Wuhua Jiang

Dynamic Predictive Scores for Cardiac Surgery–Associated Acute Kidney Injury

Background Cardiac surgery–associated acute kidney injury (CSA‐AKI) is a common complication with a poor prognosis. In order to identify modifiable perioperative risk factors for AKI, which existing risk scores are insufficient to predict, a dynamic clinical risk score to allow clinicians to estimate the risk of CSA‐AKI from preoperative to early postoperative periods is needed. Methods and Results A total of 7233 cardiac surgery patients in our institution from January 2010 to April 2013 were enrolled prospectively and distributed into 2 cohorts. Among the derivation cohort, logistic regression was used to analyze CSA‐AKI risk factors preoperatively, on the day of ICU admittance and 24 hours after ICU admittance. Sex, age, valve surgery combined with coronary artery bypass grafting, preoperative NYHA score >2, previous cardiac surgery, preoperative kidney (without renal replacement therapy) disease, intraoperative cardiopulmonary bypass application, intraoperative erythrocyte transfusions, and postoperative low cardiac output syndrome were identified to be associated with CSA‐AKI. Among the other 1152 patients who served as a validation cohort, the point scoring of risk factor combinations led to area under receiver operator characteristics curves (AUROC) values for CSA‐AKI prediction of 0.74 (preoperative), 0.75 (on the day of ICU admission), and 0.82 (postoperative), and Hosmer–Lemeshow goodness‐of‐fit tests revealed a good agreement of expected and observed CSA‐AKI rates. Conclusions The first dynamic predictive score system, with Kidney Disease: Improving Global Outcomes (KDIGO) AKI definition, was developed and predictive efficiency for CSA‐AKI was validated in cardiac surgery patients.

Management of Cardiac Surgery-Associated Acute Kidney Injury.

Cardiac surgery-associated acute kidney injury (CSA-AKI) is known to be a common complication of cardiac surgery that is associated with poor short- and long-term outcomes. The causes of CSA-AKI include the discovered or undiscovered risk factors within the perioperative course, mostly non-modifiable; some are even iatrogenic. Recognizing and mediating risk factors preoperatively and optimizing intraoperative practices may decrease the incidence of CSA-AKI. By now, the present studies cannot confirm which drugs are better off for preventing CSA-AKI. The effect and whether early administration of these drugs to prevent CSA-AKI is effective remain uncertain, so is the administration of renal replacement therapy. We will demonstrate some typical studies that focus on the prevention of CSA-AKI and may delight further research.

High-dose versus low-dose haemofiltration for the treatment of critically ill patients with acute kidney injury: an updated systematic review and meta-analysis.

Objective The purpose of this study was to perform a systematic review and meta-analysis to evaluate the effect of high-dose versus low-dose haemofiltration on the survival of critically ill patients with acute kidney injury (AKI). We hypothesised that high-dose treatments are not associated with a higher risk of mortality. Design Meta-analysis. Setting Randomised controlled trials and two-arm prospective and retrospective studies were included. Participants Critically ill patients with AKI. Interventions Continuous renal replacement therapy. Primary and secondary outcome measures Primary outcomes: 90-day mortality, intensive care unit (ICU) mortality, hospital mortality; secondary outcomes: length of ICU and hospital stay. Result Eight studies including 2970 patients were included in the analysis. Pooled results showed no significant difference in the 90-mortality rate between patients treated with high-dose or low-dose haemofiltration (pooled OR=0.90, 95% CI 0.73 to 1.11, p=0.32). Findings were similar for ICU (pooled OR=1.12, 95% CI 0.94 to 1.34, p=0.21) and hospital mortality (pooled OR=1.03, 95% CI 0.81 to 1.30, p=0.84). Length of ICU and hospital stay were similar between high-dose and low-dose groups. Pooled results are not overly influenced by any one study, different cut-off points of prescribed dose or different cut-off points of delivered dose. Meta-regression analysis indicated that the results were not affected by the percentage of patients with sepsis or septic shock. Conclusion High-dose and low-dose haemofiltration produce similar outcomes with respect to mortality and length of ICU and hospital stay in critically ill patients with AKI. This study was not registered at the time the data were collected and analysed. It has since been registered on 17 February 2017 at http://www.researchregistry.com/, registration number: reviewregistry211.

