.2-4.9), 2.8 (2.7-3.1) after incident CHD, stroke, HF and AF, respectively. HRs were highest in first 3 months post-CVD incidence declining to baseline after 3 years. Incident HF hospitalizations showed the strongest association with KFRT [HR 46 (95% CI: 43-50) within 3 months] after adjustment for other CVD subtype incidence.

CONCLUSION

Incident CVD events strongly and independently associate with future KFRT risk, most notably after HF, then CHD, stroke, and AF. Optimal strategies for addressing the dramatic risk of KFRT following CVD events are needed.

Analysis of risk factors for severe acute kidney injury in patients with acute myocardial infarction: A retrospective study

Background

Patients with acute myocardial infarction (AMI) complicated by acute kidney injury (AKI) tend to have a poor prognosis. However, the exact mechanism of the co-occurrence of the two diseases is unknown. Therefore, this study aims to determine the risk factors for severe AKI in patients with AMI.

Methods

A total of 2022 patients were included in the Medical Information Mart for Intensive Care. Variables were identified via univariate logistic regression, and the variables were corrected via multivariate logistic regression. Restricted cubic splines were used to examine the risks associated with the variables. The Kaplan-Meier method was used to compare the risk of severe AKI among the patients.

Results

Patients with severe AKI had a higher in-hospital mortality rate (28.6% vs. 9.0%, P < 0.001) and a longer duration of intensive care (6.5 days vs. 2.9 days, P < 0.001). In patients with AMI, the mean systolic blood pressure (SBP); international normalized ratio (INR); the levels of blood urea nitrogen (BUN), glucose, and calcium; and a history of liver disease were found to be the independent risk factors for developing severe AKI after their admission. Increased levels of BUN and blood glucose and a high INR increased the risk of severe AKI; however, increased levels of calcium decreased the risk; SBP presented a U-shaped curve relationship.

Conclusions

Patients with severe AKI have a poor prognosis following an episode of AMI. Furthermore, in patients with AMI, SBP; INR; a history of liver disease; and the levels of BUN, glucose, and calcium are the independent risk factors for developing severe AKI after their admission.

BMI Modifies Increased Mortality Risk of Post-PCI STEMI Patients with AKI

Mortality from acute ST elevation myocardial infarction (STEMI) was significantly reduced with the introduction of percutaneous catheterization intervention (PCI) but remains high in patients who develop acute kidney injury (AKI). Previous studies found overweight to be protective from mortality in patients suffering from STEMI and AKI separately but not as they occur concurrently. This study aimed to establish the relationship between AKI and mortality in STEMI patients after PCI and whether body mass index (BMI) has a protective impact. Between January 2008 and June 2016, two thousand one hundred and forty-one patients with STEMI underwent PCI and were admitted to the Tel Aviv Medical Center Cardiac Intensive Care Unit. Their demographic, laboratory, and clinical data were collected and analyzed. We compared all-cause mortality in patients who developed AKI after PCI for STEMI and those who did not. In total, 178 patients (10%) developed AKI and had higher mortality (p < 0.001). Logistic regression analysis was performed to determine the relationship between AKI, BMI, and mortality. AKI was significantly associated with both 30-day and overall mortality, while BMI had a significant protective effect. Survival analysis found a significant difference in 30-day and overall survival between patients with and without AKI with a significant protective effect of BMI on survival at 30 days. AKI presents a major risk for mortality and poor survival after PCI for STEMI, yet a beneficial effect of increased BMI modifies it.

Lactate level and lactate clearance for acute kidney injury prediction among patients admitted with ST-segment elevation myocardial infarction: A retrospective cohort study

Background

Hyperlactatemia is a prognostic marker among patients with ST-segment elevation acute myocardial infarction (STEMI). However, the predictive value of lactate and the dynamic change associated with acute kidney injury (AKI) among patients with STEMI, remain poorly understood. We aimed to compare single lactate values at admission (Lacadm) and 12 h after admission (Lac12h) with lactate clearance (LC) 12 h after admission for AKI prediction in patients with STEMI.

Methods

A total of 1,784 patients with STEMI were included. The study endpoint was AKI occurrence during hospitalization. The predictive value of lactate levels measured at admission and 12 h after admission and LC for AKI prediction was determined using multivariate logistic regression analyses and compared with receiver operator characteristic (ROC) curve analysis.

Results

Overall, AKI was observed in 353 (19.8%) patients. In multivariate logistic regression analyses, Lacadm ≥ 4.3 mmol/L (OR: 1.53; 95% CI: 1.01-2.30), Lac12h ≥ 2.1 mmol/L (OR: 1.81; 95% CI: 1.36-2.42), and LC ≥ -7.5% (OR: 0.40; 95% CI: 0.30-0.53) were the independent predictive factors for AKI after adjusting for confounders. ROC curve analysis results revealed that Lac12h (0.639; 95% CI: 0.616-0.661) exhibited a significantly higher area under the curve (AUC) than those of Lacadm (0.551; 95% CI: 0.527-0.574) and LC (0.593; 95% CI: 0.570-0.616) in the prediction of AKI. LC (△AUC = 0.037, p < 0.001) and Lac12h (△AUC = 0.017, p = 0.029) enhanced the discrimination capacity of Mehran Risk Score (MRS) for AKI among patients undergoing emergency coronary angiography.

Conclusion

Lac12h is more effective for AKI prediction among patients with STEMI than Lacadm and LC. Furthermore, Lac12h and LC enhance the prediction capacity of MRS for AKI among patients after emergency coronary angiography.

Evaluating the Application of Chronic Heart Failure Therapies and Developing Treatments in Individuals With Recent Myocardial Infarction: A Review

Importance

Despite advances in cardiac care, patients remain at a high risk of death and the development of heart failure (HF) following myocardial infarction (MI). These risks are highest in patients with reduced ejection fraction (EF) or signs of HF immediately after MI. Drugs to mitigate these risks have been identified through the systematic evaluation of therapies with proven efficacy in patients with HF and reduced EF (HFrEF).

Observations

Although landmark studies in patients with HFrEF consistently exclude patients with recent MI, dedicated post-MI trials of these drugs have led to multiple therapies with proven benefit in these patients. However, not all therapies with proven efficacy in patients with chronic HF have been shown to provide benefit in the post-MI population, as recently evidenced by the discrepant results between chronic HF and post-MI trials of sacubitril-valsartan. Similarly, multiple trials of early and aggressive use of therapies effective in chronic heart failure immediately post-MI failed to demonstrate benefit or were associated with harm, emphasizing the vulnerability of the post-MI population.

