Simplifying contrast-induced acute kidney injury prediction after primary percutaneous coronary intervention: the age, creatinine and ejection fraction score

Intraprocedural continuous saline infusion lines significantly reduce the incidence of acute kidney injury during endovascular procedures for stroke and myocardial infarction: evidence from a systematic review and meta-regression

BACKGROUND

Contrast media used in mechanical therapies for stroke and myocardial infarction represent a significant cause of acute kidney injury (AKI) in acute medical scenarios. Although the continuous saline infusion line (CSIL) is a standard procedure to prevent thrombus formation within the catheter during neurovascular interventions of mechanical thrombectomy (MT), it is not utilized in percutaneous coronary interventions (PCI).

METHODS

A systematic review of the incidence of AKI after MT for stroke treatment was performed. These data were compared with those reported in the literature regarding the incidence of AKI after PCI for acute myocardial infarction. A random-effect model meta-regression was performed to explore the effects of CSIL on AKI incidence, using clinical details as covariates.

RESULTS

A total of 18 and 33 studies on MT and PCI were included, respectively, with 69,464 patients (30,138 [43.4%] for MT and 39,326 [56.6%] for PCI). The mean age was 63.6 years±5.8 with male 66.6%±12.8. Chronic kidney disease ranged 2.0-50.3%. Diabetes prevalence spanned 11.1% to 53.0%. Smoking status had a prevalence of 7.5-72.0%. Incidence of AKI proved highly variable (I2=98%, Cochrane's Q 2985), and appeared significantly lower in the MT subgroup than in the PCI subgroups (respectively 8.3% [95% confidence interval: 4.7-11.9%] vs. 14.7 [12.6-16.8%], P<0.05). Meta-regression showed that CSIL was significantly associated with a decreased incidence of AKI (OR=0.93 [1.001-1.16]; P=0.03).

CONCLUSIONS

Implementation of CSIL during endovascular procedures in acute settings was associated with a significant decrease in the risk of AKI, and its safety should be routinely considered in such interventions.

Predictive modeling for acute kidney injury after percutaneous coronary intervention in patients with acute coronary syndrome: a machine learning approach

BACKGROUND

Acute kidney injury (AKI) is one of the preventable complications of percutaneous coronary intervention (PCI). This study aimed to develop machine learning (ML) models to predict AKI after PCI in patients with acute coronary syndrome (ACS).

METHODS

This study was conducted at Tehran Heart Center from 2015 to 2020. Several variables were used to design five ML models: Naïve Bayes (NB), Logistic Regression (LR), CatBoost (CB), Multi-layer Perception (MLP), and Random Forest (RF). Feature importance was evaluated with the RF model, CB model, and LR coefficients while SHAP beeswarm plots based on the CB model were also used for deriving the importance of variables in the population using pre-procedural variables and all variables. Sensitivity, specificity, and the area under the receiver operating characteristics curve (ROC-AUC) were used as the evaluation measures.

RESULTS

A total of 4592 patients were included, and 646 (14.1%) experienced AKI. The train data consisted of 3672 and the test data included 920 cases. The patient population had a mean age of 65.6 ± 11.2 years and 73.1% male predominance. Notably, left ventricular ejection fraction (LVEF) and fasting plasma glucose (FPG) had the highest feature importance when training the RF model on only pre-procedural features. SHAP plots for all features demonstrated LVEF and age as the top features. With pre-procedural variables only, CB had the highest AUC for the prediction of AKI (AUC 0.755, 95% CI 0.713 to 0.797), while RF had the highest sensitivity (75.9%) and MLP had the highest specificity (64.35%). However, when considering pre-procedural, procedural, and post-procedural features, RF outperformed other models (AUC: 0.775). In this analysis, CB achieved the highest sensitivity (82.95%) and NB had the highest specificity (82.93%).

CONCLUSION

Our analyses showed that ML models can predict AKI with acceptable performance. This has potential clinical utility for assessing the individualized risk of AKI in ACS patients undergoing PCI. Additionally, the identified features in the models may aid in mitigating these risk factors.

