1
|
Shin S, Choi TY, Han DH, Choi B, Cho E, Seog Y, Koo BN. An explainable machine learning model to predict early and late acute kidney injury after major hepatectomy. HPB (Oxford) 2024:S1365-182X(24)01271-1. [PMID: 38705794 DOI: 10.1016/j.hpb.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 12/13/2023] [Accepted: 04/19/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Risk assessment models for acute kidney injury (AKI) after major hepatectomy that differentiate between early and late AKI are lacking. This retrospective study aimed to create a model predicting AKI through machine learning and identify features that contribute to the development of early and late AKI. METHODS Patients that underwent major hepatectomy were categorized into the No-AKI, Early-AKI (within 48 h) or Late-AKI group (between 48 h and 7 days). Modeling was done with 20 perioperative features and the performance of prediction models were measured by the area under the receiver operating characteristic curve (AUROCC). Shapley Additive Explanation (SHAP) values were utilized to explain the outcome of the prediction model. RESULTS Of the 1383 patients included in this study, 1229, 110 and 44 patients were categorized into the No-AKI, Early-AKI and Late-AKI group, respectively. The CatBoost classifier exhibited the greatest AUROCC of 0.758 (95% CI: 0.671-0.847) and was found to differentiate well between Early and Late-AKI. We identified different perioperative features for predicting each outcome and found 1-year mortality to be greater for Early-AKI. CONCLUSIONS Our results suggest that risk factors are different for Early and Late-AKI after major hepatectomy, and 1-year mortality is greater for Early-AKI.
Collapse
Affiliation(s)
- Seokyung Shin
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Tae Y Choi
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Dai H Han
- Department of Surgery, Division of Hepato-biliary and Pancreatic Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Boin Choi
- Severance Hospital, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Eunsung Cho
- Severance Hospital, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Yeong Seog
- Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Severance Hospital, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodamun-gu, Seoul 03722, South Korea.
| |
Collapse
|
2
|
Zhuo XY, Lei SH, Sun L, Bai YW, Wu J, Zheng YJ, Liu KX, Liu WF, Zhao BC. Preoperative risk prediction models for acute kidney injury after noncardiac surgery: an independent external validation cohort study. Br J Anaesth 2024:S0007-0912(24)00097-7. [PMID: 38527923 DOI: 10.1016/j.bja.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/27/2024] Open
Abstract
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.
Collapse
Affiliation(s)
- Xiao-Yu Zhuo
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China
| | - Shao-Hui Lei
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Lan Sun
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Biostatistics, Lejiu Healthcare Technology Co., Ltd, Hangzhou, China
| | - Ya-Wen Bai
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Jiao Wu
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Yong-Jia Zheng
- College of Anaesthesiology, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Wei-Feng Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China.
| | - Bing-Cheng Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China; Guangdong Provincial Key Laboratory of Precision Anaesthesia and Perioperative Organ Protection, Guangzhou, China; College of Anaesthesiology, Southern Medical University, Guangzhou, China; Outcomes Research Consortium, Cleveland, OH, USA.
| |
Collapse
|
3
|
Demirjian S, Huml A, Bakaeen F, Poggio E, Geube M, Shaw A, Gillinov AM, Gadegbeku CA. Sex Bias in Prediction and Diagnosis of Cardiac Surgery Associated Acute Kidney Injury. Res Sq 2024:rs.3.rs-3660617. [PMID: 38558997 PMCID: PMC10980107 DOI: 10.21203/rs.3.rs-3660617/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Female sex has been recognized as a risk factor for cardiac surgery associated acute kidney injury (CS-AKI). The current study sought to evaluate whether female sex is a risk factor for CS-AKI, or modifies the association of peri-operative change in serum creatinine with CS-AKI. Methods Observational study of adult patients undergoing cardiac surgery between 2000 and 2019 in a single U.S. center. The main variable of interest was registered patient sex, identified from electronic medical records. The main outcome was CS-AKI within 2 weeks of surgery. Results Of 58526 patients, 19353 (33%) were female; 12934 (22%) incurred AKI based on ≥ 0.3 mg/dL or ≥ 50% rise in serum creatinine (any AKI), 3320 (5.7%) had moderate to severe AKI, and 1018 (1.7%) required dialysis within 2 weeks of surgery. Female sex was associated with higher risk for AKI in models that were based on preoperative serum creatinine (OR, 1.35; 95% CI, 1.29-1.42), and lower risk with the use of estimated glomerular filtration, (OR, 0.90; 95% CI, 0.86-0.95). The risk for moderate to severe CS-AKI for a given immediate peri-operative change in serum creatinine was higher in female compared to male patients (p < .0001 and p < .0001 for non-linearity), and the association was modified by pre-operative kidney function (p < .0001 for interaction). Conclusions The association of patient sex with CS-AKI and its direction was dependent on the operational definition of pre-operative kidney function, and differential outcome misclassification due to AKI defined by absolute change in serum creatinine.
Collapse
|
4
|
Almutairi A, Alenezi F, Tamim H, Sadat M, Humaid FB, AlMatrood A, Syed Y, Arabi Y. The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation. Ann Saudi Med 2024; 44:104-110. [PMID: 38615183 PMCID: PMC11016152 DOI: 10.5144/0256-4947.2024.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 12/08/2023] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs. OBJECTIVE Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality. DESIGN Retrospective cohort. SETTING Intensive care unit. PATIENTS AND METHODS We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI. MAIN OUTCOME MEASURES The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement. RESULTS Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality. CONCLUSION Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction. LIMITATIONS Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.
Collapse
Affiliation(s)
- Abdulmajed Almutairi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Farhan Alenezi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Musharaf Sadat
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Felwa Bin Humaid
- Intensive Care Unit, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Amal AlMatrood
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yadullah Syed
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
5
|
Thorsdottir H, Long TE, Palsson R, Sigurdsson MI. The epidemiology and outcomes of acute kidney injury following orthopaedic procedures: A retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:26-34. [PMID: 37726880 DOI: 10.1111/aas.14332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a serious complication following major surgery. This study examined the incidence and risk factors of AKI following orthopaedic surgeries in an Icelandic cohort, as well as the association between AKI and patient- and surgery-related factors. METHODS This retrospective cohort study comprised all patients 18 years and older who underwent orthopaedic surgeries at Landspitali - The National University Hospital in the years 2006-2018 with available serum creatinine (SCr) measurements adjacent to the surgery to stage AKI. AKI was defined according to SCr portion of the KDIGO criteria. Logistic regression was used to identify patient- and surgical factors related to progression of AKI and Poisson-regression was used to explore changes in incidence. RESULTS A total of 222 cases of AKI following 3208 surgeries (6.9%) were identified in the study period with a rise in the incidence by about 17% per year. Higher age (odds ratio (OR), 1.02, 95% confidence interval (CI), 1.01-1.04 per year) and underlying reduction in kidney function (OR 1.93 (1.30-2.81), 3.24 (2.08-4.96) and 4.08 (2.35-6.96) for estimated glomerular filtration rate (eGFR) of 30-59, 15-29 and <15 mL/min/1.73 m2 compared with eGFR >60 mL/min/1.73 m2 ) were associated with higher risk of AKI, but female sex was associated with decreased odds (OR = 0.73; 95% CI, 0.54-0.98). After correcting for age, sex, preoperative kidney function, emergency surgery and underlying comorbidities and frailty, there was an increased risk of long-term mortality in patients with AKI (HR 1.41, 95% CI 1.08-1.85), and patients who developed AKI also had accelerated progression of chronic kidney disease compared with patients who did not develop AKI. CONCLUSIONS The incidence of AKI following orthopaedic surgeries is increasing and is associated with adverse outcomes. It is important that elderly individuals and patients who have reduced kidney function receive adequate monitoring and surveillance in the perioperative period.
Collapse
Affiliation(s)
| | - Thorir E Long
- Division of Nephrology, Skane University Hospital, Lund, Sweden
| | - Runolfur Palsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Nephrology, Internal Medicine and Emergency Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Martin I Sigurdsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Division of Anesthesia and Intensive Care Medicine, Perioperative Services, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| |
Collapse
|
6
|
Karway GK, Koyner JL, Caskey J, Spicer AB, Carey KA, Gilbert ER, Dligach D, Mayampurath A, Afshar M, Churpek MM. Development and external validation of multimodal postoperative acute kidney injury risk machine learning models. JAMIA Open 2023; 6:ooad109. [PMID: 38144168 PMCID: PMC10746378 DOI: 10.1093/jamiaopen/ooad109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/18/2023] [Accepted: 12/11/2023] [Indexed: 12/26/2023] Open
Abstract
Objectives To develop and externally validate machine learning models using structured and unstructured electronic health record data to predict postoperative acute kidney injury (AKI) across inpatient settings. Materials and Methods Data for adult postoperative admissions to the Loyola University Medical Center (2009-2017) were used for model development and admissions to the University of Wisconsin-Madison (2009-2020) were used for validation. Structured features included demographics, vital signs, laboratory results, and nurse-documented scores. Unstructured text from clinical notes were converted into concept unique identifiers (CUIs) using the clinical Text Analysis and Knowledge Extraction System. The primary outcome was the development of Kidney Disease Improvement Global Outcomes stage 2 AKI within 7 days after leaving the operating room. We derived unimodal extreme gradient boosting machines (XGBoost) and elastic net logistic regression (GLMNET) models using structured-only data and multimodal models combining structured data with CUI features. Model comparison was performed using the receiver operating characteristic curve (AUROC), with Delong's test for statistical differences. Results The study cohort included 138 389 adult patient admissions (mean [SD] age 58 [16] years; 11 506 [8%] African-American; and 70 826 [51%] female) across the 2 sites. Of those, 2959 (2.1%) developed stage 2 AKI or higher. Across all data types, XGBoost outperformed GLMNET (mean AUROC 0.81 [95% confidence interval (CI), 0.80-0.82] vs 0.78 [95% CI, 0.77-0.79]). The multimodal XGBoost model incorporating CUIs parameterized as term frequency-inverse document frequency (TF-IDF) showed the highest discrimination performance (AUROC 0.82 [95% CI, 0.81-0.83]) over unimodal models (AUROC 0.79 [95% CI, 0.78-0.80]). Discussion A multimodality approach with structured data and TF-IDF weighting of CUIs increased model performance over structured data-only models. Conclusion These findings highlight the predictive power of CUIs when merged with structured data for clinical prediction models, which may improve the detection of postoperative AKI.
Collapse
Affiliation(s)
- George K Karway
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL 60637, United States
| | - John Caskey
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Alexandra B Spicer
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
| | - Kyle A Carey
- Section of Nephrology, Department of Medicine, University of Chicago, Chicago, IL 60637, United States
| | - Emily R Gilbert
- Department of Medicine, Loyola University Chicago, Chicago, IL 60153, United States
| | - Dmitriy Dligach
- Department of Computer Science, Loyola University Chicago, Chicago, IL 60626, United States
| | - Anoop Mayampurath
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI 53726, United States
| | - Majid Afshar
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI 53726, United States
| | - Matthew M Churpek
- Department of Medicine, University of Wisconsin-Madison, Madison, WI 53792, United States
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI 53726, United States
| |
Collapse
|
7
|
Xing J, Loh SKN. Perioperative acute kidney injury: Current knowledge and the role of anaesthesiologists. Proceedings of Singapore Healthcare 2023. [DOI: 10.1177/20101058231163406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Among the different types of perioperative organ injury, acute kidney injury (AKI) occurs frequently and is consistently associated with increased rates of mortality and mortality. Despite development of many clinical trials to assess perioperative interventions, reliable means to prevent or reverse AKI are still lacking. Objectives This narrative review discusses recent literature on modifiable risk factors, current approaches to prevention and potential directions for future research. Methods A Pubmed search with the relevant keywords was done for articles published in the last 10 years. Results New insights into preoperative identification and optimisation, intraoperative strategies, including the choice of anaesthetic, haemodynamic and fluid management, have been made, with the aim of preventing perioperative AKI. Conclusion A patient-centric multidisciplinary approach is essential to protect kidney function of patients going for surgery. Much can be done by anaesthesiologists perioperatively, to reduce the risk of development of AKI, especially in susceptible patients. There is a need for further multicentred trials to enhance the currently generic perioperative recommendations.