Conclusions and Relevance

Trials of patients at high risk of HF following MI have emphasized the differences between the post-MI and HFrEF populations and the necessity for dedicated trials in the post-MI population. This review summarizes trials studying the use of these therapies for at-risk patients following MI from therapies used in patients with HFrEF and exploring new potential therapies for this high-risk population.

Clinical Characteristics and Risk Factors of In-Hospital Mortality in Patients With Acute Myocardial Infarction With Subsequent Gastrointestinal Bleeding: A Single-Center Experience

Objective

Gastrointestinal bleeding (GIB) post acute myocardial infarction (AMI) is a severe clinical condition with a poor prognosis. The purpose of the study was to evaluate the rate of in-hospital mortality in patients with GIB post-AMI and to identify the potential risk factors of this situation.

Methods

In this single-center retrospective study, a total of 154 patients diagnosed with AMI who subsequently suffered GIB were enrolled from October 2013 to December 2021. Demographic, laboratory, and clinical data were collected. The in-hospital mortality was the outcome of interest. Logistic regression analysis was used to investigate the potential risk factors of in-hospital mortality.

Results

Among the 154 subjects included in the final analysis, the mean age was 65.58 ± 11.20 years, and 104 (67.53%) were males. GIB occurred in 11 patients after thrombolytic therapy, 50 patients after percutaneous coronary intervention (PCI), and 93 patients during drug conservative treatment. A total of 41 patients died in the hospital. The in-hospital mortality rate of the thrombolysis group, PCI group, and drug conservative treatment group was 27.27% (3/11), 28.00% (14/50), and 25.81% (24/93), respectively. There was no difference in the in-hospital mortality among the three groups. The multivariate logistic regression analysis showed that the peak levels of TnI (OR 1.07, 95% CI 1.02–1.12, P = 0.011), condition of cardiogenic shock after admission (OR 14.52, 95% CI 3.36–62.62, P < 0.001), and the use of the mechanical ventilator (OR 8.14, 95% CI 2.03–32.59, P = 0.003) were significantly associated with in-hospital mortality.

Conclusion

Regardless of the treatment strategy for AMI, once GIB occurred, the prognosis was poor. High in-hospital mortality in patients with GIB post-AMI was independently associated with the peak levels of TnI, condition of cardiogenic shock, and the use of a mechanical ventilator.

Hospitalization Outcomes Related to Acute Kidney Injury in Inpatients With Acute Myocardial Infarction: A Cross-Sectional Nationwide Study

Objective

To delineate the differences in demographic characteristics and hospitalization outcomes in patients with acute myocardial infarction by comorbid acute kidney injury (AKI) and to explore the risk factors for in-hospital mortality due to AKI in acute myocardial infarction (AMI) inpatients.

Methods

We conducted a retrospective cross-sectional study using a nationwide inpatient sample and included 77,585 adult inpatients with AMI and further divided by the presence of a co-diagnosis of AKI. A logistic regression model was used to evaluate the odds ratio (OR) of the association between in-hospital mortality and AKI and other comorbidities.

Results

The prevalence of AKI in AMI inpatients during hospitalization was 11.69%. Among AMI inpatients with AKI, it was prevalent in males (73.9%) and whites (48.8%). Patients with AKI had a higher prevalence of complicated comorbid hypertension (58.7%), diabetes with complications (34.8%), cardiogenic shock (17.4%), and drug abuse (12.3%). Male patients had lower odds of in-hospital mortality (OR 0.69; 95% Cl 0.61-0.79) compared to females. Hispanics had a higher association with mortality (OR 1.45; 95% Cl 1.21-1.74) than whites and other races/ethnicities. Patients who developed cardiogenic shock were at 17 times higher odds of in-hospital mortality (OR 17.25; 95% CI 15.14-19.67), followed by AKI (OR 4.64; 95% CI 4.06-5.31), and alcohol abuse (OR 1.29; 95% CI 1.03-1.64). The in-hospital mortality rate among AMI inpatients with AKI (7.6%) was significantly higher compared to that seen in the non-AKI cohort (0.9%).

Conclusion

AMI inpatients with AKI during hospitalization was prevalent in males and whites. Among the demographic risk factors, females and Hispanics had a higher likelihood of in-hospital mortality during the inpatient management of AMI. Cardiogenic shock and AKI increased the odds of in-hospital mortality compared to other comorbidities in AMI inpatients.

The Role of Gut-Derived, Protein-Bound Uremic Toxins in the Cardiovascular Complications of Acute Kidney Injury

Acute kidney injury (AKI) is a frequent disease encountered in the hospital, with a higher incidence in intensive care units. Despite progress in renal replacement therapy, AKI is still associated with early and late complications, especially cardiovascular events and mortality. The role of gut-derived protein-bound uremic toxins (PBUTs) in vascular and cardiac dysfunction has been extensively studied during chronic kidney disease (CKD), in particular, that of indoxyl sulfate (IS), para-cresyl sulfate (PCS), and indole-3-acetic acid (IAA), resulting in both experimental and clinical evidence. PBUTs, which accumulate when the excretory function of the kidneys is impaired, have a deleterious effect on and cause damage to cardiovascular tissues. However, the link between PBUTs and the cardiovascular complications of AKI and the pathophysiological mechanisms potentially involved are unclear. This review aims to summarize available data concerning the participation of PBUTs in the early and late cardiovascular complications of AKI.

Impact of Acute and Chronic Kidney Disease on Heart Failure Hospitalizations After Acute Myocardial Infarction

Very few studies evaluated the impact of acute kidney injury (AKI) and chronic kidney disease (CKD) on heart failure (HF) hospitalization risk following an acute myocardial infarction (AMI). For this retrospective cohort analysis, we identified adult AMI survivors from January to June 2014 from the United States Nationwide Readmissions Database. Outcomes were a 6-month HF, fatal HF, composite of HF during the AMI or a 6-month HF, and a composite of 6-month HF or death during a non-HF-related admission. We analyzed differences in outcomes across categories of patients without renal injury, AKI without CKD, stable CKD, AKI on CKD, and end-stage renal disease (ESRD). Of 237,549 AMI survivors, AKI was present in 13.8%, CKD in 16.5%, ESRD in 3.4%, and AKI on CKD in 7.7%. Patients with renal failure had lower coronary revascularization rates and higher in-hospital HF. A 6-month HF hospitalization occurred in 12,934 patients (5.4%). Compared with patients without renal failure (3.3%), 6-month HF admission rate was higher in patients with AKI on CKD (14.6%; odds ratio [OR] 1.99; 95% confidence interval [CI] 1.81 to 2.19), ESRD (11.2%; OR 1.57; 95% CI 1.36 to 1.81), stable CKD (10.7%; OR 1.72; 95% CI 1.56 to 1.88), and AKI (8.6%; OR 1.52; 95% CI 1.36 to 1.70). Results were generally homogenous in prespecified subgroups and for the other outcomes. In conclusion, 1 in 4 AMI survivors had either acute or chronic renal failure. The presence of any form of renal failure was associated with a substantially increased risk of 6-month HF hospitalizations and associated mortality with the highest risk associated with AKI on CKD.

