Acute kidney injury based on the KDIGO criteria among ST elevation myocardial infarction patients treated by primary percutaneous intervention

Impact of care bundles on the occurrence and outcomes of acute kidney injury among patients with ST-segment elevation myocardial infarction

BACKGROUND

Several reports suggested that compliance with acute kidney injury care bundles among hospitalized patients resulted in improved kidney and patient outcomes. We investigated the effect of acute kidney injury care bundle utilization on the incidence of acute kidney injury and renal outcomes in a large cohort of myocardial infarction patients treated with percutaneous coronary intervention.

METHODS

We included patients with myocardial infarction admitted following percutaneous coronary intervention between January 2008 and December 2020. From January 2016, acute kidney injury care bundle was implemented in our cardiac intensive care unit. Acute kidney injury care bundle consisted of simple standardized investigations and interventions, including strict monitoring of serum creatinine and urine analysis, planning investigations, treatment, and guidance about seeking nephrologist advice. Patients' records were evaluated for the occurrence of acute kidney injury, its severity, and recovery, before and after the implementation of acute kidney injury care bundle.

RESULTS

We included 2646 patients (1941 patients in the years 2008-2015 and 705 patients in the years 2016-2020). Implementation of care bundles resulted in a significant decrease in the occurrence of acute kidney injury from 190/1945 to 42/705 (10-6%; p < 0.001), with a trend for lower acute kidney injury score > 1 (20% vs. 25%; p = 0.07) and higher acute kidney injury recovery (62% vs. 45%, p = 0.001). Using a multivariable regression model, the use of care bundles resulted in a 45% decrease in the relative risk for acute kidney injury (HR 0.55, 95% CI 0.37-0.82, p < 0.001).

CONCLUSION

Among patients with ST-elevation myocardial infarction, treated with percutaneous coronary intervention and admitted to our cardiac intensive care unit over the period January 2008-December 2020, compliance with acute kidney injury care bundle was independently associated with a significant decrease in occurrence of acute kidney injury and with better renal outcomes following acute kidney injury. Further interventions, such as e-alert systems for acute kidney injury, could improve utilization of the acute kidney injury care bundle and optimize its clinical benefits.

Risk Factors and Outcome of Acute Kidney Injury following Acute Myocardial Infarction-A Case Series Study from 2009 to 2019

Background: Historically, acute kidney injury (AKI) has been a common severe complication of acute myocardial infarction (MI). As percutaneous coronary interventions have become more widely used, AMI outcomes have significantly improved. However, post-AMI AKI epidemiology and its associated factors are not well-understood in the age of interventional cardiology. Materials and methods: This is a retrospective study examining changes in creatinine levels in all patients admitted for AMI in a single medical center between August 2009 and February 2019. KDIGO criteria were used to define the different stages of post-AMI AKI. Results: The study included 1299 eligible cases, among which 213 (16.4%) developed AKI during AMI index admission; and 128 (60.1%), 46 (21.6%), and 39 (18.3%) were classified as KDIGO stages 1, 2, and 3, respectively. Compared with non-AKI subjects, the AKI group had a higher prevalence of non-STEMI (48.4% vs. 29.1%, p < 0.001), higher Killip class (3 or 4), and higher in-hospital mortality (15% vs. 2.5%, p < 0.001). During the index MI hospitalization, 13.6% (29/213) of the post-MI AKI patients received hemodialysis. Baseline abnormal creatinine (≥1.5 mg/dL), dyslipidemia, and more advanced KDIGO stages (2 or 3) were associated with an increased risk of requiring in-hospital hemodialysis. Moreover, a more advanced KDIGO stage (≥2) was correlated with higher all-cause in-hospital mortality. Conclusion: AMI patients remain at risk of AKI, which negatively affects their survival in the modern age.

Biomarker-Guided Assessment of Acute Kidney Injury Phenotypes E among ST-Segment Elevation Myocardial Infarction Patients