Risk factors associated with contrast-associated acute kidney injury in ST-segment elevation myocardial infarction patients: a systematic review and meta-analysis

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the risk factors for contrast-associated acute kidney injury (CA-AKI) in ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched the databases of PubMed, Embase and Ovid, up to February 2022, for observational studies that investigated the association between risk factors and CA-AKI.

RESULTS

A total of 21 studies were included in the meta-analysis. Of the total 22 015 participants, 2728 developed CA-AKI. Pooled incidence was 11.91% (95% CI 9.69%, 14.14%). Patients with CA-AKI were more likely to be older, female, also had comorbidities (hypertension, diabetes, previous heart failure). Smoking (OR: 0.60; 95% CI 0.52, 0.69) and family history of CAD (coronary artery disease) (OR: 0.76; 95% CI 0.60, 0.95) were associated with lower risk of CA-AKI. Left anterior descending (LAD) artery occlusion (OR: 1.39; 95% CI 1.21, 1.59), left main disease (OR: 4.62; 95% CI 2.24, 9.53) and multivessel coronary disease (OR: 1.33; 95% CI 1.11, 1.60) were risk factors for CA-AKI. Contrast volume (weighted mean difference: 20.40; 95% CI 11.02, 29.79) was associated with increased risk in patients receiving iso-osmolar or low-osmolar non-ionic contrast.

CONCLUSIONS

In addition to the known risk factors, LAD artery infarction, left main disease and multivessel disease are risk factors for CA-AKI. The unexpected favourable association between smoking, as well as family history of CAD, and CA-AKI requires further investigation.

PROSPERO REGISTRATION NUMBER

CRD42021289868.

CHA2DS2-VASc, a Simple Clinical Score Expanding Its Boundaries to Predict Contrast-Induced Acute Kidney Injury After Primary Percutaneous Coronary Interventions

Objective

Promising results of CHA₂DS₂-VASc score have been reported for the prediction of contrast-induced acute kidney injury (CI-AKI) after percutaneous coronary intervention (PCI). However, data of its predictive strength in the context of primary PCI are not available. Therefore, in this study, we have assessed predictive value of CHA₂DS₂-VASc score for CI-AKI after primary PCI.

Methods

This analytical cross-sectional study was conducted between January 2021 and June 2021 at the National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan. Inclusion criteria of the study was consecutive adult patients who had undergone primary PCI. Baseline CHA₂DS₂-VASc score was calculated, and either a 25% or 0.5 mg/dL increase in post-procedure serum creatinine level as compared to baseline level was categorized as CI-AKI.

Results

A total of 691 patients were included, of which 82.1% (567) were male. CI-AKI after primary PCI was observed in 63 (9.1%) patients, out of which 66.7% (42) of patients had CHA₂DS₂-VASc score of ≥2. The area under the curve (AUC) for the score was 0.725 [0.662 to 0.788] with a sensitivity and specificity of 66.7% [63.1% to 70.2%] and 66.7% [53.7% to 78.1%], respectively, at a cut-off value of ≥2. In multivariable analysis, left ventricular ejection fraction ≤30% and CHA₂DS₂-VASc ≥2 were found to be independent predictors with adjusted odds ratios of 2.19 [1.06–4.5] and 2.13 [1.13–4.01], respectively.

Conclusion

CHA₂DS₂-VASc score has a good predictive value for the prediction of CI-AKI after primary PCI. Criteria of CHA₂DS₂-VASc ≥2 can be used for the risk stratification of CI-AKI after primary PCI.