Interleukin-10 attenuates renal injury after myocardial infarction in diabetes

Acute kidney injury (AKI) is a common complication after myocardial infarction (MI) and associated with significant morbidity and mortality. AKI after MI occurs more frequently in patients with diabetes, however, the underlying mechanisms are poorly understood, and specific treatments are lacking. Using the murine MI model, we show that diabetic mice had higher expression of the kidney injury marker, neutrophil gelatinase-associated lipocalin (NGAL), 3 days after MI compared with control mice. This higher expression of NGAL was still significant after controlling for differences in myocardial infarct size between diabetic and control mice. Prior data demonstrate increased cell-free hemoglobin after MI in diabetic mice. Therefore, we investigated heme clearance components, including heme oxygenase 1 (HO-1) and CD163, in the kidneys and found that both HO-1 and CD163 were dysregulated in diabetic mice pre-MI and post-MI. Significantly higher levels of urine iron were also observed in diabetic mice compared with control mice after MI. Next, the renal protective effect of interleukin 10 (IL-10) after MI was tested in diabetic MI. IL-10 treatment demonstrated multiple protective effects after diabetic MI including reduction in acute renal inflammation, upregulation of renal heme clearance pathways, attenuation of chronic renal fibrosis, and reduction in albuminuria after diabetic MI. In vitro, IL-10 potentiated hemoglobin-induced HO-1 expression in mouse bone marrow-derived macrophages and renal proximal tubule (HK-2) cells. Furthermore, IL-10 reduced hemoglobin-induced reactive oxygen species in HK-2 cells and collagen synthesis in mouse embryonic fibroblast cells. We conclude that impaired renal heme clearance pathways in diabetes contribute to AKI after MI, and IL-10 attenuates renal injury after diabetic MI.

Association of the Novel Inflammatory Marker Systemic Immune-Inflammation index and Contrast-Induced Nephropathy in Patients Undergoing Transcatheter Aortic Valve Replacement for Severe Aortic Stenosis

This study investigated whether the systemic immune-inflammation index (SII) is an independent predictor of contrast-induced nephropathy (CIN) in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. TAVR patients (n = 130) were included in the study. The patients were divided into 2 groups: those who developed CIN [CIN (+)] and those who did not [CIN (−)]. The SII was calculated as the ratio of the product of the total neutrophil count and the total platelet count to the lymphocyte count. CIN developed in 20 (15.3%) patients after TAVR. White blood cell count (7.66 ± 1.75 vs 6.78 ± 1.71 103/mm3 P = .038), neutrophil count (5.1 (3.9–6.7) vs 4.2 (3.5-5.1) 103/mm3 P = .024), neutrophillymphocyte ratio (4.20 (2.39–7.00) vs 2.75 (2.06-3.88), P = .010) and SII index (1069 (616–1514) vs 598 (426-955), P = .003) were at higher levels in patients with CIN. In addition, the SII index was an independent predictor for the development of CIN. The SII index, which can be easily calculated from a complete blood count, is an independent predictor of CIN in patients undergoing TAVR for severe aortic stenosis.

Predictors of contrast-induced nephropathy in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Background

Contrast-induced nephropathy (CIN) is a serious complication with primary percutaneous coronary intervention (PPCI). We aimed to study the different predictors of CIN and determine the cutoff point of contrast volume (CV)/creatinine clearance (CrCl) and the applicability of CHA2DS2-VASC score in the prediction of CIN after PPCI in ST-elevation myocardial infarction (STEMI) patients. Four hundred patients presented with STEMI and eligible for primary PCI were included in the study. Patients with GFR < 30 ml/min were excluded from the study.

Results

Fifty-four (13.5%) patients who developed CIN who were older (64.20 ± 13.16 vs. 55.80 ± 10.58) had a higher prevalence of diabetes mellitus (DM), hypertension (HTN), and female gender than those without CIN. They also had a higher Killip class and lower hemoglobin (HB) level (P < 0.05) compared to those with no CIN. The incidence of no CIN was (85.8%) in the low-risk Mehran score group and 14.2% in the moderate-risk group, and all patients of high and very high score group developed CIN (P<0.001). Multiple logistic regression showed that old age (OR= 1.06, 95% CI= 1.02–1.11, P< 0.001), female sex (OR= 3.1, 95% CI= 2.65–6.99, P= 0.02), high Mehran score (OR=2.48, 95% CI= 1.98–6.24, P= 0.01), CV/CrCl > 2.8 (odds ratio=1.45, 95% CI= 1.22–2.01, P= 0.03), and CHA2DS2-VASC score > 2 (odds ratio=1.90, 95% CI= 1.76–2.11, P= 0.04) were predictors of CIN.

Conclusions

Old age, female sex, high Mehran score, CHADS2-VASC score > 2, CV/CrCl > 2.8 were predictors of CIN in STEMI patients who underwent PPCI.

Acute kidney injury and in-hospital mortality in patients with ST-elevation myocardial infarction of different age groups

BACKGROUND

Acute kidney injury (AKI) is a well-known complication of ST-elevation acute myocardial infarction (STEMI) with an adverse impact on prognosis. Since AKI develops more frequently in elderly patients, we hypothesized that its higher incidence in older STEMI patients might explain their increased in-hospital mortality. We assessed the relationship between AKI and in-hospital mortality in patients with STEMI of different age groups.

METHODS

We retrospectively evaluated 5136 STEMI patients treated with primary percutaneous coronary intervention (pPCI). We defined AKI as ≥0.5 mg/dl creatinine increase in the first 72 h. Patients were grouped according to age (<75 [n = 4040] or ≥ 75 [n = 1096] years). The primary endpoint was in-hospital mortality.

RESULTS

The incidence of AKI was 7%. It was 4.6% in patients <75 years and 15.1% in those ≥75 years (P < 0.0001). The overall in-hospital mortality was 4%. It was 2.6% and 8.5% in patients younger and older than 75 years, respectively (P < 0.0001). It was higher in AKI than in non-AKI patients, both in the overall population (27% vs. 2%) and in the two age groups (25% vs. 2% and 29% vs. 5% in younger and older patients, respectively; P < 0.0001). The adjusted odds ratio of in-hospital mortality associated with AKI progressively decreased in parallel with increasing age decades (from 24.7 [95% CI 11.2-54.1] in patients <65 years to 3.9 [95% CI 1.6-9.7] in those >85 years).