Collapse
Affiliation(s)
- Jieyin Xing
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Samuel Kent Neng Loh
- Division of Anaesthesiology and Perioperative Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
8
|
Baldwin M, McCormick B, Foale M, Belete M, Chen C, Williams H, Stark D, Matthews E. POSU: A pilot study looking into the feasibility, safety and efficacy of a post-operative surgical unit for high-risk patients. J Intensive Care Soc 2023; 24:4-5. [PMID: 37928088 PMCID: PMC10621519 DOI: 10.1177/1751143719892795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Affiliation(s)
| | | | - Mark Foale
- Royal Devon and Exeter Hospital, Exeter, UK
| | | | | | | | | | | |
Collapse
|
9
|
Almonacid-Cardenas F, Saab R, Nemirovsky ES, Rivas E, Araujo-Duran J, Mao G, Esa WAS, Ruetzler K, Argalious M, Turan A. The effect of intraoperative positive end expiratory pressure and tidal volume on postoperative acute kidney injury after orthopedic surgery. Acta Anaesthesiol Scand 2023; 67:1348-1355. [PMID: 37650561 DOI: 10.1111/aas.14314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND To test whether higher intraoperative PEEP levels and/or higher TV levels are associated with higher incidence of postoperative AKI within the first postoperative week, in adult patients having orthopedic surgeries under general anesthesia. METHODS We conducted a sub analysis of a non-randomized alternating intervention cross over study performed in patients undergoing orthopedic surgery under general anesthesia at Cleveland Clinic, Cleveland, OH. We included four different combinations of PEEP (5 or 8 cm H2 O) and TV (6 or 10 mL/kg of PBW) that alternated each week in the six orthopedic operating rooms. Our primary outcome was postoperative AKI defined by the KDIGO criteria with baseline creatinine as the closest preoperative value to the time of surgery obtained within 30 days and postoperative value as the highest creatinine value within 7 days after surgery. Secondary outcome was the maximum postoperative in-hospital creatinine level within seven postoperative days. MAIN RESULTS A total of 1933 patients were included in the analysis. The incidence of AKI was 6.8% in the study population and similar in high TV versus low TV group and high PEEP versus low PEEP group. Neither TV nor PEEP significantly impacted AKI incidence. The estimated odds ratio of AKI comparing TV = 6 mL/kg to TV = 10 mL/kg was 0.96 (97.5% CI: 0.63, 1.46; p = .811); while the estimated odds ratio of AKI comparing PEEP = 5cm H2 O to PEEP = 8cm H2 O was 0.92 (97.5% CI: 0.60, 1.39; p = .623). No interaction was found between TV and PEEP on AKI. Additionally, neither TV nor PEEP had a significant effect on the seven postoperative day creatinine levels. CONCLUSION Higher levels of PEEP or TV during mechanical ventilation in adult patients undergoing orthopedic surgeries under general anesthesia do not increase the odds of developing postoperative AKI within the narrow limits studied.
Collapse
Affiliation(s)
| | - Remie Saab
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eitan Scher Nemirovsky
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eva Rivas
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesia, Hospital Clinic of Barcelona, IDIBAPS, Universidad de Barcelona, Barcelona, Spain
| | - Jorge Araujo-Duran
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Guangmei Mao
- Department of Quantitative Health Services, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wael Ali Sakr Esa
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Maged Argalious
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Alparslan Turan
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
10
|
Cao X, Liang Y, Feng H, Chen L, Liu S. Construction and evaluation of a risk prediction model for pulmonary infection-associated acute kidney injury in intensive care units. Clin Transl Sci 2023; 16:1923-1934. [PMID: 37488744 PMCID: PMC10582653 DOI: 10.1111/cts.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/29/2023] [Accepted: 07/06/2023] [Indexed: 07/26/2023] Open
Abstract
Acute kidney injury (AKI) is one of the common complications of pulmonary infections. However, nomograms predicting the risk of early-onset AKI in patients with pulmonary infections have not been comprehensively researched. In this study, 3278 patients with pulmonary infection were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. These patients were randomly divided into training and validation cohorts, with the training cohort used for model building and the validation cohort used for validation. Independent risk factors for patients with pulmonary infection were determined using the least absolute shrinkage and selection operator (LASSO) method and forward stepwise logistic regression, which revealed that 11 independent risk factors for AKI in patients with pulmonary infections were congestive heart failure (CHF), hypertension, diabetes, transcutaneous oxygen saturation (SpO2), 24-h urine output, white blood cells (WBC), serum creatinine (Scr), prothrombin time (PT), potential of hydrogen (PH), vasopressor use, and mechanical ventilation (MV) use. The nomogram was then constructed and validated. The area under the receiver operating characteristic curve (AUC) values of the nomogram were 0.770 (95% CI = 0.789-0.807) in the training cohort and 0.724 (95% CI = 0.754-0.784) in the validation cohort. High AUC values indicated the good discriminative ability of the nomogram, while the calibration curves and Hosmer-Lemeshow test results indicated that the nomogram was well-calibrated. Improvements in net reclassification index (NRI) and integrated discrimination improvement (IDI) values indicate that our nomogram was superior to the Simplified Acute Physiology Score (SAPS) II scoring system, and the decision-curve analysis (DCA) curves indicate that the nomogram has good clinical application. We established a risk-prediction model for AKI in patients with pulmonary infection, which has good discriminative power and is superior to the SAPS II scoring system. This model can provide clinical reference information for patients with this type of disease in the intensive care unit.
Collapse
Affiliation(s)
- Xinyi Cao
- Department of Pulmonary and Critical Care MedicineThe First Affiliated Hospital of Jinan UniversityGuangzhouGuangdong ProvinceChina
- Department of Pulmonary and Critical Care Medicine, Central People's Hospital of ZhanjiangZhanjiangGuangdong ProvinceChina
| | - Yongzhi Liang
- Department of Intensive Care UnitThe First Affiliated Hospital of Jinan UniversityGuangzhouGuangdong ProvinceChina
| | - Honglin Feng
- Department of Pulmonary and Critical Care MedicineThe First Affiliated Hospital of Jinan UniversityGuangzhouGuangdong ProvinceChina
| | - Li Chen
- Department of Pulmonary and Critical Care MedicineThe First Affiliated Hospital of Jinan UniversityGuangzhouGuangdong ProvinceChina
| | - Shengming Liu
- Department of Pulmonary and Critical Care MedicineThe First Affiliated Hospital of Jinan UniversityGuangzhouGuangdong ProvinceChina
| |
Collapse
|
11
|
Jia XY, Wang XR, Jiang YY, An MZ, Pei DQ, Li ZP, Zhou QH. Effect of intraoperative low vs. conventional tidal volume on the incidence of postoperative acute kidney injury after noncardiac surgery: a two-center randomized clinical trial. Minerva Anestesiol 2023; 89:762-772. [PMID: 36943711 DOI: 10.23736/s0375-9393.23.17097-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND In adults undergoing noncardiac surgery, the correlation between intraoperative tidal volume and postoperative acute kidney injury (AKI) is unclear. This study aimed to investigate the effects of low tidal volume ventilation on the incidence of postoperative AKI compared with conventional tidal volume in adults undergoing noncardiac surgery. METHODS This was a two-center prospective randomized controlled trial on adult patients who underwent noncardiac surgery and had a mechanical ventilation of >60 min. Patients were randomized to receive either a tidal volume of 6 mL/kg pre-predicted body weight (PBW, low tidal volume) or a tidal volume of 10 mL/kg pre-predicted body weight (conventional tidal volume). The primary outcome was the incidence of AKI after non-cardiac surgery. Appropriate statistical methods were used for this study. RESULTS Among the 1982 randomized patients, 943 with low tidal volume and 958 with conventional tidal volume were evaluable for the primary outcome. Postoperative AKI occurred in 12 patients (1.3%) in the low tidal volume group and 11 patients (1.1%) in the conventional tidal volume group, with an odds ratio of 0.889 (95%CI, 0.391-2.03) and a relative risk of 0.999 ([95%CI, 0.989-1.01]; P=0.804). Postoperative serum creatinine levels increased in 284 (30.0%) patients with low tidal volume compared to 316 (32.0%) patients with conventional tidal volume (P=0.251). No difference in postoperative serum creatinine levels was found between the two groups (57.5 [49.0-68.2] μmol/L vs. 58.8[50.4-69.5] μmol/L, P=0.056). CONCLUSIONS Among adults undergoing noncardiac surgery, low tidal volume mechanical ventilation did not significantly reduce the incidence of postoperative AKI compared with conventional tidal volume.
Collapse
Affiliation(s)
- Xiao-Yu Jia
- Department of Anesthesia Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xu-Ru Wang
- Department of Anesthesia Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Yan-Yu Jiang
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
- Department of Anesthesia Medicine, Bengbu Medical College, Bengbu, China
| | - Ming-Zi An
- Department of Anesthesia Medicine, Zhejiang Chinese Medical University, Hangzhou, China
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Da-Qing Pei
- Department of Anesthesiology, Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Zhen-Ping Li
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Qing-He Zhou
- Department of Anesthesiology and Pain Medicine, Affiliated Hospital of Jiaxing University, Jiaxing, China -
| |
Collapse
|
12
|
Leis AM, Mathis MR, Kheterpal S, Zawistowski M, Mukherjee B, Pace N, O'Reilly-Shah VN, Smith JA, Karvonen-Gutierrez CA. Cardiometabolic disease and obesity patterns differentially predict acute kidney injury after total joint replacement: a retrospective analysis. Br J Anaesth 2023; 131:37-46. [PMID: 37188560 PMCID: PMC10308436 DOI: 10.1016/j.bja.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 05/17/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a frequent yet understudied postoperative total joint arthroplasty complication. This study aimed to describe cardiometabolic disease co-occurrence using latent class analysis, and associated postoperative AKI risk. METHODS This retrospective analysis examined patients ≥18 years old undergoing primary total knee or hip arthroplasties within the US Multicenter Perioperative Outcomes Group of hospitals from 2008 to 2019. AKI was defined using modified Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Latent classes were constructed from eight cardiometabolic diseases including hypertension, diabetes, and coronary artery disease, excluding obesity. A mixed-effects logistic regression model was constructed for the outcome of any AKI and the exposure of interaction between latent class and obesity status adjusting for preoperative and intraoperative covariates. RESULTS Of 81 639 cases, 4007 (4.9%) developed AKI. Patients with AKI were more commonly older and non-Hispanic Black, with more significant comorbidity. A latent class model selected three groups of cardiometabolic patterning, labelled 'hypertension only' (n=37 223), 'metabolic syndrome (MetS)' (n=36 503), and 'MetS+cardiovascular disease (CVD)' (n=7913). After adjustment, latent class/obesity interaction groups had differential risk of AKI compared with those in 'hypertension only'/non-obese. Those 'hypertension only'/obese had 1.7-fold increased odds of AKI (95% confidence interval [CI]: 1.5-2.0). Compared with 'hypertension only'/non-obese, those 'MetS+CVD'/obese had the highest odds of AKI (odds ratio 3.1, 95% CI: 2.6-3.7), whereas 'MetS+CVD'/non-obese had 2.2 times the odds of AKI (95% CI: 1.8-2.7; model area under the curve 0.76). CONCLUSIONS The risk of postoperative AKI varies widely between patients. The current study suggests that the co-occurrence of metabolic conditions (diabetes mellitus, hypertension), with or without obesity, is a more important risk factor for acute kidney injury than individual comorbid diseases.