Association of decreasing hemoglobin levels with the incidence of acute kidney injury after percutaneous coronary intervention: a prospective multi-center study

Acute kidney injury (AKI) is common in patients undergoing percutaneous coronary intervention (PCI). One risk factor for AKI is periprocedural hemoglobin drop level (> 3 g/dL); however, whether the relationship between hemoglobin drop and AKI is linear or nonlinear remains unknown. We aimed to investigate the relationship between periprocedural hemoglobin drop and AKI after PCI. We evaluated 14,273 consecutive patients undergoing PCI between September 2008 and March 2019. AKI was defined as an absolute or a relative increase in serum creatinine level of 0.3 mg/dL or 50%, respectively. Restricted cubic spline was constructed to assess the association between hemoglobin drop and AKI by logistic regression and machine learning (ML) models, which were used to predict the risk of AKI. The patients' mean age was 68.4 ± 11.6 years; the AKI incidence was 10.5% (N = 1499). An absolute > 3 g/dL or 20% relative decrease in hemoglobin level was an independent predictor of AKI incidence (odds ratio, OR [95% confidence interval, CI]: 2.24 [1.92-2.61], P < 0.001; 2.35 [2.04-2.71], P < 0.001, respectively). An adjusted restricted cubic spline demonstrated that absolute/relative decrease in hemoglobin was linearly associated with AKI. Logistic and ML models with absolute/relative hemoglobin changes were comparable while estimating the risk of AKI (absolute area under the curve [AUC] (logistic):0.826, AUC (ML): 0.820; relative AUC (logistic): 0.818, AUC (ML): 0.816). An absolute/relative decrease in periprocedural hemoglobin after PCI was linearly associated with AKI. Detection of a relative/absolute decrease in hemoglobin may help clinicians identify individuals as high risk for AKI after PCI.

Advances in the pathogenesis and prevention of contrast-induced nephropathy

With the increasing application of medical imaging contrast materials, contrast-induced nephropathy has become one of the leading causes of iatrogenic renal insufficiency. The underlying mechanism is associated with renal medullary hypoxia, direct toxicity of contrast agents, oxidative stress, apoptosis, immune/inflammation and epigenetic regulation in contrast-induced nephropathy. Up to date, there is no effective therapy for contrast-induced nephropathy, and thus risk predication and effective preventive strategies are keys to reduce the occurrence of contrast-induced nephropathy. It was found that the proper use of contrast medium, personalized hydration, and high-dose statins may reduce the occurrence of contrast-induced nephropathy, while antioxidants have not shown significant therapeutic benefits. Additionally, the role of remote ischemia preconditioning and vasodilators in the prevention of contrast-induced nephropathy needs further study. This review aims to discuss the incidence, pathogenesis, risk prediction, and preventive strategies for contrast-induced nephropathy.

Validation of acute kidney injury prediction scores in critically ill patients

Prediction of acute kidney injury (AKI) in critically ill patients allows prompt intervention that improves outcome. We aimed for external validation of two AKI prediction scores that can be bedside calculated. A prospective observational study included patients admitted to medical and surgical critical care units. Performance of two AKI prediction scores, Malhotra score and acute kidney injury prediction score (APS), was assessed for their ability to predict AKI. The best cutoff point for each score was determined by Youden index. Area under the receiving operation characteristic curve, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were used to assess performance of each score. Univariate and multivariate regression analyses were done to detect the predictability of AKI. Goodness-of-fit and kappa Cohen agreement tests were done to show whether the expected score results fit well and agree with the observed results. AKI prevalence was 37.6%. The best cutoff values were 5 and 4 for Malhotra score and APS, respectively. Area under the curve for Malhotra 5 was 0.712 and for APS 4 was 0.652 with nearly similar sensitivity and specificity. Regression analysis demonstrated that Malhotra 5 was the independent predictor of AKI. Goodness-of-fit test showed significant results denoting lack of fit between the scores and the actual results. Kappa test showed moderate agreement for Malhotra 5 and fair agreement for APS 4. Both scores showed moderate performance for AKI prediction. Malhotra 5 showed better performance compared to APS 4. Multicenter international study is warranted to develop a universal model that can predict AKI in critically ill patients.

Elevated neutrophil-to-lymphocyte ratio can predict procedural adverse events in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Elevated neutrophil-to-lymphocyte ratio (NLR) is an indirect marker of inflammation, and is associated with adverse clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to investigate the usefulness of NLR to predict procedural adverse events is patients who underwent primary percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

Consecutive patients with STEMI who underwent primary PCI were divided into low and high NLR, whereas high was defined as an NLR value above 75° percentile (≥9.45). The occurrence of procedural complications, in-hospital, and 30-day major adverse cardiovascular events and 1-year all-cause mortality were evaluated.