CONCLUSIONS

In STEMI patients treated with pPCI, AKI incidence and in-hospital mortality steadily increase with age. However, the prognostic impact of AKI is progressively reduced as age increases.

Acute Kidney Injury Following Admission with Acute Coronary Syndrome: The Role of Diabetes Mellitus

Purpose: To evaluate the role of diabetes mellitus in the incidence, risk factors, and outcomes of AKI (acute kidney injury) in patients admitted with ACS (acute coronary syndrome). Methods: We performed a comparative evaluation of ACS patients with vs. without DM who developed AKI enrolled in the biennial ACS Israeli Surveys (ACSIS) between 2000 and 2018. AKI was defined as an absolute increase in serum creatinine (≥0.5 mg/dL) or above 1.5 mg/dL or new renal replacement therapy upon admission with ACS. Outcomes included 30-day major adverse cardiovascular events (MACE) and 1-year all-cause mortality. Results: The current study included a total of 16,879 patients, median age 64 (IQR 54–74), 77% males, 36% with DM. The incidence of AKI was significantly higher among patients with vs. without DM (8.4% vs. 4.7%, p < 0.001). The rates of 30-day MACE (40.8% vs. 13.4%, p < 0.001) and 1-year mortality (43.7% vs. 10%, p < 0.001) were significantly greater among diabetic patients who developed vs. those who did not develop AKI respectively, yet very similar among patients that developed AKI with vs. without DM (30-day MACE 40.8% vs. 40.3%, p = 0.9 1-year mortality 43.7 vs. 44.8%, p = 0.8, respectively). Multivariate analyses adjusted to potential confounders, showed similar independent predictors of AKI among patients with and without DM, comprising; older age, chronic kidney disease, congestive heart failure, and peripheral arterial disease. Conclusions: Although patients with DM are at much greater risk for AKI when admitted with ACS, the independent predictors of AKI and the worse patient outcomes when AKI occurs, are similar irrespective to DM status.

Prognostic nutritional index and the risk of acute kidney injury in patients with acute coronary syndrome

OBJECTIVE

Recent studies have linked malnutrition with undesirable outcomes in cardiovascular diseases. However, the underlying mechanism is unknown. Contrast-induced acute kidney injury (CI-AKI) increased cardiovascular mortality after percutaneous coronary intervention (PCI). This study hypothesizes that prognostic nutritional index (PNI) plays a role in the development of CI-AKI in patients with acute coronary syndrome undergoing emergency PCI.

METHODS

This study enrolled 551 patients. PNI was determined as 10× serum albumin (g/dL)+0.005×total lymphocyte count (mm3). CI-AKI was characterized as the increase in serum creatinine ≥0.3 mg/dL level within 48 h after PCI. Patients were classified as either CI-AKI (+) or CI-AKI (-).

RESULTS

CI-AKI has occurred in 72 of 551 patients (13.1%). PNI was significantly lower in the CI-AKI (+) group than in the CI-AKI (-) group (44.4±6.6 versus 47.2±5.8, p<0.001, respectively). Multivariate logistic regression analysis showed that PNI [odds ratio, OR: 1.631, 95% confidence interval (CI): 1.168-2.308, p=0.02] and estimated glomerular filtration rate (OR: 3.26, 95%CI 1.733-6.143, p<0.001) were independent risk factors for CI-AKI.

CONCLUSIONS

PNI is an independent risk factor for CI-AKI. The development of CI-AKI may be the mechanism responsible for the relationship between poor nutritional status and adverse cardiac events.

Clinical Outcomes Following Emergent Percutaneous Coronary Intervention for Acute Total/Subtotal Occlusion of the Left Main Coronary Artery

BACKGROUND

Data regarding the clinical features, outcomes and prognostic factors in patients presenting with acute total/subtotal occlusion of the unprotected left main coronary artery (LMCA) remain limited.

METHODS AND RESULTS

From a multi-center registry, 134 patients due to acute total/subtotal occlusion of the unprotected LMCA were reviewed. Emergency room (ER) status classification was defined according to the presence of cardiogenic shock and cardiopulmonary arrest (CPA) in the ER (class 1=no cardiogenic shock; class 2= cardiogenic shock but not CPA; and class 3=CPA). In-hospital mortality and cerebral performance category (CPC) as the endpoints were evaluated. One-half (67/134) of the enrolled patients presented with total occlusion of the unprotected LMCA. Regarding ER status classification, class 1, 2, and 3 were observed in 30.6%, 45.5%, and 23.9% of the patients, respectively. In-hospital mortality occurred in 73 (54.5%) patients; of the remaining patients, 52 (85.3%) could be discharged with a CPC 1 or 2. ER status classification (odds ratio 4.4 [95% confidence interval: 2.33-10.67]; P<0.001) and total occlusion of the unprotected LMCA (odds ratio 8.29 [95% confidence interval 2.93-23.46]; P<0.001) were strong predictors of in-hospital mortality.

CONCLUSIONS

Acute total/subtotal occlusion involving the unprotected LMCA appeared to be associated with high in-hospital mortality. ER status classification and initial flow in the unprotected LMCA were significant predictive factors of in-hospital mortality.

Predictive Value of Lymphocyte-to-monocyte Ratio in Patients with Contrast-induced Nephropathy After Percutaneous Coronary Intervention for Acute Coronary Syndrome

Background and Objectives

Lymphocyte-to-monocyte ratio (LMR) has emerged as a new indirect marker of inflammation, which is associated with adverse outcomes in cardiovascular diseases. The aim of this study was to evaluate whether admission LMR is associated with contrast-induced nephropathy (CIN) in patients who underwent percutaneous coronary intervention for acute coronary syndrome (ACS).

Methods

A total of 873 patients were assessed. LMR was calculated via dividing lymphocyte count by monocyte count.

Results

LMR was significantly lower in the with-CIN group. ROC analysis showed that the LMR ratios <2.52 predicted CIN development with sensitivity of 66.3% and specificity of 55.8%. Multivariate analysis showed that eGFR, admission glucose, and LMR were independent predictors of CIN in patients with ACS.

Conclusion

LMR is an easily accessible marker and could be used as a predictor of CIN in patients with ACS undergoing percutaneous coronary intervention.

Creatinine variation improves Zwolle score in selecting low-risk patients after ST-segment elevation myocardial infarction

BACKGROUND

The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation (Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI).

METHODS AND RESULTS

A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications.