Recent practice guidelines recommended the use of new stress, functional, and damage biomarkers in clinical practice to prevent and manage acute kidney injury (AKI). Biomarkers are one of the tools used to define various AKI phenotypes and provide prognostic information regardless of an acute decline in renal function. We investigated the incidence and possible implications of AKI phenotypes among ST elevation myocardial infarction patient treated with primary coronary intervention. We included 281 patients with STEMI treated with PCI. Neutrophil gelatinase associated lipocalin (NGAL) was utilized to determine structural renal damage and functional AKI was determined using the KDIGO criteria. Patients were stratified into four AKI phenotypes: no AKI, subclinical AKI, hemodynamic AKI, and severe AKI. Patients were assessed for in-hospital adverse events (MACE). A total of 46 patients (44%) had subclinical AKI, 17 (16%) had hemodynamic AKI, and 42 (40%) had severe AKI. We observed a gradual and significant increase in the occurrence of MACE between the groups being highest among patients with severe AKI (10% vs. 19% vs. 29% vs. 43%; p < 0.001). In a multivariable regression model, any AKI phenotype was independently associated with MACE with an odds ratio of 4.15 (95% CI 2.1−8.3, p < 0.001,) for subclinical AKI, 4.51 (95% CI 1.61−12.69; p = 0.004) for hemodynamic AKI, and 12.9 (95% CI 5.59−30.1, p < 0.001) for severe AKI. In conclusion, among STEMI patients, AKI is a heterogeneous condition consisting of distinct phenotypes, addition of novel biomarkers may overcome the limitations of sCr-based AKI definitions to improve AKI phenotyping and direct potential therapies.

Acute Kidney Injury Recovery Patterns in ST-Segment Elevation Myocardial Infarction Patients

Background: Acute kidney injury (AKI) is a frequent complication in patients with ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). Identification of different AKI recovery patterns may improve patient prognostic stratification. We investigated the clinical relevance of AKI recovery patterns among STEMI patients undergoing PCI. Methods: A retrospective study of 2943 STEMI patients undergoing PCI. The incidence of renal impairment, in-hospital complications, short and long-term mortality, were compared between patients without AKI, with early recovery defined as a return to baseline creatinine within 72 h, and no AKI recovery/delayed recovery defined as all other AKI cases. Results: A total of 255 (8.7%) patients developed AKI, of whom 124/255 (49%) patients had an early recovery, whereas 131/255 (51%) had no AKI recovery/delayed recovery. Patients without recovery were more likely to have in-hospital complications and higher long-term mortality (36.64% vs. 7.25%%; p < 0.001). In a multivariable regression model, the mortality hazard ratio (HR) for long term mortality remained significant for patients with no/delayed recovery AKI (HR 7.76, 95% CI 4.69 to 12.86, p < 0.001), and a strong trend among patients with resolving AKI (HR 2.09, 95% CI 0.933−4.687, p = 0.071). Conclusions: Among STEMI patients undergoing PCI, the recovery pattern of AKI is a valuable prognostic marker.

Relation of Baseline Neutrophil Gelatinase-Associated Lipocalin (NGAL) Levels and Contrast-Induced Nephropathy following Percutaneous Coronary Intervention among Chronic Kidney Disease Patients

BACKGROUND

The risk of contrast-induced acute kidney injury (CI-AKI) following coronary intervention is particularly high among patients with chronic kidney disease (CKD). Among these patients, baseline neutrophil gelatinase-associated lipocalin (NGAL), a marker of tubular damage, reflects the severity of renal impairment. We evaluated whether the baseline serum NGAL level may be a marker for the development of CI-AKI following percutaneous coronary intervention (PCI).

METHODS

Eighty-eight CKD patients treated with PCI were included. Serum NGAL levels were drawn upon hospital admission. Receiver operator characteristic (ROC) methods were used to identify the optimal sensitivity and specificity for the observed NGAL level compared with the estimated glomerular filtration rate (eGFR) calculated for patients with CI-AKI.

RESULTS

Overall CI-AKI incidence was 43%. Baseline serum NGAL levels were significantly higher in patients with CI-AKI than in patients without CI-AKI (150 vs. 103 ng/mL, p < 0.001). According to the ROC curve, baseline NGAL levels performed better than eGFR to predict CI-AKI (AUC 0.753 vs. 0.604), with the optimal cutoff value for baseline NGAL to predict CI-AKI being 127 ng/mL (sensitivity of 68% and specificity of 68%, p < 0.001). In a multivariate logistic regression model, the NGAL level >127 ng/mL ng/mL was independently associated with CI-AKI (HR 9.84, 95% CI: 1.96-40.3; p = 0.01).

CONCLUSION

Baseline serum NGAL levels in CKD patients may identify a high-risk population for CI-AKI following PCI. Further studies on larger populations are required to validate the potential utility of NGAL measurements in monitoring specific CKD-associated conditions.

Neutrophil-to-lymphocyte ratio is a marker for acute kidney injury progression and mortality in critically ill populations: a population-based, multi-institutional study

Backgrounds

Neutrophil-to-lymphocyte ratio (NLR), a surrogate marker of systemic response to physiological stress, is used for prognosis prediction in many diseases. However, the usefulness of this marker for predicting acute kidney injury (AKI) progression is unclear.

