Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

Background

Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort.

Methods and results

We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table).

Conclusion

Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

P2767Outcomes and incremental prognostic value of renal function impairment after acute pulmonary embolism

Background

We explored the relation between adverse outcomes after acute pulmonary embolism (PE)and renal dysfunction classified by estimated glomerular filtration rate (eGFR) using the CKD-EPI equation. We assessed the incremental value of adding eGFR CKD-EPI to the ESC score for predicting 30d mortality.

Methods

Prospective, multicenter study of 1664 acute PE admitted from 01/2011 to 12/2017. Pts were categorized in 4 eGFR groups: Group 1 (eGFR ≥60 ml/min/1.73m2, n=1178), group 2 (45–59; n=257); group 3 (30–44; n=150), group 4 (≤29; n=79).

Results

All-cause and CV death at 30 days and 6 months were higher in group 3 (p=0.005 and p=0.03) and group 4 (p<0.001 and p<0.001 respectively) vs group 1. Major bleeding at 30d and 6m was higher in group 2 vs group 1 (p=0.003 for both). Renal dysfunction combined with the ESC prognostic algorithm for prediction of 30d death improved discriminatory capacity of the model and enabled reclassification in different risk categories in 27% of pts (Table).

Without eGFR CKD-EPI OR (95% CI) With eGFR CKD-EPI OR (95% CI) ESC algorithm 2.59 (1.95–3.43) 2.30 (1.72–3.07) eGFR CKD-EPI – 2.60 (1.62–4.7) Measures of fit   Bayes information criterion 607.30 599.32   Akaike information criterion 596.47 583.06   C-statistic 0.71* 0.77*   P (Hosmer-Lemeshow) 0.057 0.43   Integrated discrimination improvement – 0.054 (0.052–0.056)   Net reclassification improvement – 0.93 (0.90–0.95) Prognostic performance   Sensitivity 62.5 (51.2–72.3) 76.2 (61.5–90.2)   Specificity 64.2 (49.1–74.4) 69.9 (47.6–83.5)   Positive predictive value 10.1 (8.2–11.3) 16.2 (14.2–18.2)   Negative predictive value 0.97 (0.96–0.98) 98.1 (97.2–99.2)   Positive likelihood ratio 1.96 (1.12–3.41) 2.12 (1.54–3.12)   Negative likelihood ratio 0.50 (0.25–1.81) 0.54 (0.20–1.56)   Youden index 0.31 (0.28–0.34) 0.39 (0.36–0.41) Difference in C-statistic: *p=0.04.

Conclusion

Renal function impairment increases the rate of adverse events after acute PE. Combined with the ESC early mortality risk score, eGFR improves risk classification.