CONCLUSION

Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.

Molecular imaging of inflammation crosstalk along the cardio-renal axis following acute myocardial infarction

Rationale: Acute myocardial infarction (MI) triggers a systemic inflammatory response including crosstalk along the heart-kidney axis. We employed radionuclide-based inflammation-targeted whole-body molecular imaging to identify potential cardio-renal crosstalk after MI in a translational setup. Methods: Serial whole-body positron emission tomography (PET) with the specific CXCR4 ligand 68Ga-Pentixafor was performed after MI in mice. Tracer retention in kidneys and heart was compared to hematopoietic organs to evaluate systemic inflammation, validated by ex vivo analysis and correlated with progressive contractile dysfunction. Additionally, 96 patients underwent 68Ga-Pentixafor PET within the first week after MI, for systems-based image analysis and to determine prognostic value for adverse renal outcome. Results: In mice, transient myocardial CXCR4 upregulation occurred early after MI. Cardiac and renal PET signal directly correlated over the time course (r = 0.62, p < 0.0001), suggesting an inflammatory link between organs. Ex-vivo autoradiography (r = 0.9, p < 0.01) and CD68 immunostaining indicated signal localization to inflammatory cell content. Renal signal at 7d was inversely proportional to left ventricular ejection fraction at 6 weeks after MI (r = -0.79, p < 0.01). In patients, renal CXCR4 signal also correlated with signal from infarct (r = 0.25, p < 0.05) and remote myocardium (r = 0.39, p < 0.0001). Glomerular filtration rate (GFR) was available in 48/96 (50%) during follow-up. Worsening of renal function (GFR loss >5 mL/min/1.73m2), occurred a mean 80.5 days after MI in 16/48 (33.3%). Kaplan-Meier analysis revealed adverse renal outcome for patients with elevated remote myocardial CXCR4 signal (p < 0.05). Multivariate Cox analysis confirmed an independent predictive value (relative to baseline GFR, LVEF, infarct size; HR, 5.27). Conclusion: Systems-based CXCR4-targeted molecular imaging identifies inflammatory crosstalk along the cardio-renal axis early after MI.

NITRATE-CIN Study: Protocol of a Randomized (1:1) Single-Center, UK, Double-Blind Placebo-Controlled Trial Testing the Effect of Inorganic Nitrate on Contrast-Induced Nephropathy in Patients Undergoing Coronary Angiography for Acute Coronary Syndromes

BACKGROUND

Contrast-induced nephropathy (CIN), an acute kidney injury resulting from the administration of intravascular iodinated contrast media, is a significant cause of morbidity/mortality following coronary angiographic procedures in high-risk patients. Despite preventative measures intended to mitigate the risk of CIN, there remains a need for novel effective treatments. Evidence suggests that delivery of nitric oxide (NO) through chemical reduction of inorganic nitrate to NO may offer a novel therapeutic strategy to reduce CIN and thus preserve long term renal function.

DESIGN

The NITRATE-CIN trial is a single-center, randomized, double-blind placebo-controlled trial, which plans to recruit 640 patients presenting with acute coronary syndromes (ACS) who are at risk of CIN. Patients will be randomized to either inorganic nitrate therapy (capsules containing 12 mmol KNO3) or placebo capsules containing potassium chloride (KCl) daily for 5 days. The primary endpoint is development of CIN using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. A key secondary endpoint is renal function over a 3-month follow-up period. Additional secondary endpoints include serum renal biomarkers (e.g. neutrophil gelatinase-associated lipocalin) at 6 h, 48 h and 3 months following administration of contrast. Cost-effectiveness of inorganic nitrate therapy will also be evaluated.

SUMMARY

This study is designed to investigate the hypothesis that inorganic nitrate treatment decreases the rate of CIN as part of semi-emergent coronary angiography for ACS. Inorganic nitrate is a simple and easy to administer intervention that may prove useful in prevention of CIN in at-risk patients undergoing coronary angiographic procedures.

Systemic Immune Inflammation Index: A Novel Predictor of Contrast-Induced Nephropathy in Patients With Non-ST Segment Elevation Myocardial Infarction

We investigated whether the systemic immune inflammation index (SII) on admission is an independent risk factor that predicts the development of contrast-induced nephropathy (CIN) in patients with non-ST segment elevation myocardial infarction (NSTEMI) who underwent percutaneous coronary intervention (PCI). A total of 429 patients with NSTEMI were enrolled in the study. Contrast-induced nephropathy was defined as an increase in serum creatinine level of ≥0.5 mg/dL or ≥25% above baseline within 72 hour after the procedure. Patients were divided into 2 groups: with and without CIN. Demographics, clinical risk factors, angiographic and laboratory parameters, CIN incidence, and SII score were compared between the 2 groups. Non-ST segment elevation myocardial infarction patients, who developed CIN, had higher glucose levels (P = .009), neutrophil counts (P < .001), platelet counts (P < .001), neutrophil-lymphocyte ratios (P < .001), high sensitivity C-reactive protein levels (P = .009), and SII levels (P < .001) than those who did not develop CIN. The receiver operating characteristic curve analysis showed that at a cutoff of 933.2, the value of SII exhibited 77.6% sensitivity and 69.2% specificity for detecting CIN. Our study showed that the SII levels on admission were independently associated with CIN development after PCI in patients with NSTEMI.

Predictive value of stress hyperglycemia ratio for the occurrence of acute kidney injury in acute myocardial infarction patients with diabetes

Background

Acute hyperglycemia has been recognized as a robust predictor for occurrence of acute kidney injury (AKI) in nondiabetic patients with acute myocardial infarction (AMI), however, its discriminatory ability for AKI is unclear in diabetic patients after an AMI. Here, we investigated whether stress hyperglycemia ratio (SHR), a novel index with the combined evaluation of acute and chronic glycemic levels, may have a better predictive value of AKI as compared with admission glycemia alone in diabetic patients following AMI.

Methods

SHR was calculated with admission blood glucose (ABG) divided by the glycated hemoglobin-derived estimated average glucose. A total of 1215 diabetic patients with AMI were enrolled and divided according to SHR tertiles. Baseline characteristics and outcomes were compared. The primary endpoint was AKI and secondary endpoints included all-cause death and cardiogenic shock during hospitalization. The logistic regression analysis was performed to identify potential risk factors. Accuracy was defined with area under the curve (AUC) by a receiver-operating characteristic (ROC) curve analysis.