Acute Kidney Injury in Cardiac Surgery

Patients who have undergone cardiac surgery are at high risk of acute kidney injury (AKI) and often associated with poor short- and long-term outcomes. It is considered that the burden of AKI can be reduced and the quality of care can be improved by raising the appropriate awareness and using the right tools for early prevention and better management, by (1) improving awareness by understanding the epidemiology and pathophysiology; (2) using tools for risk assessment for early prevention; (3) increasing the use of electronic screening for early diagnosis; and (4) developing right clinical strategies for better treatment. In this review, we will update some typical studies as well as some new concepts, which focus on the quality of care of CSA-AKI.

Quality Measures in Acute Kidney Injury Management

Acute kidney injury (AKI) is common in clinical practice and associated with increased risk for death and major morbidity. Although some meaningful clinical guidelines were published, the quality of AKI healthcare remains suboptimal. Some AKI quality improvement methods, such as guidelines-based training programs, the referral from nephrology, and electronic data system have been found to be potentially beneficial, but further validation is required. Quality measures (QMs) for structure, process, and outcome of AKI care need to be further developed, evaluated, and implemented to ensure utmost quality of AKI care. However, many unknowns remain in this field. Some commonly used QMs like mortality are still difficult to realize in AKI quality control because of the heterogeneity in AKI practice. More evidence is needed to improve the AKI quality control system. These are challenges that will need to be addressed in the future.

Acute Kidney Injury Risk Assessment

Acute kidney injury (AKI) is a common global health challenge, affecting patient morbidity adversely and resulting in an estimated 1.4 million deaths per year. Since the International Society of Nephrology proposed a goal of eliminating preventable deaths from AKI by 2025, implementation of this program remains far from optimistic not only because of the lack of resources but also because of the scarce data addressing the epidemiology and causes of AKI, especially in developing countries, the relative insufficient health care resources to diagnose and treat AKI, and the delayed awareness of the impact of AKI on patient outcomes. Therefore, quality measures of the AKI management are crucial to ensure a better outcome achieved with integrated resource.

Validation of Four Prediction Scores for Cardiac Surgery-Associated Acute Kidney Injury in Chinese Patients

Objective To assess the clinical value of four models for the prediction of cardiac surgery-associated acute kidney injury (CSA-AKI) and severe AKI which renal replacement therapy was needed (RRT-AKI) in Chinese patients. Methods 1587 patients who underwent cardiac surgery in the department of cardiac surgery in the Zhongshan Hospital, Fudan University, between January 2013 and December 2013 were enrolled in this research. Evaluating the predicting value for cardiac surgery-associated AKI (AKICS score) and RRT-AKI (Cleveland score, SRI and Mehta score) by Hosmer-Lemeshow goodness-of-fit test for the calibration and area under receiver operating characteristic curve (AUROC) for the discrimination. Results Based on 2012 KDIGO (Kidney Disease: Improving Global Outcomes) AKI definition, the incidence of AKI and RRT-AKI was 37.4% (594/1587) and 1.1% (18/1587), respectively. The mortality of AKI and RRT-AKI was 6.1% (36/594) and 66.7% (12/18), respectively, while the total mortality was 2.8% (44/1587). The discrimination (AUROC=0.610) for the prediction of CSA-AKI of AKICS was low, while the calibration (x2=7.55, P=0.109) was fair. For the prediction of RRT-AKI, the discrimination of Cleveland score (AUROC=0.684), Mehta score (AUROC=0.708) and SRI (AUROC=0.622) were not good; while the calibration of them were fair (Cleveland score x2=1.918, P=0.166; Mehta score x2=9.209, P=0.238; SRI x2=2.976, P=0.271). Conclusion In our single-center study, based upon valve surgery dominant and less diabetes mellitus patients, according to KDIGO AKI definition, the predictive value of the four models, combining discrimination and calibration, for respective primary event, were not convincible.