Collapse
Affiliation(s)
- Aleda M Leis
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.
| | - Michael R Mathis
- Department of Anaesthesiology, University of Michigan, Ann Arbor, MI, USA; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, MI, USA
| | - Sachin Kheterpal
- Department of Anaesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Matthew Zawistowski
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Bhramar Mukherjee
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Nathan Pace
- Department of Anaesthesiology, University of Utah, Salt Lake City, UT, USA
| | - Vikas N O'Reilly-Shah
- Department of Anaesthesiology & Pain Medicine, University of Washington, Seattle, WA, USA
| | - Jennifer A Smith
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | |
Collapse
|
13
|
Feng Y, Wang AY, Jun M, Pu L, Weisbord SD, Bellomo R, Hong D, Gallagher M. Characterization of Risk Prediction Models for Acute Kidney Injury: A Systematic Review and Meta-analysis. JAMA Netw Open 2023; 6:e2313359. [PMID: 37184837 DOI: 10.1001/jamanetworkopen.2023.13359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2023] Open
Abstract
Importance Despite the expansion of published prediction models for acute kidney injury (AKI), there is little evidence of uptake of these models beyond their local derivation nor data on their association with patient outcomes. Objective To systematically review published AKI prediction models across all clinical subsettings. Data Sources MEDLINE via PubMed (January 1946 to April 2021) and Embase (January 1947 to April 2021) were searched using medical subject headings and text words related to AKI and prediction models. Study Selection All studies that developed a prediction model for AKI, defined as a statistical model with at least 2 predictive variables to estimate future occurrence of AKI, were eligible for inclusion. There was no limitation on study populations or methodological designs. Data Extraction and Synthesis Two authors independently searched the literature, screened the studies, and extracted and analyzed the data following the Preferred Reporting Items for Systematic Review and Meta-analyses guideline. The data were pooled using a random-effects model, with subgroups defined by 4 clinical settings. Between-study heterogeneity was explored using multiple methods, and funnel plot analysis was used to identify publication bias. Main Outcomes and Measures C statistic was used to measure the discrimination of prediction models. Results Of the 6955 studies initially identified through literature searching, 150 studies, with 14.4 million participants, met the inclusion criteria. The study characteristics differed widely in design, population, AKI definition, and model performance assessments. The overall pooled C statistic was 0.80 (95% CI, 0.79-0.81), with pooled C statistics in different clinical subsettings ranging from 0.78 (95% CI, 0.75-0.80) to 0.82 (95% CI, 0.78-0.86). Between-study heterogeneity was high overall and in the different clinical settings (eg, contrast medium-associated AKI: I2 = 99.9%; P < .001), and multiple methods did not identify any clear sources. A high proportion of models had a high risk of bias (126 [84.4%]) according to the Prediction Model Risk Of Bias Assessment Tool. Conclusions and Relevance In this study, the discrimination of the published AKI prediction models was good, reflected by high C statistics; however, the wide variation in the clinical settings, populations, and predictive variables likely drives the highly heterogenous findings that limit clinical utility. Standardized procedures for development and validation of prediction models are urgently needed.
Collapse
Affiliation(s)
- Yunlin Feng
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Amanda Y Wang
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Concord Clinical School, University of Sydney, Sydney, Australia
- The Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Min Jun
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Lei Pu
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Steven D Weisbord
- Renal Section, Medicine Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Daqing Hong
- Department of Nephrology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Martin Gallagher
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|
14
|
Abu-Saleh A, Feintuch L, Shani A, Rahamimov R, Rahamimov N. Insertion of a urinary catheter on admission lowers acute kidney injury incidence in patients with hip fractures. Int Orthop 2023. [PMID: 36884049 DOI: 10.1007/s00264-023-05755-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/27/2023] [Indexed: 03/09/2023]
Abstract
PURPOSE Acute kidney injury (AKI) is a common adverse event in patients undergoing hip fracture repair surgery, increasing morbidity and mortality. Our study hypothesis was that routine insertion of a urinary catheter, on admission to the hospital or immediately before surgery, will reduce AKI incidence in hip fracture patients. METHODS Determined by alternating days of admission, a urinary catheter was inserted routinely on admission (catheter group) or as needed (non-catheter group) in 250 consecutive patients who presented with a hip fracture to our emergency department. The incidence of AKI according to the KDIGO criteria and morbidity and mortality were compared between the study groups. RESULTS The overall incidence of AKI was 11.6% (29/250). The catheter group (N = 122) had a significantly lower rate of AKI (6.6% vs. 16% p = 0.018). At 12-month follow-up, the overall mortality was 10.8% (27/250), in-hospital 7.4% (2/27), short-term (within 30 days) 7.4% (2/27), and long-term (30 days to 1 year) 85.8% (23/27). All in-hospital mortality occurred in the AKI group. Patients with no AKI had a better survival rate; however, the difference was not significant (p-value = 0.21). Mortality rate was lower in the catheter group but not significant (8.2% compared with 13.8% in the non-catheter group, p = 0.225). Post-operative respiratory and cardiac complications were more frequent in the AKI group (p = 0.02 and 0.043 accordingly). CONCLUSIONS Insertion of a urinary catheter upon admission or before surgery lowered AKI incidence significantly. Peri-operative AKI was associated with higher rates of post-operative complications and worse survival.
Collapse
|
15
|
Lei SH, Guo GF, Yan T, Zhao BC, Qiu SD, Liu KX. Acute Kidney Injury After General Thoracic Surgery: A Systematic Review and Meta-Analysis. J Surg Res 2023; 287:72-81. [PMID: 36870304 DOI: 10.1016/j.jss.2023.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 12/28/2022] [Accepted: 01/27/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION The clinical importance of postoperative acute kidney injury (AKI) in patients undergoing general thoracic surgery is unclear. We aimed to systematically review the incidence, risk factors, and prognostic implications of AKI as a complication after general thoracic surgery. METHODS We searched PubMed, EMBASE, and the Cochrane Library from January 2004 to September 2021. Observational or interventional studies that enrolled ≥50 patients undergoing general thoracic surgery and reported postoperative AKI defined using contemporary consensus criteria were included for meta-analysis. RESULTS Thirty-seven articles reporting 35 unique cohorts were eligible. In 29 studies that enrolled 58,140 consecutive patients, the pooled incidence of postoperative AKI was 8.0% (95% confidence interval [CI]: 6.2-10.0). The incidence was 3.8 (2.0-6.2) % after sublobar resection, 6.7 (4.1-9.9) % after lobectomy, 12.1 (8.1-16.6) % after bilobectomy/pneumonectomy, and 10.5 (5.6-16.7) % after esophagectomy. Considerable heterogeneity in reported incidences of AKI was observed across studies. Short-term mortality was higher (unadjusted risk ratio: 5.07, 95% CI: 2.99-8.60) and length of hospital stay was longer (weighted mean difference: 3.53, 95% CI: 2.56-4.49, d) in patients with postoperative AKI (11 studies, 28,480 patients). Several risk factors for AKI after thoracic surgery were identified. CONCLUSIONS AKI occurs frequently after general thoracic surgery and is associated with increased short-term mortality and length of hospital stay. For patients undergoing general thoracic surgery, AKI may be an important postoperative complication that needs early risk evaluation and mitigation.
Collapse
Affiliation(s)
- Shao-Hui Lei
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Gao-Feng Guo
- Department of Anesthesiology and Perioperative Medicine, Henan Provincial People's Hospital, People's Hospital of Zhengzhou University, Zhengzhou, China
| | - Ting Yan
- Department of Anesthesiology, Fujian Medical University Union Hospital, Fuzhou, China
| | - Bing-Cheng Zhao
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Shi-Da Qiu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ke-Xuan Liu
- Department of Anesthesiology, Nanfang Hospital, Southern Medical University, Guangzhou, China.
| |
Collapse
|
16
|
Kulkarni S, Richardson T, Green A, Acharya R, Latif A, Johnson D, Naqvi H, Gella S. Reducing incidence of postoperative acute kidney injury in trauma and orthopaedics patients: a quality improvement project. BMJ Open Qual 2023; 12:bmjoq-2022-002124. [PMID: 36868574 PMCID: PMC9990687 DOI: 10.1136/bmjoq-2022-002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/18/2023] [Indexed: 03/05/2023] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is a common postoperative complication which increases morbidity and mortality. This quality improvement project aimed to implement measures targeting known risk factors to decrease the incidence of postoperative AKI in trauma and orthopaedics (T&O) patients. METHODS Data were collected across three six-month to 7-month cycles between 2017 and 2020, analysing all elective and emergency T&O operated patients within a single NHS Trust (n=714, 1008 and 928, respectively). Patients who developed a postoperative AKI were identified using biochemical criteria and data were collected on known AKI risk factors, including use of nephrotoxic medications, and patient outcomes. In the final cycle, the same variables were collected for patients without AKI. Between cycles, measures implemented included: preoperative and postoperative medication reconciliation aiming to stop nephrotoxic medications, orthogeriatrician review of high-risk patients and junior doctor teaching on fluid therapy. Statistical analysis was undertaken to determine the incidence of postoperative AKI across cycles, prevalence of risk factors and impact on length of hospital stay and postoperative mortality. RESULTS There was a statistically significant decrease in postoperative AKI incidence from 4.27% (43 of 1008 patients) in cycle 2 to 2.05% (19 of 928) in cycle 3 (p=0.006), with a notable decrease in use of nephrotoxic medications. Significant predictors for the development of postoperative AKI included use of diuretics and receiving multiple nephrotoxic drug classes. Development of postoperative AKI significantly increased length of hospital stay by 7.11 days on average (95% CI: 4.84 to 9.38 days, p<0.001) and risk of 1-year postoperative mortality (OR 3.22, 95% CI: 1.03 to 10.55, p=0.046). CONCLUSION This project demonstrates that a multifaceted approach targeting modifiable risk factors can reduce incidence of postoperative AKI in T&O patients, which may lead to reduced length of hospital stay and postoperative mortality.
Collapse
Affiliation(s)
- Sanat Kulkarni
- Department of Trauma and Orthopaedics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Thomas Richardson
- Department of Trauma and Orthopaedics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Alice Green
- University of Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Radhika Acharya
- University of Birmingham Medical School, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Arusa Latif
- Department of Trauma and Orthopaedics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Dakota Johnson
- Department of Information, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Huma Naqvi
- Department of Geriatric Medicine, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Sreenadh Gella
- Department of Trauma and Orthopaedics, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| |
Collapse
|
17
|
Pan L, Liu Z, Wu H, Wang H, Wang H, Ning T, Liang G, Cao Y. Construction and Validation of a Nomogram for Predicting Acute Kidney Injury After Hip Fracture Surgery. Clin Interv Aging 2023; 18:181-191. [PMID: 36818547 PMCID: PMC9936559 DOI: 10.2147/cia.s399314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 02/08/2023] [Indexed: 02/13/2023] Open
Abstract
Background Acute kidney injury (AKI), characterized by sudden impairment of kidney function, is an uncommon complication following hip fracture surgery that is associated with increased morbidity and mortality. We constructed a nomogram to stratify patients according to risk of AKI after hip fracture surgery to guide clinicians in the implementation of timely interventions. Methods Patients who received hip fracture surgery from January 2015 to December 2021 were retrospectively identified and divided into a training set (n=448, surgery from January 2015 to December 2019) and a validation set (n=200, surgery from January 2020 to December 2021). Univariate and multivariate logistic regression were used to identify risk factors for AKI after surgery in the training set. A nomogram was constructed based the risk factors for AKI, and was evaluated by receiver operating characteristic (ROC) analysis, calibration curves, and decision curve analysis (DCA). Results The mean age was 82.0±6.22 years-old and the prevalence of post-surgical AKI was 13.3%. Age, American Society of Anesthesiologists (ASA) score, the preexistence of chronic kidney disease (CKD), cemented surgery and the decrease of hemoglobin on the first day after surgery were identified as independent risk factors of AKI after hip fracture surgery, and a predictive nomogram was established based on the multivariable model. The predictive nomogram had good discrimination ability (training set: AUC: 0.784, 95% CI: 0.720-0.848; validation set: AUC: 0.804, 95% CI: 0.704-0.903), and showed good validation ability and clinical usefulness based on a calibration plot and decision curve analysis. Conclusion A nomogram that incorporated five risk factors including age, ASA score, preexisting CKD, cemented surgery and the decrease of hemoglobin on the first day after surgery had good predictive performance and discrimination. Use of our results for early stratification and intervention has the potential to improve the outcomes of patients receiving hip fracture surgery. Future large, multicenter cohorts are needed to verify the model's performance.