Results

In AMI patients with diabetes, the incidence of AKI (4.4%, 7.8%, 13.0%; p < 0.001), all-cause death (2.7%, 3.6%, 6.4%; p = 0.027) and cardiogenic shock (4.9%, 7.6%, 11.6%; p = 0.002) all increased with the rising tertile levels of SHR. After multivariate adjustment, elevated SHR was significantly associated with an increased risk of AKI (odds ratio 3.18, 95% confidence interval: 1.99–5.09, p < 0.001) while ABG was no longer a risk factor of AKI. The SHR was also strongly related to the AKI risk in subgroups of patients. At ROC analysis, SHR accurately predicted AKI in overall (AUC 0.64) and a risk model consisted of SHR, left ventricular ejection fraction, N-terminal B-type natriuretic peptide, and estimated glomerular filtration rate (eGFR) yielded a superior predictive value (AUC 0.83) for AKI.

Conclusion

The novel index SHR is a better predictor of AKI and in-hospital mortality and morbidity than admission glycemia in AMI patients with diabetes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01962-2.

Machine Learning to Predict Contrast-Induced Acute Kidney Injury in Patients With Acute Myocardial Infarction

Objective: To develop predictive models for contrast induced acute kidney injury (CI-AKI) among acute myocardial infarction (AMI) patients treated invasively.

Methods: Patients with AMI who underwent angiography therapy were enrolled and randomly divided into training cohort (75%) and validation cohort (25%). Machine learning algorithms were used to construct predictive models for CI-AKI. The predictive models were tested in a validation cohort.

Results: A total of 1,495 patients with AMI were included. Of all the patients, 226 (15.1%) cases developed CI-AKI. In the validation cohort, Random Forest (RF) model with top 15 variables reached an area under the curve (AUC) of 0.82 (95% CI: 0.76–0.87), while the best logistic model had an AUC of 0.69 (95% CI: 0.62–0.76). ACEF (age, creatinine, and ejection fraction) model reached an AUC of 0.62 (95% CI: 0.53–0.71). RF model with top 15 variables achieved a high recall rate of 71.9% and an accuracy of 73.5% in the validation group. Random Forest model significantly outperformed logistic regression in every comparison.

Conclusions: Machine learning algorithms especially Random Forest algorithm improves the accuracy of risk stratifying patients with AMI and should be used to accurately identify the risk of CI-AKI in AMI patients.

Contemporary National Outcomes of Acute Myocardial Infarction-Cardiogenic Shock in Patients with Prior Chronic Kidney Disease and End-Stage Renal Disease

Background: There are limited data on acute myocardial infarction with cardiogenic shock (AMI-CS) stratified by chronic kidney disease (CKD) stages. Objective: To assess clinical outcomes in AMI-CS stratified by CKD stages. Methods: A retrospective cohort of AMI-CS during 2005–2016 from the National Inpatient Sample was categorized as no CKD, CKD stage-III (CKD-III), CKD stage-IV (CKD-IV) and end-stage renal disease (ESRD). CKD-I/II were excluded. Outcomes included in-hospital mortality, use of coronary angiography, percutaneous coronary intervention (PCI) and mechanical circulatory support (MCS). We also evaluated acute kidney injury (AKI) and acute hemodialysis in non-ESRD admissions. Results: Of 372,412 AMI-CS admissions, CKD-III, CKD-IV and ESRD comprised 20,380 (5.5%), 7367 (2.0%) and 18,109 (4.9%), respectively. Admissions with CKD were, on average, older, of the White race, bearing Medicare insurance, of a lower socioeconomic stratum, with higher comorbidities, and higher rates of acute organ failure. Compared to the cohort without CKD, CKD-III, CKD-IV and ESRD had lower use of coronary angiography (72.7%, 67.1%, 56.9%, 61.1%), PCI (53.7%, 43.8%, 38.4%, 37.6%) and MCS (47.9%, 38.3%, 33.3%, 34.2%), respectively (all p < 0.001). AKI and acute hemodialysis use increased with increase in CKD stage (no CKD–38.5%, 2.6%; CKD-III–79.1%, 6.5%; CKD-IV–84.3%, 12.3%; p < 0.001). ESRD (adjusted odds ratio [OR] 1.25 [95% confidence interval {CI} 1.21–1.31]; p < 0.001), but not CKD-III (OR 0.72 [95% CI 0.69–0.75); p < 0.001) or CKD-IV (OR 0.82 [95 CI 0.77–0.87] was predictive of in-hospital mortality. Conclusions: CKD/ESRD is associated with lower use of evidence-based therapies. ESRD was an independent predictor of higher in-hospital mortality in AMI-CS.

Calprotectin and Neutrophil Gelatinase-Associated Lipocalin As Biomarkers of Acute Kidney Injury in Acute Coronary Syndrome

BACKGROUND

Acute kidney injury (AKI) is increasingly being seen in patients with acute coronary syndromes (ACS) and it is associated with higher short-term and long-term morbidity and mortality. Therefore, it is of paramount importance to identify those ACS patients at risk for the development of AKI. The objective of this study was to evaluate two different plasma biomarkers calprotectin and neutrophil gelatinase-associated lipocalin (NGAL) in early detecting the development of AKI in ACS patients.

METHODS

172 ACS patients admitted to the Coronary Care Unit in Yantai Yuhuangding Hospital were prospectively enrolled. Their blood samples were obtained on admission and subjected to enzyme-linked immunosorbent assay to determine the levels of novel biomarkers. The clinical data and biomarkers were recorded and analyzed.

RESULTS

In this study, 23 (13.4%) patients had a diagnosis of AKI. Statistical analysis demonstrated that in ACS patients with AKI, the following two biomarkers were significantly higher than these without AKI: plasma calprotectin (5942.26 ± 1955.88 ng/mL vs. 3210.29 ± 1833.60 ng/mL, p < 0.001) and plasma NGAL (164.91 ± 43.63 ng/mL vs. 122.48 ± 27.33 ng/mL, p < 0.001). Plasma calprotectin and NGAL could discriminate the development of AKI respectively with an area under the ROC curve (AUC) of 0.864 and 0.850. A combination of the two plasma biomarkers calprotectin and NGAL could early discriminate AKI in ACS patients with an AUC of 0.898.

CONCLUSIONS

This study demonstrated a promising panel of plasma calprotectin and NGAL as early diagnostic biomarkers for AKI in ACS patients.