RESULTS

We included 664 patients with a mean age of 60.5 (±12.1) years and 66.3% were male. In multivariate analysis, NLR remained an independent predictor of in-hospital death [relative risk (RR)=1.03; 95% confidence interval (CI)=1.00-1.08; P=0.04], contrast-induced nephropathy (RR=2.35; 95% CI=1.11-4.71; P=0.02), distal embolization (RR=2.72; 95% CI=1.55-4.75; P<0.001), and no-reflow (RR=2.31; 95% CI=2.31-4.68; P=0.01). The area under the curve for distal embolization was 0.67, 0.64 for no-reflow and 0.62 for procedural complications. A low value of NLR had an excellent negative predictive value of 97.8, 96.9, and 92.1 for distal embolization, no-reflow, and procedural complications, respectively.

CONCLUSION

High NLR is an independent predictor of distal embolization, no-reflow, and procedural complications in patients with STEMI who underwent primary PCI. A low NLR value has an excellent negative predictive value for these procedural outcomes. NLR may be a useful and inexpensive tool that may be used at bedside.

Predictive Value of CHA2DS2-VASc Score for Ischemic Events in Patients Undergoing Percutaneous Coronary Intervention

We evaluated the association of preprocedure CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex) score with ischemic events in patients undergoing percutaneous coronary intervention (PCI). The Dryad Digital Repository enrolled 2533 patients between July 2009 and August 2011. We recorded 1-year ischemic events. Univariate and multivariable logistic regression analyses were used to analyze the association between CHA₂DS₂-VASc score and ischemic events. Receiver operating characteristic curves were used to evaluate the accuracy of CHA₂DS₂-VASc score in predicting long-term ischemic events. Long-term death (9.5 vs 2.8%), cardiac death (2.9 vs 1.4%), and nonfatal stroke (1.9 vs 0.7%) were significantly higher in the CHA₂DS₂-VASc score ≥2 group than the CHA₂DS₂-VASc score ≤1 group. The CHA₂DS₂-VASc score was a predictor for all-cause death (odds ratio [95% confidence interval]: 3.71 [1.89-7.30]). The risk factors for all-cause death in CHA₂DS₂-VASc score ≥2 patients included age, diagnosis, heart failure, older myocardial infarction, diabetes, and chronic obstructive pulmonary disease, while the risk factor for CHA₂DS₂-VASc score ≤1 patients was age. In conclusion, the CHA₂DS₂-VASc score is associated with long-term all-cause death, cardiac death, and stroke in patients undergoing PCI, and it may have a potential use for risk stratification for patients who undergo PCI.

Development and Validation of Nomogram to Predict Acute Kidney Injury in Patients with Acute Myocardial Infarction Treated Invasively

To identify patients who are likely to develop contrast-induced acute kidney injury (CI-AKI) in patients with acute myocardial infarction (AMI), a nomogram was developed in AMI patients. Totally 920 patients with AMI were enrolled in our study. The discrimination and calibration of the model were validated. External validations were also carried out in a cohort of 386 AMI patients. Our results showed in the 920 eligible AMI patients, 114 patients (21.3%) developed CI-AKI in the derivation group (n = 534), while in the validation set (n = 386), 50 patients (13%) developed CI-AKI. CI-AKI model included the following six predictors: hemoglobin, contrast volume >100 ml, hypotension before procedure, eGFR, log BNP, and age. The area under the curve (AUC) was 0.775 (95% confidence interval [CI]: 0.732–0.819) in the derivation group and 0.715 (95% CI: 0.631–0.799) in the validation group. The Hosmer-Lemeshow test has a p value of 0.557, which confirms the model’s goodness of fit. The AUC of the Mehran risk score was 0.556 (95% CI: 0.498–0.615) in the derivation group. The validated nomogram provided a useful predictive value for CI-AKI in patients with AMI.