Collapse
Affiliation(s)
- Liping Pan
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Zhenning Liu
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Hao Wu
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Hao Wang
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Hongbin Wang
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Taiguo Ning
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Guanghua Liang
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Yongping Cao
- Department of Orthopedics, Peking University First Hospital, Beijing, 100034, People's Republic of China
| |
Collapse
|
18
|
Stille K, Kribben A, Herget-Rosenthal S. Incidence, severity, risk factors and outcomes of acute kidney injury in older adults: systematic review and meta-analysis. J Nephrol 2022; 35:2237-2250. [PMID: 35932418 DOI: 10.1007/s40620-022-01381-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 06/10/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Old age was identified as a strong risk factor for acute kidney injury (AKI). Our objectives were to provide estimates of AKI, risk factors and outcomes in patients ≥ 75 years for whom data are scarce. METHODS Observational studies and randomized controlled trials between 2005 and 2021 with patients of mean or median age ≥ 75 years, reporting AKI according to current definitions. Data on AKI incidence, risk factors and mortality were analyzed separately in unselected (UC) and acute heart failure (AHF) cohorts. RESULTS Twenty-six observational studies and 4 randomized controlled trials with 51,111 UC and 25,414 AHF patients were included. Ages averaged 79.4 and 79.8 years, respectively. Pooled risk ratios (RRs) of AKI rates were 26.29% (95% confidence intervals (CI) 13.20-41.97) (UC) and 24.21% (95% CI 20.03-28.65) (AHF). In both cohorts, AKI was associated with decreased estimated glomerular filtration rate at baseline, chronic kidney disease (UC: RR 1.80 (95% CI 1.15-2.80), AHF: RR 1.51 (95% CI 1.26-1.95) and hypertension (UC: RR 1.30 (95% CI 1.09-1.56), AHF: RR 1.07 (95% CI 1.05-1.09). RRs of AKI in patients on renin-angiotensin-inhibitors were 0.87 (95% CI 0.78-0.97) and 0.88 (95% CI 0.78-0.98) in UC and AHF, respectively. AKI was consistently associated with increased risk of in-hospital mortality (UC: RR 3.15 (95% CI 2.28-4.35), AHF: RR 4.28 (95% CI 2.53-7.24). CONCLUSION AKI is frequent in patients ≥ 75 years. While reduced renal function at baseline, CKD and hypertension were associated with AKI development, renin-angiotensin-inhibitors may be protective. Older AKI patients showed higher short-term mortality rates.
Collapse
Affiliation(s)
- Kolja Stille
- Department of Medicine, Rotes Kreuz Krankenhaus, St. Pauli Deich 24, 28199, Bremen, Germany
| | - Andreas Kribben
- Department of Nephrology, Universitätsklinikum, Universität Duisburg-Essen, Essen, Germany
| | - Stefan Herget-Rosenthal
- Department of Medicine, Rotes Kreuz Krankenhaus, St. Pauli Deich 24, 28199, Bremen, Germany. .,Department of Nephrology, Universitätsklinikum, Universität Duisburg-Essen, Essen, Germany.
| |
Collapse
|
19
|
Abstract
Postoperative AKI is a common complication of major surgery and is associated with significant morbidity and mortality. The Kidney Disease Improving Global Outcomes AKI definition allows consensus classification and identification of postoperative AKI through changes in serum creatinine and/or urine output. However, such conventional diagnostic criteria may be inaccurate in the postoperative period, suggesting a potential to refine diagnosis by application of novel diagnostic biomarkers. Risk factors for the development of postoperative AKI can be thought of in terms of preoperative, intraoperative, and postoperative factors and, as such, represent areas that may be targeted perioperatively to minimize the risk of AKI. The treatment of postoperative AKI remains predominantly supportive, although application of management bundles may translate into improved outcomes.
Collapse
Affiliation(s)
- Naomi Boyer
- Department of Critical Care, Royal Surrey Hospital, Guildford, United Kingdom
- SPACeR Group (Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group), Royal Surrey Hospital, Guildford, United Kingdom
| | - Jack Eldridge
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Adult Critical Care Unit, Royal London Hospital Barts Health National Health Service Trust, London, United Kingdom
| | - John R. Prowle
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- Adult Critical Care Unit, Royal London Hospital Barts Health National Health Service Trust, London, United Kingdom
| | - Lui G. Forni
- Department of Critical Care, Royal Surrey Hospital, Guildford, United Kingdom
- SPACeR Group (Surrey Peri-Operative, Anaesthesia and Critical Care Collaborative Research Group), Royal Surrey Hospital, Guildford, United Kingdom
- Department of Clinical and Experimental Medicine, Faculty of Health Sciences, University of Surrey, Guildford, United Kingdom
| |
Collapse
|
20
|
Agar A, Gulabi D, Sahin A, Gunes O, Hancerli CO, Kılıc B, Erturk C. Acute kidney injury after hip fracture surgery in patients over 80 years of age. Arch Orthop Trauma Surg 2022; 142:2245-2252. [PMID: 34056678 DOI: 10.1007/s00402-021-03969-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the study is to determine the rate of acute kidney injury (AKI) after hip fracture surgery over the age of 80 and to investigate the factors associated with AKI. METHODS From January 2015 to January 2020, 589 patients who underwent surgery of hip fractures at our institution were retrospectively reviewed. Serum creatinine (sCr) was analysed daily pre- and postoperatively during the hospital stay. Patients were divided into groups; AKI and non-AKI based on KDIGO (Kidney Disease Global Outcomes) criteria. The incidence, risk factors, and mortality of postoperative AKI were investigated. RESULTS Out of 589 patients, 58 developed an AKI (9.8%). Smoking (p: 0.004), pre and postoperative low albumin level (p < 0.05), pre- and postoperative high potassium level (p < 0.05), pre- and postoperative high urea levels (p < 0.05), high amount of intra-operative bleeding (p: 0.003) and prolonged surgery time (p: 0.003) were found to be risk factors associated with AKI. Although the mortality rate was higher in the AKI group, it was not statistically significant (p > 0.05). CONCLUSION AKI is a temporary but common complication following hip fracture surgery, which can also be predicted if risk factors are adequately observed. It typically increases the length of hospital stays, mortality and morbidity. LEVEL OF EVIDENCE Level III evidence, Retrospective comparative study.
Collapse
Affiliation(s)
- Anil Agar
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey.
| | - Deniz Gulabi
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| | - Adem Sahin
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| | - Orhan Gunes
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| | - Cafer Ozgur Hancerli
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| | - Bulent Kılıc
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| | - Cemil Erturk
- Orthopaedic and Traumatology Department, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Atakent mah, Istanbul cad. No: 1, Kucukcekmece, 34303, Istanbul, Turkey
| |
Collapse
|
21
|
Wood D, Moy SF, Zhang S, Lightfoot N. Impact of a prescriber and patient educational intervention on discharge analgesia prescribing and hospital readmission rates following elective unilateral total hip and knee arthroplasty. BMJ Open Qual 2022; 11:bmjoq-2021-001672. [PMID: 35914816 PMCID: PMC9345064 DOI: 10.1136/bmjoq-2021-001672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 07/11/2022] [Indexed: 11/03/2022] Open
Abstract
IntroductionPain management after elective, unilateral total hip and knee arthroplasty (THA and TKA) should use a multimodal approach. At discharge, challenges include ensuring correct prescribing practices to optimise analgesia and rationalise opioid use as well as ensuring patients are adequately educated to take these medications safely and effectively in the community. This audit cycle reports on a prescriber and patient education intervention using printed guidelines, educational outreach and prescription standardisation along with a patient information sheet to address the high unplanned readmission rate following THA and TKA at our institution.MethodsTwo cohorts of patients were identified before (2016) and after (2019) the introduction of the educational package. The primary outcome was the unplanned hospital readmission rate in the 42 days following discharge. Secondary outcomes were the compliance with the set prescribing standards and the prescription of strong opioid medications (morphine or oxycodone) on discharge.ResultsThere was a reduction in the readmission rate from 20.4% to 10.0% (p=0.004). Readmission rates for pain and constipation were also reduced. The prescribing of tramadol (p<0.001) and non-steroidal anti-inflammatory drugs (p<0.001) both increased while the number of patients who received a strong opioid at discharge decreased (p<0.001) as did the number of patients who received a sustained release strong opioid (p<0.001).ConclusionWe have observed significant improvement in discharge prescribing which coincided with a reduction in unplanned readmissions after elective TKA and THA. Our approach used prescriber guidelines, education and standardisation with printed information for patients to enhance understanding and recall.
Collapse
Affiliation(s)
- Daniel Wood
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Shuh Fen Moy
- Anaesthesia, Auckland City Hospital, Auckland, New Zealand
| | - Shiran Zhang
- Orthopaedics, Middlemore Hospital, Auckland, New Zealand
| | - Nicholas Lightfoot
- Anaesthesia and Pain Medicine, Middlemore Hospital, Auckland, New Zealand
| |
Collapse
|
22
|
Angerett NR, Yevtukh A, Ferguson CM, Kahan ME, Ali M, Hallock RH. Improving Postoperative Acute Kidney Injury Rates Following Primary Total Joint Arthroplasty. J Arthroplasty 2022; 37:S1004-S1009. [PMID: 34952163 DOI: 10.1016/j.arth.2021.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/05/2021] [Accepted: 12/15/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Perioperative hip and knee arthroplasty complications remain a significant clinical and financial burden. Our institution has shifted to developing protocols to decrease these perioperative complications. This study focuses on acute kidney injury (AKI) rate status post primary total joint arthroplasty (TJA). Current literature demonstrates a 2%-15% incidence of AKI following TJA. However, there is a paucity of published literature on protocols that have effectively reduced AKI rates following TJA. The purpose of this study is to evaluate the effect that our institutionally developed perioperative renal protocol had on the postoperative AKI rates. METHODS A retrospective cohort study was performed. Patient demographics, baseline creatinine, and postoperative creatinine values during the patient's hospitalization were collected and analyzed. The preintervention cohort data contained all patients at our institution who underwent a primary TJA from November 1, 2016 to January 1, 2018. The postintervention cohort included all primary TJA patients from July 1, 2018 to February 2, 2020. AKI was defined using the AKI Network classification system comparing baseline and postoperative creatinine values. A multivariate analysis was performed to determine the statistical significance of our results. RESULTS Before intervention 1013 patients underwent a primary TJA with 68 patients developing an AKI postoperatively. After intervention 2169 patients underwent primary TJA with 90 patients developing an AKI (6.71% vs 4.15%; P = .0015, odds ratio = 0.59, 95% confidence interval = 0.42-0.82). CONCLUSION This study demonstrated that implementation of a perioperative renal protocol can significantly reduce AKI rates. A reduction in AKI rates following TJA will result in improved outcomes and secondarily decrease the financial impact of postoperative complications seen following TJA.
Collapse
Affiliation(s)
- Nathan R Angerett
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, Baltimore, MD; Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD
| | | | | | - Michael E Kahan
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Rubin Institute for Advanced Orthopedics, Center for Joint Preservation & Replacement, Sinai Hospital of Baltimore, Baltimore, MD; Department of Orthopaedic Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Muzaffar Ali
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA
| | - Richard H Hallock
- Department of Orthopaedic Surgery, UPMC Harrisburg, Harrisburg, PA; Orthopedic Institute of Pennsylvania, Camp Hill, PA
| |
Collapse
|
23
|
Liu K, Zhang X, Chen W, Yu ASL, Kellum JA, Matheny ME, Simpson SQ, Hu Y, Liu M. Development and Validation of a Personalized Model With Transfer Learning for Acute Kidney Injury Risk Estimation Using Electronic Health Records. JAMA Netw Open 2022; 5:e2219776. [PMID: 35796212 PMCID: PMC9250052 DOI: 10.1001/jamanetworkopen.2022.19776] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
IMPORTANCE Acute kidney injury (AKI) is a heterogeneous syndrome prevalent among hospitalized patients. Personalized risk estimation and risk factor identification may allow effective intervention and improved outcomes. OBJECTIVE To develop and validate personalized AKI risk estimation models using electronic health records (EHRs), examine whether personalized models were beneficial in comparison with global and subgroup models, and assess the heterogeneity of risk factors and their outcomes in different subpopulations. DESIGN, SETTING, AND PARTICIPANTS This diagnostic study analyzed EHR data from 1 tertiary care hospital and used machine learning and logistic regression to develop and validate global, subgroup, and personalized risk estimation models. Transfer learning was implemented to enhance the personalized model. Predictor outcomes across subpopulations were analyzed, and metaregression was used to explore predictor interactions. Adults who were hospitalized for 2 or more days from November 1, 2007, to December 31, 2016, were included in the analysis. Patients with moderate or severe kidney dysfunction at admission were excluded. Data were analyzed between August 28, 2019, and May 8, 2022. EXPOSURES Clinical and laboratory variables in the EHR. MAIN OUTCOMES AND MEASURES The main outcome was AKI of any severity, and AKI was defined using the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Performance of the models was measured with area under the receiver operating characteristic curve (AUROC), area under the precision-recall curve, and calibration. RESULTS The study cohort comprised 76 957 inpatient encounters. Patients had a mean (SD) age of 55.5 (17.4) years and included 42 159 men (54.8%). The personalized model with transfer learning outperformed the global model for AKI estimation in terms of AUROC among general inpatients (0.78 [95% CI, 0.77-0.79] vs 0.76 [95% CI, 0.75-0.76]; P < .001) and across the high-risk subgroups (0.79 [95% CI, 0.78-0.80] vs 0.75 [95% CI, 0.74-0.77]; P < .001) and low-risk subgroups (0.74 [95% CI, 0.73-0.75] vs 0.71 [95% CI, 0.70-0.72]; P < .001). The AUROC improvement reached 0.13 for the high-risk subgroups, such as those undergoing liver transplant and cardiac surgery. Moreover, the personalized model with transfer learning performed better than or comparably with the best published models in well-studied AKI subgroups. Predictor outcomes varied significantly between patients, and interaction analysis uncovered modifiers of the predictor outcomes. CONCLUSIONS AND RELEVANCE Results of this study demonstrated that a personalized modeling with transfer learning is an improved AKI risk estimation approach that can be used across diverse patient subgroups. Risk factor heterogeneity and interactions at the individual level highlighted the need for agile, personalized care.