Anemia Among Patients Undergoing Transcatheter Mitral Valve Repair: From the National Inpatient Sample in the United States

Background The prevalence and impact of anemia on the outcomes of transcatheter mitral valve repair (TMVr) have not been well-studied. Anemia is a commonly encountered comorbidity among patients with cardiovascular disorders and is frequently under-recognized. The study aimed to analyze the prevalence of anemia and its impact on post-TMVr in-hospital outcomes. Methods The National Inpatient Sample (NIS) was queried to identify all patients who underwent TMVr from 2011-2015 in the United States by utilizing suitable International Classification of Diseases, Ninth Revision (ICD-9) codes. The baseline characteristics and in-hospital outcomes were compared among patients with and without anemia. Results A total of 4,382 patients were identified. Out of these, 978 (22.3%) patients had baseline anemia. Anemic patients were noted to have a higher burden of co-morbidities, including chronic kidney disease, hypertension, and diabetes mellitus. The in-hospital mortality was higher but not statistically significant between anemic and non-anemic patients (3.6% vs 2.6%; odds ratio (OR): 1.44; confidence interval (CI): 0.85-2.46, p=0.179). The other adverse outcomes, including the length of stay, the requirement for blood transfusions, the incidence of post-implant acute kidney injury, hemodialysis, and the cost of hospitalization, were higher in anemic patients. Conclusion Anemia was present in one out of five patients undergoing TMVr in this nationally representative cohort. Baseline anemia showed numerically higher but not statistically significant in-hospital mortality and was associated with other in-hospital adverse outcomes. Further larger studies are needed to highlight the importance of anemia in the TMVr procedure.

Adaptive Autophagy Offers Cardiorenal Protection in Rats with Acute Myocardial Infarction

Objective

Understanding the multifactorial changes involved in the kidney and heart after acute myocardial infarction (AMI) is prerequisite for further mechanisms and early intervention, especially autophagy changes. Here, we discussed the role of adaptive autophagy in the heart and kidney of rats with AMI.

Methods

A rat model of AMI was established by ligating the left anterior descending branch of the coronary artery. Animals were sacrificed at 2 and 4 weeks after the operation to assess the morphological and functional changes of the heart and kidney, as well as the autophagy pathway. In vitro, HK-2 and AC16 cell injuries and the autophagy pathway were assayed after autophagy was inhibited by 3-methyladenine (3-MA) in a hypoxia incubator.

Results

We found that the left ventricular systolic pressure (LVSP) significantly decreased in the model group at weeks 2 and 4. At weeks 2 and 4, the level of urinary kidney injury molecule 1 (uKIM1) of the model group was significantly higher than the sham group. At week 4, urinary neutrophil gelatinase-associated lipocalcin (uNGAL) and urinary albumin also significantly increased. At week 2, microtubule-associated protein 1 light chain 3-II (LC3-II), ATG5, and Beclin1 were significantly elevated in the heart and kidney compared with the sham-operated rats, but there was no change in p62 levels. At week 4, LC3-II did not significantly increase and p62 levels significantly increased. In addition, 3-MA markedly increased KIM1, NGAL, and the activity of caspase-3 in the hypoxic HK-2 and AC16 cell.

Conclusion

Autophagy will undergo adaptive changes and play a protective role in the heart and kidney of rats after AMI.

Determinants of In-Hospital Mortality After Percutaneous Coronary Intervention: A Machine Learning Approach

Background

The ability to accurately predict the occurrence of in‐hospital death after percutaneous coronary intervention is important for clinical decision‐making. We sought to utilize the New York Percutaneous Coronary Intervention Reporting System in order to elucidate the determinants of in‐hospital mortality in patients undergoing percutaneous coronary intervention across New York State.

Methods and Results

We examined 479 804 patients undergoing percutaneous coronary intervention between 2004 and 2012, utilizing traditional and advanced machine learning algorithms to determine the most significant predictors of in‐hospital mortality. The entire data were randomly split into a training (80%) and a testing set (20%). Tuned hyperparameters were used to generate a trained model while the performance of the model was independently evaluated on the testing set after plotting a receiver‐operator characteristic curve and using the output measure of the area under the curve (AUC) and the associated 95% CIs. Mean age was 65.2±11.9 years and 68.5% were women. There were 2549 in‐hospital deaths within the patient population. A boosted ensemble algorithm (AdaBoost) had optimal discrimination with AUC of 0.927 (95% CI 0.923–0.929) compared with AUC of 0.913 for XGBoost (95% CI 0.906–0.919, P=0.02), AUC of 0.892 for Random Forest (95% CI 0.889–0.896, P<0.01), and AUC of 0.908 for logistic regression (95% CI 0.907–0.910, P<0.01). The 2 most significant predictors were age and ejection fraction.

Conclusions

A big data approach that utilizes advanced machine learning algorithms identifies new associations among risk factors and provides high accuracy for the prediction of in‐hospital mortality in patients undergoing percutaneous coronary intervention.

See Editorial by Garratt and Schneider

Empagliflozin attenuates acute kidney injury after myocardial infarction in diabetic rats

Acute kidney injury (AKI) predicts poor prognosis in patients with acute myocardial infarction (MI) and diabetes mellitus (DM) is an independent risk factor of AKI. Recent clinical studies have shown the beneficial effects of sodium-glucose cotransporter 2 (SGLT2) inhibitors on cardiovascular and renal outcomes in patients with DM. We recently reported that canagliflozin normalized susceptibility of diabetic rats to AKI after acute MI via β-hydroxybutyrate-mediated suppression of NOX expression. Here we examined whether the same renoprotective effect is shared by empagliflozin. Serum creatinine levels were not changed by MI induced by coronary artery occlusion in LETO, non-diabetic control rats, and OLETF, obese type 2 diabetic rats. However, immunohistochemistry revealed that MI increased renal expression of NGAL and KIM-1, early markers of tubular injury, by 3.2-fold and 2.6-fold, respectively, in OLETF. These increases in injury markers were not observed in LETO. Pretreatment with empagliflozin of OLETF for 2 weeks improved hyperglycemia, increased blood β-hydroxybutyrate level, and suppressed MI-induced expression of NGAL and KIM-1. Empagliflozin suppressed upregulation of NOX2 and NOX4 in the kidney of OLETF. Taken together with the results of our previous study, it was concluded that treatment with the SGLT2 inhibitor protects the diabetic kidney from MI-induced AKI.

Incidence, underlying conditions, and outcomes of patients receiving acute renal replacement therapies in tertiary cardiac intensive care units: An analysis from the Critical Care Cardiology Trials Network Registry

BACKGROUND

The prevalence of renal disease in cardiac intensive care units (CICUs) is increasing, but little is known about the utilization, concurrent therapies, and outcomes of patients requiring acute renal replacement therapy (RRT) in this specialized environment.

METHODS

In the Critical Care Cardiology Trials Network, 16 centers submitted data on CICU admissions including acute RRT (defined as continuous renal replacement therapy and/or acute intermittent dialysis).

RESULTS

Among 2,985 admissions, 178 (6.0%; interhospital range 1.0%-16.0%) received acute RRT. Patients receiving RRT, versus not, were more commonly admitted for cardiogenic shock (15.7% vs 4.2%, P < .01), cardiac arrest (9.6% vs 3.7%, P < .01), and acute general medical diagnoses (10.7% vs 5.8%, P < .01), whereas acute coronary syndromes (16.9% vs 32.1%, P < .01) were less frequent. Variables independently associated with acute RRT included diabetes, heart failure, liver disease, severe valvular disease, shock, cardiac arrest, hypertension, and younger age. In patients receiving acute RRT, versus not, advanced therapies including mechanical ventilation (55.6% vs 18.0%), vasoactive support (73.0% vs 35.2%), invasive hemodynamic monitoring (59.6% vs 29.2%), and mechanical circulatory support (27.5% vs 8.4%) were more common. Acute RRT was associated with higher in-hospital mortality (42.1% vs 9.3%, adjusted odds ratio 3.74, 95% CI, 2.52-5.53) and longer median length of stay (10.0 vs 5.3 days, P < .01). In conclusion, acute RRT in contemporary CICUs was associated with the provision of other advanced therapies and lower survival.

CONCLUSIONS

These data underscore the risks associated with the provision of renal support in patients with primary cardiovascular problems and the need to develop standardized indications and potential futility measures in this specialized population.

Risk factors for acute kidney injury in patients with acute myocardial infarction

BACKGROUND

Acute kidney injury (AKI) is a serious and fatal complication of acute myocardial infarction (AMI). It has high short- and long-term mortality rates and a poor prognosis but is potentially preventable. However, the current incidence, risk factors, and outcomes of AKI in the Chinese population are not well understood and would serve the first step to identify high-risk patients who could receive preventative care.

METHODS

The medical data of 1124 hospitalized patients diagnosed with AMI from October 2013 to September 2015 were reviewed. AKI was defined according to the 2012 Kidney Disease Improving Global Outcomes criteria. All the patients were divided into either the AKI group or the non-AKI group. A univariate comparison analysis was performed to identify possible risk factors associated with AKI. A multiple logistic regression analysis was used to identify the independent risk factors for AKI in patients with AMI.

RESULTS

Overall, the incidence of AKI was 26.0%. The mortality rate of the AKI group was 20.5%, and the mortality rate of the non-AKI group was 0.6% (P < 0.001). Logistic regression analysis showed that the independent risk factors for AKI in patients with AMI included: age (>60 years old) (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.02-1.05, P = 0.000), hypertension (OR 2.51, 95% CI 1.62-3.87, P = 0.000), chronic kidney disease (OR 3.52, 95% CI 2.01-6.16, P = 0.000), Killip class ≥3 (OR 5.22, 95% CI 3.07-8.87, P = 0.000), extensive anterior myocardial infarction (OR 3.02, 95% CI 1.85-4.93, P = 0.000), use of furosemide (OR 1.02, 95% CI 1.02-1.03, P = 0.000), non-use of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker (OR 1.58, 95% CI 1.04-2.40, P = 0.032). These factors provided an accurate tool to identify patients at high risk of developing AKI.

CONCLUSIONS

Approximately 26.0% of patients undergoing AMI developed AKI, and the development of AKI was strongly correlated with in-hospital mortality. The risk factors for AKI in patients with AMI were determined to help identify high-risk patients and make appropriate clinical decisions.

The Association of Fractional Pulse Pressure with Acute Kidney Injury in Patients Undergoing Coronary Intervention due to ST-Segment Elevated Myocardial Infarction

OBJECTIVE

Acute kidney injury (AKI), which is prevalent in ST-segment elevated myocardial infarction (STEMI) patients who have undergone primary percutaneous coronary intervention (PCI), is associated with poor cardiovascular outcomes. As high pulse pressure (PP) is associated with adverse cardiovascular events, the present study's aim was to evaluate the relationship between fractional PP (PPf) and AKI in patients with STEMI who underwent primary PCI.

SUBJECTS AND METHODS

All laboratory findings as well as echocardiographic and angiographic data of 1,170 consecutive STEMI patients were retrospectively screened. PPf was calculated from the pressures invasively measured after sheath insertion and before performing coronary angiography.

RESULTS

From 1,170 eligible STEMI patients (mean age 56 years, 18.2% female), AKI developed in 143 (12.2%) patients. The PPf and pulsatility index were significantly higher in patients with AKI than those without (0.53 ± 0.10 vs. 0.61 ± 0.10, p < 0.001, and 0.80 ± 0.03 vs. 0.82 ± 0.03, p < 0.001, respectively). PPf was also found to be associated with AKI in univariable (OR 2.183, 95% CI 1.823-2.614, p< 0.001) and multivariable (OR 1.874, 95% CI 1.513-2.322, p < 0.001) analysis. In-hospital mortality was higher in patients with AKI than those without.

CONCLUSION

Invasively measured PPf, which can be easily measured and has no additional cost in STEMI patients undergoing coronary intervention, is an independent predictor of AKI. In addition, PPf is superior to other blood pressure values and derivatives in AKI prediction.

Development and internal validation of a prediction model for hospital-acquired acute kidney injury

Background

Predictive models and clinical risk scores for hospital-acquired acute kidney injury (AKI) are mainly focused on critical and surgical patients. We have used the electronic clinical records from a tertiary care general hospital to develop a risk score for new-onset AKI in general inpatients that can be estimated automatically from clinical records.

Methods

A total of 47 466 patients met inclusion criteria within a 2-year period. Of these, 2385 (5.0%) developed hospital-acquired AKI. Step-wise regression modelling and Bayesian model averaging were used to develop the Madrid Acute Kidney Injury Prediction Score (MAKIPS), which contains 23 variables, all obtainable automatically from electronic clinical records at admission. Bootstrap resampling was employed for internal validation. To optimize calibration, a penalized logistic regression model was estimated by the least absolute shrinkage and selection operator (lasso) method of coefficient shrinkage after estimation.

Results

The area under the curve of the receiver operating characteristic curve of the MAKIPS score to predict hospital-acquired AKI at admission was 0.811. Among individual variables, the highest odds ratios, all >2.5, for hospital-acquired AKI were conferred by abdominal, cardiovascular or urological surgery followed by congestive heart failure. An online tool (http://www.bioestadistica.net/MAKIPS.aspx) will facilitate validation in other hospital environments.

Conclusions

MAKIPS is a new risk score to predict the risk of hospital-acquired AKI, based on variables present at admission in the electronic clinical records. This may help to identify patients who require specific monitoring because of a high risk of AKI.