Collapse
Affiliation(s)
- Kang Liu
- Big Data Decision Institute, Jinan University, Guangzhou, Guangdong, China
| | - Xiangzhou Zhang
- Big Data Decision Institute, Jinan University, Guangzhou, Guangdong, China
| | - Weiqi Chen
- Big Data Decision Institute, Jinan University, Guangzhou, Guangdong, China
| | - Alan S. L. Yu
- Division of Nephrology and Hypertension and the Jared Grantham Kidney Institute, School of Medicine, University of Kansas Medical Center, Kansas City
| | - John A. Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael E. Matheny
- Department of Biomedical Informatics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
- Geriatrics Research Education and Clinical Care Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
| | - Steven Q. Simpson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City
| | - Yong Hu
- Big Data Decision Institute, Jinan University, Guangzhou, Guangdong, China
| | - Mei Liu
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City
| |
Collapse
|
24
|
Lumley R, Tadross D, Amos L, Headon E, Tomlinson J. The management of acute kidney injury in orthopaedic patients. Clin Med (Lond) 2022; 22 Suppl 4:64. [PMID: 38614597 PMCID: PMC9600846 DOI: 10.7861/clinmed.22-4-s64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Lucy Amos
- Sheffield Teaching Hospitals, Sheffield, UK
| | | | | |
Collapse
|
25
|
Wang J, Dong Y, Zhao B, Liu K. Preoperative NT-proBNP and LVEF for the prediction of acute kidney injury after noncardiac surgery: a single-centre retrospective study. BMC Anesthesiol 2022; 22:196. [PMID: 35751021 PMCID: PMC9229082 DOI: 10.1186/s12871-022-01727-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
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 ).
Collapse
Affiliation(s)
- Jiaqi Wang
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Yehong Dong
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China
| | - Bingcheng Zhao
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China.
| | - Kexuan Liu
- Department of Anaesthesiology, Nanfang Hospital, Southern Medical University, 1838 Guangzhou Avenue North, Guangzhou, 510515, China.
| |
Collapse
|
26
|
Yee MY, Harrison E, Pius R, Gillies M. Changes in perioperative red cell transfusion practice over time in patients undergoing surgery for upper gastrointestinal and liver cancer: a retrospective cohort study at a single tertiary centre. BMJ Open 2022; 12:e054193. [PMID: 35534069 PMCID: PMC9086641 DOI: 10.1136/bmjopen-2021-054193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES Optimum transfusion trigger for adults undergoing cancer surgery is uncertain. Published guidelines recommend restrictive transfusion strategies in hospitalised adults. We aimed to measure the red cell transfusion rate and haemoglobin trigger in patients undergoing cancer surgery and how closely practice reflected published guidelines. DESIGN Retrospective cohort study. SETTING Single tertiary centre. PARTICIPANTS Adult patients undergoing surgery for upper gastrointestinal or liver malignancy. EXPOSURE Postguideline change (2015-2017) versus preguideline change (2011-2012). OUTCOME MEASURES Primary: transfusion rate, secondary: transfusion trigger. Multivariable logistic regression was used to assess factors and adjust for confounders affecting our outcome measures. RESULTS 1578 surgical records were identified for 1520 patients. 946/1530 (62%) patients had preoperative anaemia. The transfusion rate decreased from 23% in 2011-2012 to 14% in 2015-2017. This change remained significant after adjusting for other variables associated with transfusion rates. Mean pretransfusion haemoglobin in those who were transfused was 78±13 g/L in 2011-2012 and 80±15 g/L in 2015-2017. This change in haemoglobin transfusion triggers was not significant. CONCLUSION Transfusion rate has decreased over the study period in patients undergoing surgery for malignancy and is consistent with a restrictive transfusion strategy.
Collapse
Affiliation(s)
- Mei Yi Yee
- Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Ewen Harrison
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Riinu Pius
- Clinical Surgery, University of Edinburgh, Edinburgh, UK
| | - Michael Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| |
Collapse
|
27
|
Chen Q, Zhang Y, Zhang M, Li Z, Liu J. Application of Machine Learning Algorithms to Predict Acute Kidney Injury in Elderly Orthopedic Postoperative Patients. Clin Interv Aging 2022; 17:317-330. [PMID: 35386749 PMCID: PMC8979591 DOI: 10.2147/cia.s349978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/10/2022] [Indexed: 12/13/2022] Open
Abstract
Objective There has been a worldwide increment in acute kidney injury (AKI) incidence among elderly orthopedic operative patients. The AKI prediction model provides patients’ early detection a possibility at risk of AKI; most of the AKI prediction models derive, however, from the cardiothoracic operation. The purpose of this study is to predict the risk of AKI in elderly patients after orthopedic surgery based on machine learning algorithm models. Methods We organized a retrospective study being comprised of 1000 patients with postoperative AKI undergoing orthopedic surgery from September 2016, to June, 2021. They were divided into training (80%;n=799) and test (20%;n=201) sets.We utilized nine machine learning (ML) algorithms and used intraoperative information and preoperative clinical features to acquire models to predict AKI. The performance of the model was evaluated according to the area under the receiver operating characteristic (AUC), sensitivity, specificity and accuracy. Select the optimal model and establish the nomogram to make the prediction model visualization. The concordance statistic (C-statistic) and calibration curve were used to discriminate and calibrate the nomogram respectively. Results In predicting AKI, nine ML algorithms posted AUC of 0.656–1.000 in the training cohort, with the randomforest standing out and AUC of 0.674–0.821 in the test cohort, with the logistic regression model standing out. Thus, we applied the logistic regression model to establish nomogram. The nomogram was comprised of ten variables: age, body mass index, American Society of Anesthesiologists, hypoproteinemia, hypertension, diabetes, anemia, duration of low mean arterial pressure, mean arterial pressure, transfusion.The calibration curves showed good agreement between prediction and observation in both the training and test sets. Conclusion By including intraoperative and preoperative risk factors, ML algorithm can predict AKI and logistic regression model performing the best. Our prediction model and nomogram that are based on this ML algorithm can help lead decision-making for strategies to inhibit AKI over the perioperative duration.
Collapse
Affiliation(s)
- Qiuchong Chen
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Yixue Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Mengjun Zhang
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Ziying Li
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
| | - Jindong Liu
- Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, Jiangsu, People’s Republic of China
- Correspondence: Jindong Liu, Department of Anesthesiology, The Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road West, Quanshan District, Xuzhou, Jiangsu, 221000, People’s Republic of China, Email
| |
Collapse
|
28
|
Lee SH, Kim HR, Seo HY, Seon JK. A comparative study of 21,194 UKAs and 49,270 HTOs for the risk of unanticipated events in mid-age patients from the national claims data in South Korea. BMC Musculoskelet Disord 2022; 23:127. [PMID: 35135508 PMCID: PMC8827168 DOI: 10.1186/s12891-022-05080-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 02/02/2022] [Indexed: 12/02/2022] Open
Abstract
Background Both high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA) are well-established treatments for medial knee osteoarthritis (OA). However, over the past 20 years, results of comparisons of long-term survival rates and outcomes have remained controversial. Furthermore, in patients at the boundary age, from 50 to 70 years, considering age as a treatment indication, selecting a surgical method is difficult. Therefore, we aimed to investigate conversion rates to total knee arthroplasty (TKA) and perioperative adverse outcomes between the two surgical methods in mid-age patients. Methods We extracted data from the Korean National Health Insurance claims database. A total of 70,464 patients aged between 50 and 70 years, considered as mid-age patients were included in the final study population. We used a multivariable Cox proportional hazard regression model, adjusting for potential confounders such as age, sex, insurance type, region of residence, hospital type, comorbidities, and the Charlson comorbidity Index (CCI). Results Of the 70,464 patients, 21,194 were treated with UKA and 49,270 were treated with HTO. HTO showed a higher risk of revision than UKA at five, and 10 years and during the whole observation period. The incidence of deep vein thromboembolism, and surgical site infection was significantly higher in UKA than in HTO. Conclusions It is important to choose an appropriate surgical method considering that UKA has better results in terms of long-term survival rates but may have a higher incidence of various complications.
Collapse
Affiliation(s)
- Sun-Ho Lee
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, Republic of Korea
| | - Hae-Rim Kim
- College of Natural Science, School of Statistics, University of Seoul, Seoul, Republic of Korea
| | - Hyoung-Yeon Seo
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, Republic of Korea
| | - Jong-Keun Seon
- Department of Orthopedic Surgery, Chonnam National University Medical School and Hospital, 322 Seoyang-ro, Hwasun-eup, Hwasun-gun, Jeollanam-do, Republic of Korea.
| |
Collapse
|
29
|
Ko S, Jo C, Chang CB, Lee YS, Moon YW, Youm JW, Han HS, Lee MC, Lee H, Ro DH. A web-based machine-learning algorithm predicting postoperative acute kidney injury after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2022; 30:545-554. [PMID: 32880677 DOI: 10.1007/s00167-020-06258-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 08/24/2020] [Indexed: 12/15/2022]
Abstract
PURPOSE Acute kidney injury (AKI) is a deleterious complication after total knee arthroplasty (TKA). The purposes of this study were to identify preoperative risk factors and develop a web-based prediction model for postoperative AKI, and assess how AKI affected the progression to ESRD. METHOD The study included 5757 patients treated in three tertiary teaching hospitals. The model was developed using data on 5302 patients from two hospitals and externally validated in 455 patients from the third hospital. Eighteen preoperative variables were collected and feature selection was performed. A gradient boosting machine (GBM) was used to predict AKI. A tenfold-stratified area under the curve (AUC) served as the metric for internal validation. Calibration was performed via isotonic regression and evaluated using a calibration plot. End-stage renal disease (ESRD) was followed up for an average of 41.7 months. RESULTS AKI develops in up to 10% of patients undergoing TKA, increasing the risk of progression to ESRD. The ESRD odds ratio of AKI patients (compared to non-AKI patients) was 9.8 (95% confidence interval 4.3-22.4). Six key predictors of postoperative AKI were selected: higher preoperative levels of creatinine in serum, the use of general anesthesia, male sex, a higher ASA class (> 3), use of a renin-angiotensin-aldosterone system inhibitor, and no use of tranexamic acid (all p < 0.001). The predictive performance of our model was good (area under the curve 0.78 [95% CI 0.74-0.81] in the developmental cohort and improved in the external validation cohort (0.89). Our model can be accessed at https://safetka.net . CONCLUSIONS A web-based predictive model for AKI after TKA was developed using a machine-learning algorithm featuring six preoperative variables. The model is simple and has been validated to improve both short- and long-term prognoses of TKA patients. Postoperative AKI may lead to ESRD, which surgeons should strive to avoid. LEVEL OF EVIDENCE Diagnostic level II.
Collapse
Affiliation(s)
- Sunho Ko
- Seoul National University College of Medicine, Seoul, South Korea
| | - Changwung Jo
- Seoul National University College of Medicine, Seoul, South Korea
| | - Chong Bum Chang
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Yong Seuk Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul, South Korea
| | - Young-Wan Moon
- Department of Orthopedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Jae Woo Youm
- Department of Orthopedic Surgery, Samsung Medical Center, Seoul, South Korea
| | - Hyuk-Soo Han
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Myung Chul Lee
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Du Hyun Ro
- Department of Orthopedic Surgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Korea.
| |
Collapse
|
30
|
Hu L, Gao L, Zhang D, Hou Y, He LL, Zhang H, Liang Y, Xu J, Chen C. The incidence, risk factors and outcomes of acute kidney injury in critically ill patients undergoing emergency surgery: a prospective observational study. BMC Nephrol 2022; 23:42. [PMID: 35065624 PMCID: PMC8782702 DOI: 10.1186/s12882-022-02675-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 01/18/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Without sufficient evidence in postoperative acute kidney injury (AKI) in critically ill patients undergoing emergency surgery, it is meaningful to explore the incidence, risk factors, and prognosis of postoperative AKI. METHODS A prospective observational study was conducted in the general intensive care units (ICUs) from January 2014 to March 2018. Variables about preoperation, intraoperation and postoperation were collected. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. RESULTS Among 383 critically ill patients undergoing emergency surgery, 151 (39.4%) patients developed postoperative AKI. Postoperative reoperation, postoperative Acute Physiology and Chronic Health Evaluation (APACHE II) score, and postoperative serum lactic acid (LAC) were independent risk factors for postoperative AKI, with the adjusted odds ratio (ORadj) of 1.854 (95% confidence interval [CI], 1.091-3.152), 1.059 (95%CI, 1.018-1.102), and 1.239 (95%CI, 1.047-1.467), respectively. Compared with the non-AKI group, duration of mechanical ventilation, renal replacement therapy, ICU and hospital mortality, ICU and hospital length of stay, total ICU and hospital costs were higher in the AKI group. CONCLUSIONS Postoperative reoperation, postoperative APACHE II score, and postoperative LAC were independent risk factors of postoperative AKI in critically ill patients undergoing emergency surgery.
Collapse
Affiliation(s)
- Linhui Hu
- Department of Critical Care Medicine, Maoming People’s Hospital, 101 Weimin Road, Maoming, 525000 Guangdong China
- Department of Clinical Research Center, Maoming People’s Hospital, 101 Weimin Road, Maoming, 525000 Guangdong China
| | - Lu Gao
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, 510630 Guangdong China
| | - Danqing Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041 Guangdong China
| | - Yating Hou
- Department of Oncology, Maoming People’s Hospital, 101 Weimin Road, Maoming, 525000 Guangdong China
| | - Lin Ling He
- Department of Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080 Guangdong China
| | - Huidan Zhang
- Department of Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080 Guangdong China
| | - Yufan Liang
- Department of Critical Care Medicine, Maoming People’s Hospital, 101 Weimin Road, Maoming, 525000 Guangdong China
| | - Jing Xu
- Department of Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080 Guangdong China
| | - Chunbo Chen
- Department of Critical Care Medicine, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou, 510080 Guangdong China
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, 96 Dongchuan Road, Guangzhou, 510080 Guangdong China
- The Second School of Clinical Medicine, Southern Medical University, 253 Gongye Dadao Middle, Guangzhou, 510280 China
| |
Collapse
|
31
|
Wang L, Zhao YT. Development and Validation of a Prediction Model for Acute Kidney Injury Among Patients With Acute Decompensated Heart Failure. Front Cardiovasc Med 2021; 8:719307. [PMID: 34869626 PMCID: PMC8634389 DOI: 10.3389/fcvm.2021.719307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Acute kidney injury is an adverse event that carries significant morbidity among patients with acute decompensated heart failure (ADHF). We planned to develop a parsimonious model that is simple enough to use in clinical practice to predict the risk of acute kidney injury (AKI) occurrence. Methods: Six hundred and fifty patients with ADHF were enrolled in this study. Data for each patient were collected from medical records. We took three different approaches of variable selection to derive four multivariable logistic regression model. We selected six candidate predictors that led to a relatively stable outcome in different models to derive the final prediction model. The prediction model was verified through the use of the C-Statistics and calibration curve. Results: Acute kidney injury occurred in 42.8% of the patients. Advanced age, diabetes, previous renal dysfunction, high baseline creatinine, high B-type natriuretic peptide, and hypoalbuminemia were the strongest predictors for AKI. The prediction model showed moderate discrimination C-Statistics: 0.766 (95% CI, 0.729-0.803) and good identical calibration. Conclusion: In this study, we developed a prediction model and nomogram to estimate the risk of AKI among patients with ADHF. It may help clinical physicians detect AKI and manage it promptly.
Collapse
Affiliation(s)
- Lei Wang
- Department of Cardiology, Aerospace Center Hospital, Beijing, China
| | - Yun-Tao Zhao
- Department of Cardiology, Aerospace Center Hospital, Beijing, China
| |
Collapse
|
32
|
Hultström M, Peng D, Becirovic Agic M, Cupples CG, Cupples WA, Mitrou N. Surgical trauma is associated with renal immune cell activation in rats: A microarray study. Physiol Rep 2021; 9:e15142. [PMID: 34889077 PMCID: PMC8661512 DOI: 10.14814/phy2.15142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 11/22/2021] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is a common perioperative complication that is associated with increased mortality. This study investigates the renal gene expression in male Long-Evans rats after prolonged anesthesia and surgery to detect molecular mechanisms that could predispose the kidneys to injury upon further insults. Healthy and streptozotocin diabetic rats that underwent autoregulatory investigation in an earlier study were compared to rats that were sacrificed quickly for mRNA quantification in the same study. Prolonged surgery caused massive changes in renal mRNA expression by microarray analysis, which was validated by quantitative real-time PCR with good correlation. Furthermore, bioinformatics analysis using gene ontology and pathway analysis identified biological processes involved in immune system activation, such as immune system processes (p = 1.3 × 10-80 ), immune response (p = 1.3 × 10-60 ), and regulation of cytokine production (p = 1.7 × 10-52 ). PCR analysis of specific cell type markers indicated that the gene activation in kidneys was most probably macrophages, while granulocytes and T cell appeared less activated. Immunohistochemistry was used to quantify immune cell infiltration and showed no difference between groups indicating that the genetic activation depends on the activation of resident cells, or infiltration of a relatively small number of highly activated cells. In follow-up experiments, surgery was performed on healthy rats under standard and sterile condition showing similar expression of immune cell markers, which suggests that the inflammation was indeed caused by the surgical trauma rather than by bacterial infection. In conclusion, surgical trauma is associated with rapid activation of immune cells, most likely macrophages in rat kidneys.
Collapse
Affiliation(s)
- Michael Hultström
- Department of Medical Cell BiologyIntegrative PhysiologyUppsala UniversityUppsalaSweden
- Department of Surgical SciencesAnesthesia and Intensive Care MedicineUppsala UniversityUppsalaSweden
| | - Di Peng
- Department of Medical Cell BiologyIntegrative PhysiologyUppsala UniversityUppsalaSweden
| | - Mediha Becirovic Agic
- Department of Medical Cell BiologyIntegrative PhysiologyUppsala UniversityUppsalaSweden
| | - Claire G. Cupples
- Department of Molecular Biology and BiochemistrySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - William A. Cupples
- Department of Biomedical Physiology and KinesiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
| | - Nicholas Mitrou
- Department of Biomedical Physiology and KinesiologySimon Fraser UniversityBurnabyBritish ColumbiaCanada
- Department of SurgeryUniversity of Western OntarioLondonOntarioCanada
| |
Collapse
|
33
|
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
Collapse
Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| |
Collapse
|
34
|
STARSurg Collaborative . Impact of postoperative acute kidney injury in patients undergoing major gastrointestinal surgery on 1-year survival and renal outcomes: a national multicentre cohort study. BJS Open 2021; 5:zrab134. [PMID: 35029656 DOI: 10.1093/bjsopen/zrab134] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 11/23/2021] [Indexed: 01/21/2023] Open
Abstract
Background The intermediate-term impact of acute kidney injury (AKI) in patients after major gastrointestinal and liver surgery has not been well characterized. This study aimed to evaluate the 1-year mortality rate and renal outcomes associated with postoperative AKI in a national prospective cohort. Methods This prospective multicentre, observational cohort with 1-year postoperative follow-up included adults undergoing major gastrointestinal and liver surgery across the UK and Ireland between 23 September and 18 November 2015. AKI was defined according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The primary outcome was death at 1-year after surgery, and the secondary outcome was Major Adverse Kidney Events (MAKE-365). Cox proportionate and multilevel logistic regression were used to account for case mix. Results Of 5745 patients across 173 centres, 1-year follow-up data was completed for 3504 patients (62.2 per cent, 126 centres), with attrition largely explained by centre non-participation (63.1 per cent). Some 13.6 per cent (475 of 3504) patients developed AKI by 7 days after surgery (stage 1: 9.2 per cent; stage 2/3: 4.3 per cent). At 1 year, 10.8 per cent (378 patients) experienced a MAKE-365 endpoint (303 patients had died, 61 had renal replacement therapy and 78 had renal dysfunction). Patients who experienced AKI by 7 days after surgery had a higher hazard of death at 1 year for KDIGO stage 1 (hazard ratio 1.50 (95 per cent c.i. 1.08 to 2.08), P = 0.016) and KDIGO stage 2/3 (hazard ratio 2.96 (95 per cent c.i. 2.02 to 4.33), P < 0.001). Both KDIGO stage 1 (odds ratio 2.09 (95 per cent c.i. 1.50 to 2.92), P < 0.001) and stage 2/3 (odds ratio 9.26 (95 per cent c.i. 6.31 to 13.59), P < 0.001) AKI were independently associated with MAKE-365. Conclusion AKI events within 7 days after gastrointestinal or liver surgery are associated with significantly worse survival and renal outcomes at 1 year.
Collapse
|
35
|
Nishimoto M, Murashima M, Kokubu M, Matsui M, Eriguchi M, Samejima KI, Akai Y, Tsuruya K. External Validation of a Prediction Model for Acute Kidney Injury Following Noncardiac Surgery. JAMA Netw Open 2021; 4:e2127362. [PMID: 34661665 PMCID: PMC8524308 DOI: 10.1001/jamanetworkopen.2021.27362] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE The Simple Postoperative AKI Risk (SPARK) index is a prediction model for postoperative acute kidney injury (PO-AKI) in patients undergoing noncardiac surgery. External validation has not been performed. OBJECTIVE To externally validate the SPARK index. DESIGN, SETTING, AND PARTICIPANTS This single-center retrospective cohort study included adults who underwent noncardiac surgery under general anesthesia from 2007 to 2011. Those with obstetric or urological surgery, estimated glomerular filtration rate (eGFR) of less than 15 mL/min/1.73 m2, preoperative dialysis, or an expected surgical duration of less than 1 hour were excluded. The study was conducted at Nara Medical University Hospital. Data analysis was conducted from January to July 2021. EXPOSURES Risk factors for AKI included in SPARK index. MAIN OUTCOMES AND MEASURES PO-AKI, defined as an increase in serum creatinine of at least 0.3 mg/dL within 48 hours or 150% compared with preoperative baseline value or urine output of less than 0.5 mL/kg/h for at least 6 hours within 1 week after surgery, and critical AKI, defined as either AKI stage 2 or greater and/or any AKI connected to postoperative death or requiring kidney replacement therapy before discharge. The discrimination and calibration of the SPARK index were examined with area under the receiver operating characteristic curves (AUC) and calibration plots, respectively. RESULTS Among 5135 participants (2410 [46.9%] men), 303 (5.9%) developed PO-AKI, and 137 (2.7%) developed critical AKI. Compared with the SPARK cohort, participants in our cohort were older (median [IQR] age, 56 [44-66] years vs 63 [50-73] years), had lower baseline eGFR (median [IQR], 82.1 [71.4-95.1] mL/min/1.73 m2 vs 78.2 [65.6-92.2] mL/min/1.73 m2), and had a higher prevalence of comorbidities (eg, diabetes: 3956 of 51 041 [7.8%] vs 802 [15.6%]). The incidence of PO-AKI and critical AKI increased as the scores on the SPARK index increased. For example, 10 of 593 participants (1.7%) in SPARK class A, indicating lowest risk, experienced PO-AKI, while 53 of 332 (16.0%) in SPARK class D, indicating highest risk, experienced PO-AKI. However, AUCs for PO-AKI and critical AKI were 0.67 (95% CI, 0.63-0.70) and 0.62 (95% CI, 0.57-0.67), respectively, and the calibration was poor (PO-AKI: y = 0.24x + 3.28; R2 = 0.86; critical AKI: y = 0.20x + 2.08; R2 = 0.51). Older age, diabetes, expected surgical duration, emergency surgery, renin-angiotensin-aldosterone system blockade use, and hyponatremia were not associated with PO-AKI in our cohort, resulting in overestimation of the predicted probability of AKI in our cohort. CONCLUSIONS AND RELEVANCE In this study, the incidence of PO-AKI increased as the scores on the SPARK index increased. However, the predicted probability might not be accurate in cohorts with older patients with more comorbidities.
Collapse
Affiliation(s)
| | - Miho Murashima
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
- Department of Nephrology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Maiko Kokubu
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Nara, Japan
| | - Masaru Matsui
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Nara, Japan
| | - Masahiro Eriguchi
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
| | - Ken-ichi Samejima
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
| | - Yasuhiro Akai
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, Kashihara, Nara, Japan
| |
Collapse
|
36
|
Nikkinen O, Jämsä E, Aaltonen T, Alahuhta S, Ohtonen P, Vakkala M. Perioperative acute kidney injury and urine output in lower limb arthroplasties. Acta Anaesthesiol Scand 2021; 65:1054-1064. [PMID: 33866539 DOI: 10.1111/aas.13834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 03/31/2021] [Accepted: 04/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND This study aimed to evaluate the occurrence and perioperative risk factors of acute kidney injury (AKI) in primary elective hip and knee and emergency hip arthroplasty patients. We also aimed to assess the effect of urine output (UOP) as a diagnostic criterion in addition to serum creatinine (sCr) levels. We hypothesized that emergency arthroplasties are prone to AKI and that UOP is an underrated marker of AKI. METHODS This retrospective, register-based study assessed 731 patients who underwent primary elective knee or hip arthroplasty and 170 patients who underwent emergency hip arthroplasty at Oulu University Hospital, Finland, between January 2016 and February 2017. RESULTS Of the elective patients, 18 (2.5%) developed AKI. The 1-year mortality rate was 1.5% in elective patients without AKI and 11.1% in those with AKI (P = .038). Of the emergency patients, 24 (14.1%) developed AKI. The mortality rate was 16.4% and 37.5% in emergency patients without and with AKI, respectively (P = .024). In an AKI subgroup analysis of the combined elective and emergency patients, the mortality rate was 31.3% (n = 5) in the sCr group (n = 16), 23.5% (n = 4) in the UOP group (n = 17), and 22.2% (n = 2) in AKI patients who met both the sCr and UOP criteria (n = 9). CONCLUSION Emergency hip arthroplasty is associated with an increased risk of AKI. Since AKI increases mortality in both elective and emergency arthroplasty, perioperative oliguria should also be considered as a diagnostic criterion for AKI. Focusing solely on sCr may overlook many cases of AKI.
Collapse
Affiliation(s)
- Okke Nikkinen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine University of OuluOulu University Hospital Oulu Finland
| | - Elias Jämsä
- Faculty of Medicine University of Oulu Oulu Finland
| | | | | | - Pasi Ohtonen
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine University of OuluOulu University Hospital Oulu Finland
- Division of Operative Care Oulu University Hospital Oulu Finland
- Department of Anaesthesiology Oulu University Hospital Oulu Finland
| | - Merja Vakkala
- Medical Research Center Oulu, Research Group of Surgery, Anesthesiology and Intensive Care Medicine University of OuluOulu University Hospital Oulu Finland
- Department of Anaesthesiology Oulu University Hospital Oulu Finland
| |
Collapse
|
37
|
Abstract
The Obesity Paradox describes the counterintuitive finding that although obesity contributes to the development of chronic conditions such as chronic kidney disease and cardiovascular disease, obesity seems to improve mortality in patients with these diseases. This paradox has also been sited in the critical care literature in regard to acute kidney injury, obesity and mortality. This study's objective is to examine the impact of obesity and post-surgical acute kidney injury on hospital length of stay and 2-year mortality after orthopedic surgery.We reviewed the electronic medical records of all adult elective orthopedic surgery patients over 2 years in a large academic hospital. The 1783 patients who met inclusion criteria were divided into obese (body mass index, BMI ≥ 30, n = 1123) and non-obese groups (BMI <30, n = 660). Demographics, medications, comorbidities, and perioperative variables were included in multivariable logistic regression analyses with acute kidney injury, length of hospital stay, and two-year mortality as primary outcomes. Outcomes were analyzed for the entire group, the obese cohort and the non-obese cohort.Acute kidney injury developed in 5% of the post-surgical orthopedic patients. Obesity increased the likelihood of developing acute kidney injury post orthopedic surgery (odds ratio [OR] = 1.82; 95% Confidence interval [CI] 1.05-3.15, P = .034). Acute kidney injury increased length of stay by 1.3 days and increased the odds of two-year mortality (OR = 2.08; 95% CI 1.03-4.22, P = .041). However, obese patients had a decreased likelihood of two-year mortality (OR = 0.53; 95% CI 0.33-0.84, P = .009).In adult orthopedic surgery patients, obesity increased the risk of acute kidney injury. Patients who developed an acute kidney injury had longer hospital stays and higher two-year mortality. Paradoxically, obesity decreased two-year mortality.
Collapse
Affiliation(s)
| | - William P. Hennrikus
- Department of General Surgery, Walter Reed National Military Medical Center, Bethesda, MD
| | - Erik Lehman
- Department of Public Health Sciences, Pennsylvania State University College of Medicine, Hershey, PA
| | - Michael Skolka
- Department of Neurology, Mayo Clinic Hospital, Rochester, MN
| | - Eileen Hennrikus
- Department of Internal Medicine, Pennsylvania State University College of Medicine, Hershey, PA
| |
Collapse
|
38
|
Abstract
Postoperative acute kidney injury occurs in 7% to 11% of orthopedic surgeries. The effect of preoperative angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) on the development of postoperative acute kidney injury remains controversial. Adipose tissue has its own independently regulated angiotensin system. The primary aim of this study was to examine the effects of obesity and preoperative ACEIs and ARBs on postoperative acute kidney injury. Charts were reviewed of adult elective orthopedic surgery patients during a 2-year period when patients were instructed to take their ACEI or ARB on the morning of surgery. The patients were divided into an obese cohort (body mass index [BMI] ≥30 kg/m2) and a nonobese cohort (BMI <30 kg/m2). A multivariable model was created for the outcome of acute kidney injury, using obesity as a primary predictor and adjusting for demographics, medications, comorbidities, and intraoperative parameters in a logistic regression analysis. Obesity increased the likelihood of developing acute kidney injury after orthopedic surgery (odds ratio [OR], 1.86; 95% CI, 1.07-3.22; P=.028). For every 5-unit increase in BMI, the odds of acute kidney injury were 1.43 (95% CI, 1.26-1.62; P<.001). When receiving ACEIs or ARBs, only the nonobese patients had a statistically increased likelihood of postoperative acute kidney injury (OR, 3.30; 95% CI, 1.12-9.70; P=.030). Obesity is an independent risk factor for postoperative acute kidney injury. Obesity appears to influence the effect that preoperative ACEIs and ARBs have on postoperative acute kidney injury. [Orthopedics. 2021;44(2):e253-e258.].
Collapse
|
39
|
Farrow L, Smillie S, Duncumb J, Chan B, Cranfield K, Ashcroft G, Stevenson I. Acute kidney injury in patients undergoing elective primary lower limb arthroplasty. Eur J Orthop Surg Traumatol 2021; 32:661-665. [PMID: 34081198 PMCID: PMC9001222 DOI: 10.1007/s00590-021-03024-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022]
Abstract
Purpose Recent research has outlined the increasing incidence of acute kidney injury (AKI) and its effect on morbidity/mortality. There is evidence that current rates are significantly under-reported nationally, with uncertainty about pre-operative factors that might influence AKI reduction and the impact on other healthcare outcomes such as mortality and later Chronic Kidney Disease (CKD) development. We set out to help address these current deficiencies in the literature. Methods A retrospective cohort study was undertaken using data collected from patients undergoing elective primary lower limb arthroplasty within our institution from 01/10/16–31/09/17 with a 2-year follow-up. Results 53/782 (6.8%) patients had an AKI during the study time period. This was associated with a longer inpatient stay (p < 0.001). There was no significant difference in 30-day mortality (p = 0.134), 30-day readmission (p = 1.00) or later CKD development (p = 0.63). Independent predictors of AKI were as follows: Diabetes (OR 2.49; 95%CI 1.15–5.38; p = 0.021), CKD (OR 4.59; 95%CI 2.37–8.92; p < 0.001) and Male sex (OR 2.61; 95%CI 1.42–4.78; p = 0.002). Conclusions AKI in those undergoing hip and knee arthroplasty remains under-reported at a national level. AKI development was associated with an increased length of stay, but not long-term healthcare outcomes. This may be due to the mechanism of AKI development or the low absolute numbers of AKI suffered. We have identified three pre-operative factors (Diabetes, CKD & Male Sex) that were independently predictive of AKI. Targeted interventions may reduce the risk of AKI after lower limb arthroplasty.
Collapse
Affiliation(s)
- Luke Farrow
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK. .,Woodend Hospital, Aberdeen, UK.
| | - Stacey Smillie
- Woodend Hospital, Aberdeen, UK.,University Hospital of Ayr, Ayr, UK
| | - Joseph Duncumb
- Woodend Hospital, Aberdeen, UK.,Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | | | - George Ashcroft
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK.,Woodend Hospital, Aberdeen, UK
| | | |
Collapse
|
40
|
Zhao BC, Zhuang PP, Lei SH, Qiu SD, Yang X, Li C, Liu WF, Liu KX. Pre-operative N-terminal pro-B-type natriuretic peptide for prediction of acute kidney injury after noncardiac surgery: A retrospective cohort study. Eur J Anaesthesiol 2021; 38:591-9. [PMID: 33720062 DOI: 10.1097/EJA.0000000000001495] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with poor outcomes after noncardiac surgery. Whether pre-operative N-terminal pro-B-type natriuretic peptide (NT-proBNP) predicts AKI after noncardiac surgery is unclear. OBJECTIVE To investigate the predictive role of pre-operative NT-proBNP on postoperative AKI. DESIGN Retrospective cohort study. SETTING Nanfang Hospital, Southern Medical University, China. PATIENTS Adult patients who had a serum creatinine and NT-proBNP measurement within 30 pre-operative days and at least one serum creatinine measurement within 7 days after noncardiac surgery between February 2008 and May 2018 were identified. MAIN OUTCOME MEASURES The primary outcome was postoperative AKI, defined by the kidney disease: improving global outcomes creatinine criteria. RESULTS In all, 6.1% (444 of 7248) of patients developed AKI within 1 week after surgery. Pre-operative NT-proBNP was an independent predictor of AKI after adjustment for clinical variables (OR comparing top to bottom quintiles 2.29, 95% CI, 1.47 to 3.65, P < 0.001 for trend; OR per 1-unit increment in natural log transformed NT-proBNP 1.27, 95% CI, 1.16 to 1.39). Compared with clinical variables alone, the addition of NT-proBNP improved model fit, modestly improved the discrimination (change in area under the curve from 0.764 to 0.773, P = 0.005) and reclassification (continuous net reclassification improvement 0.210, 95% CI, 0.111 to 0.308, improved integrated discrimination 0.0044, 95% CI, 0.0016 to 0.0072) of AKI and non-AKI cases, and achieved higher net benefit in decision curve analysis. CONCLUSIONS Pre-operative NT-proBNP concentrations provided predictive information for AKI in a cohort of patients undergoing noncardiac surgery, independent of and incremental to conventional risk factors. Prospective studies are required to confirm this finding and examine its clinical impact. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1900024056. www.chictr.org.cn/showproj.aspx?proj=40385.
Collapse
|
41
|
Shim JW, Ro H, Lee CS, Park J, Lee HM, Kim YS, Moon YE, Hong SH, Chae MS. Male Patients may be More Vulnerable to Acute Kidney Injury After Colorectal Surgery in an Enhanced Recovery Program: A Propensity Score Matching Analysis. World J Surg 2021; 45:1642-1651. [PMID: 33721072 DOI: 10.1007/s00268-021-06041-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Although many reports have shown that enhanced recovery after surgery (ERAS) programs improve the perioperative outcomes of patients undergoing colorectal surgery, the prevalence of early acute kidney injury (AKI) after surgery in such patients requires attention. Protective roles of the female sex in terms of chronic kidney disease and progression of ischemic renal injury have been described in many studies. We thus explored whether a sex difference was evident in terms of postoperative AKI in a colorectal ERAS setting. METHODS From January 2017 to August 2019, 453 patients underwent laparoscopic colorectal cancer resection in an enhanced recovery program. Of these, 217 female patients were propensity score (PS)-matched with 236 male patients. Then, 215 patients of either sex were compared in terms of postoperative renal function and complications. RESULTS Among the PS-matched patients, the incidence of AKI was significantly higher in male than female patients (24.2% vs. 9.8%, P < 0.001). Male patients also exhibited a greater reduction in the postoperative estimated glomerular filtration rate, compared with female patients. The male sex was associated with an approximately threefold increase in the risk of AKI. The rate of surgical complications was significantly higher in male than female patients. CONCLUSIONS Caution must be taken to prevent postoperative AKI in patients (particularly males) participating in colorectal ERAS programs. The mechanism underlying the sex difference remains unclear. Additional studies are required to determine whether male patients require perioperative management that differs from that of females, to prevent postoperative AKI.
Collapse
Affiliation(s)
- Jung-Woo Shim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hojun Ro
- Department of Anesthesiology and Pain Medicine, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chul Seung Lee
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaesik Park
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyung Mook Lee
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong-Suk Kim
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Eun Moon
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Hong
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Suk Chae
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.
| |
Collapse
|
42
|
Trongtrakul K, Patumanond J, Phairatwet P, Sawawiboon C, Chitsomkasem A, Kurathong S, Prommoon S, Trakarnvanich T, Phinyo P. External Validation of the Acute Kidney Injury Risk Prediction Score for Critically Ill Surgical Patients Who Underwent Major Non-Cardiothoracic Surgery. Healthcare (Basel) 2021; 9:209. [PMID: 33671984 DOI: 10.3390/healthcare9020209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/23/2022] Open
Abstract
Background: Acute kidney injury (AKI) is a common complication encountered in an intensive care unit (ICU). In 2020, the AKI prediction score was developed specifically for critically ill surgical patients who underwent major non-cardiothoracic surgeries. This study aimed to externally validate the AKI prediction score in terms of performance and clinical utility. Methods: External validation was carried out in a prospective cohort of patients admitted to the ICU of the Faculty of Medicine Vajira Hospital between September 2014 and September 2015. The endpoint was AKI within seven days following ICU admission. Discriminative ability was based on the area under the receiver operating characteristic curves (AuROC). Calibration and clinical usefulness were evaluated. Results: A total of 201 patients were included in the analysis. AKI occurred in 37 (18.4%) patients. The discriminative ability dropped from good in the derivation cohort, to acceptable in the validation cohort (0.839 (95%CI 0.825–0.852) vs. 0.745 (95%CI 0.652–0.838)). No evidence of lack-of-fit was identified (p = 0.754). The score had potential clinical usefulness across the range of threshold probability from 10 to 50%. Conclusions: The AKI prediction score showed an acceptable discriminative performance and calibration with potential clinical usefulness for predicting AKI risk in surgical patients who underwent major non-cardiothoracic surgery.
Collapse
|
43
|
Xue FS, Shao LJ, Liu SH. Intra-operative goal-directed therapy and postoperative acute kidney injury in high-risk patients undergoing major gastrointestinal surgery. Eur J Anaesthesiol 2021; 38:97-8. [PMID: 33273390 DOI: 10.1097/EJA.0000000000001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
44
|
Mo M, Pan L, Huang Z, Liang Y, Liao Y, Xia N. Development and Validation of a Prediction Model for Survival in Diabetic Patients With Acute Kidney Injury. Front Endocrinol (Lausanne) 2021; 12:737996. [PMID: 35002952 PMCID: PMC8727769 DOI: 10.3389/fendo.2021.737996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 12/01/2021] [Indexed: 01/08/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Manqiu Mo
- Geriatric Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ling Pan
- Department of Nephrology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zichun Huang
- Department of Cardiovascular Thoracic Surgery, The Third Affiliated Hospital of Guangxi Medical University: Nanning Second People’s Hospital, Nanning, China
| | - Yuzhen Liang
- Department of Endocrinology, The Second Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunhua Liao
- Department of Nephrology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ning Xia
- Geriatric Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
- *Correspondence: Ning Xia,
| |
Collapse
|
45
|
Affiliation(s)
- Yumeng Wen
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | |
Collapse
|
46
|
Wahba O, Mohamed KH, El Khayat RAA, El Assal AM. Acute kidney injury after prolonged neurosurgical operations. Egyptian Journal of Anaesthesia 2021. [DOI: 10.1080/11101849.2021.1975438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Affiliation(s)
- Ola Wahba
- Assiut University Faculty of Medicine, Egypt
| | | | | | | |
Collapse
|
47
|
Prowle JR, Forni LG, Bell M, Chew MS, Edwards M, Grams ME, Grocott MPW, Liu KD, McIlroy D, Murray PT, Ostermann M, Zarbock A, Bagshaw SM, Bartz R, Bell S, Bihorac A, Gan TJ, Hobson CE, Joannidis M, Koyner JL, Levett DZH, Mehta RL, Miller TE, Mythen MG, Nadim MK, Pearse RM, Rimmele T, Ronco C, Shaw AD, Kellum JA. Postoperative acute kidney injury in adult non-cardiac surgery: joint consensus report of the Acute Disease Quality Initiative and PeriOperative Quality Initiative. Nat Rev Nephrol 2021; 17:605-18. [PMID: 33976395 DOI: 10.1038/s41581-021-00418-2] [Citation(s) in RCA: 73] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/17/2021] [Indexed: 02/03/2023]
Abstract
Postoperative acute kidney injury (PO-AKI) is a common complication of major surgery that is strongly associated with short-term surgical complications and long-term adverse outcomes, including increased risk of chronic kidney disease, cardiovascular events and death. Risk factors for PO-AKI include older age and comorbid diseases such as chronic kidney disease and diabetes mellitus. PO-AKI is best defined as AKI occurring within 7 days of an operative intervention using the Kidney Disease Improving Global Outcomes (KDIGO) definition of AKI; however, additional prognostic information may be gained from detailed clinical assessment and other diagnostic investigations in the form of a focused kidney health assessment (KHA). Prevention of PO-AKI is largely based on identification of high baseline risk, monitoring and reduction of nephrotoxic insults, whereas treatment involves the application of a bundle of interventions to avoid secondary kidney injury and mitigate the severity of AKI. As PO-AKI is strongly associated with long-term adverse outcomes, some form of follow-up KHA is essential; however, the form and location of this will be dictated by the nature and severity of the AKI. In this Consensus Statement, we provide graded recommendations for AKI after non-cardiac surgery and highlight priorities for future research.
Collapse
|
48
|
Hapca S, Siddiqui MK, Kwan RS, Lim M, Matthew S, Doney AS, Pearson ER, Palmer CN, Bell S. The Relationship between AKI and CKD in Patients with Type 2 Diabetes: An Observational Cohort Study. J Am Soc Nephrol 2021; 32:138-150. [PMID: 32948670 PMCID: PMC7894655 DOI: 10.1681/asn.2020030323] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND There are few observational studies evaluating the risk of AKI in people with type 2 diabetes, and even fewer simultaneously investigating AKI and CKD in this population. This limits understanding of the interplay between AKI and CKD in people with type 2 diabetes compared with the nondiabetic population. METHODS In this retrospective, cohort study of participants with or without type 2 diabetes, we used electronic healthcare records to evaluate rates of AKI and various statistical methods to determine their relationship to CKD status and further renal function decline. RESULTS We followed the cohort of 16,700 participants (9417 with type 2 diabetes and 7283 controls without diabetes) for a median of 8.2 years. Those with diabetes were more likely than controls to develop AKI (48.6% versus 17.2%, respectively) and have preexisting CKD or CKD that developed during follow-up (46.3% versus 17.2%, respectively). In the absence of CKD, the AKI rate among people with diabetes was nearly five times that of controls (121.5 versus 24.6 per 1000 person-years). Among participants with CKD, AKI rate in people with diabetes was more than twice that of controls (384.8 versus 180.0 per 1000 person-years after CKD diagnostic date, and 109.3 versus 47.4 per 1000 person-years before CKD onset in those developing CKD after recruitment). Decline in eGFR slope before AKI episodes was steeper in people with diabetes versus controls. After AKI episodes, decline in eGFR slope became steeper in people without diabetes, but not among those with diabetes and preexisting CKD. CONCLUSIONS Patients with diabetes have significantly higher rates of AKI compared with patients without diabetes, and this remains true for individuals with preexisting CKD.
Collapse
Affiliation(s)
- Simona Hapca
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom,Division of Computing Science and Mathematics, University of Stirling, Stirling, United Kingdom
| | - Moneeza K. Siddiqui
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Ryan S.Y. Kwan
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Michelle Lim
- Renal Unit, Ninewells Hospital, Dundee, United Kingdom
| | - Shona Matthew
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Alex S.F. Doney
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Ewan R. Pearson
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Colin N.A. Palmer
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Samira Bell
- Division of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, United Kingdom,Renal Unit, Ninewells Hospital, Dundee, United Kingdom
| | | |
Collapse
|
49
|
Abstract
In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. Different mechanisms are involved in the development of postoperative AKI, frequently picturing a multifactorial etiology. For these reasons, no single renoprotective strategy will be effective for all surgical patients, and efforts have been attempted to prevent kidney injury in different ways. Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.
Collapse
Affiliation(s)
- Luca Molinari
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Ankit Sakhuja
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - John A Kellum
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
50
|
Kurth MJ, McBride WT, McLean G, Watt J, Domanska A, Lamont JV, Maguire D, Fitzgerald P, Ruddock MW. Acute kidney injury risk in orthopaedic trauma patients pre and post surgery using a biomarker algorithm and clinical risk score. Sci Rep 2020; 10:20005. [PMID: 33203963 PMCID: PMC7673130 DOI: 10.1038/s41598-020-76929-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 10/23/2020] [Indexed: 12/22/2022] Open
Abstract
Acute kidney injury (AKI) after major trauma is associated with increased mortality. The aim of this study was to assess if measurement of blood biomarkers in combination with clinical characteristics could be used to develop a tool to assist clinicians in identifying which orthopaedic trauma patients are at risk of AKI. This is a prospective study of 237 orthopaedic trauma patients who were consecutively scheduled for open reduction and internal fixation of their fracture between May 2012 and August 2013. Clinical characteristics were recorded, and 28 biomarkers were analysed in patient blood samples. Post operatively a combination of H-FABP, sTNFR1 and MK had the highest predictive ability to identify patients at risk of developing AKI (AUROC 0.885). Three clinical characteristics; age, dementia and hypertension were identified in the orthopaedic trauma patients as potential risks for the development of AKI. Combining biomarker data with clinical characteristics allowed us to develop a proactive AKI clinical tool, which grouped patients into four risk categories that were associated with a clinical management regime that impacted patient care, management, length of hospital stay, and efficient use of hospital resources.
Collapse
Affiliation(s)
- Mary Jo Kurth
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - William T McBride
- Department of Cardiac Anaesthesia, Royal Victoria Hospital, Belfast Health and Social Care Trust, 274 Grosvenor Road, Belfast, BT12 6BA, Northern Ireland, UK
| | - Gavin McLean
- Trauma and Orthopaedics, Craigavon Area Hospital, 68 Lurgan Road, Portadown, Craigavon, BT63 5QQ, Northern Ireland, UK
| | - Joanne Watt
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Anna Domanska
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - John V Lamont
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Daniel Maguire
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Peter Fitzgerald
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK
| | - Mark W Ruddock
- Randox Laboratories Ltd, 55 Diamond Road, Crumlin, County Antrim, BT29 4QY, Northern Ireland, UK.
| |
Collapse
|