Methods

This retrospective study was based on the Chang Gung Research Database. Patients admitted to the intensive care unit with a diagnosis of stage 1 or 2 AKI were identified. The primary outcome was a composite of progression to stage 3 AKI, requirement of renal replacement therapy, or 14-day in-hospital mortality. The association between NLR and the primary outcome was examined using a logistic regression model and multivariable analysis. The nonlinearity and cutoff points of this relationship were determined using a restricted cubic spline model.

Results

A total of 10,441 patients were enrolled. NLR level at the time of stage 1–2 AKI diagnosis was a marker of adverse outcomes. After adjustment for confounders, NLR was independently associated with the composite outcome of AKI progression, renal replacement therapy, or mortality. The restricted cubic spline model revealed a J-shaped curve, with the lowest odds ratio for an NLR between 7 and 38. Subgroup analysis revealed linear and J-shaped relationships between NLR and the primary outcome in patients admitted to the intensive care unit for medical reasons and for cardiovascular surgery, respectively.

Conclusions

NLR is an independent marker of AKI progression and in-hospital mortality. Because it is readily available in daily practice, it might be used for risk stratification in the AKI population.

Graphic abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s40620-021-01162-3.

Clinical Scoring for Prediction of Acute Kidney Injury in Patients with Acute ST-Segment Elevation Myocardial Infarction after Emergency Primary Percutaneous Coronary Intervention

Acute kidney injury (AKI) after a coronary intervention is common in patients with ST-segment elevation myocardial infarction (STEMI) and is associated with significant morbidity and mortality. Several scores have been developed to predict post-procedural AKI over the years. However, the AKI definitions have also evolved, which causes the definitions used in the past to be obsolete. We aimed to develop a prediction score for AKI in patients with STEMI requiring emergency primary percutaneous coronary intervention (pPCI). This study was based on a retrospective cohort of Thai patients with STEMI who underwent pPCI at the Central Chest Institute of Thailand from December 2014 to September 2019. AKI was defined as an increase in serum creatinine of at least 0.3 mg/dL from baseline within 48 h after pPCI. Logistic regression was used for modeling. A total of 1617 patients were included. Of these, 195 patients had AKI (12.1%). Eight significant predictors were identified: age, baseline creatinine, left ventricular ejection fraction (LVEF) < 40%, multi-vessel pPCI, treated with thrombus aspiration, inserted intra-aortic balloon pump (IABP), pre- and intra-procedural cardiogenic shock, and congestive heart failure. The score showed an area under the receiver operating characteristic curve of 0.78 (95% CI 0.75, 0.82) and was well-calibrated. The pPCI-AKI score showed an acceptable predictive performance and was potentially useful to help interventionists stratify the patients and provide optimal preventive management.

Elevated serum uric acid is a predictor of contrast associated acute kidney injury in patient with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

Contrast associated-acute kidney injury (CA-AKI) has been associated with adverse outcomes after ST-segment elevation myocardial infarction (STEMI). However, early markers of CA-AKI are still needed to improve risk stratification. We investigated the association between elevated serum uric acid (eSUA) and CA-AKI in patients with STEMI treated with primary percutaneous coronary intervention (pPCI).

METHODS AND RESULTS

Serum creatinine (Scr) was measured at admission and 24, 48 and 72 h after pPCI. CA-AKI was defined as an increase of 25% (CA-AKI 25%) or 0.5 mg/dl (CA-AKI 0.5) of Scr level above the baseline after 48 h following contrast administration. Multivariable analyses to investigate CA-AKI predictors were performed by binary logistic regression and multivariable backward logistic regression model. In the 3023 patients considered, CA-AKI was more frequent among patients with eSUA as compared with patients with normal SUA levels, considering both CA-AKI definitions (CA-AKI25%: 20.8% vs 16.2%, p < 0.012; CA-AKI 0.5: 10.1% vs 5.8%, p < 0.001). The association between eSUA and CA-AKI was confirmed at multivariable analyses (CA-AKI 25%: odd ratio 1.32, 95% CI 1.03-1.69, p = 0.027; CA-AKI 0.5: odd ratio 1.76, 95% CI 1.11-2.79, p = 0.016).

CONCLUSION

Elevated serum uric acid is associated with CA-AKI after reperfusion in patients with STEMI treated with pPCI.

Onset time and prognostic value of acute kidney injury in patients with acute myocardial infarction

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Even small declines in renal function are associated with worse short-term outcomes after AMI.

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The clinical impact of the timing of acute kidney injury (AKI) onset after AMI is unknown.

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Early-phase AKI is associated with poor long-term mortality.

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Late-phase AKI is not associated with poor long-term mortality.

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Careful clinical attention and intensive care should be used in patients with early-phase AKI after AMI.

Background

The mechanisms and clinical impact of acute kidney injury (AKI) after acute myocardial infarction (AMI) may differ depending on whether AKI develops during the early or late phase after AMI. The present study assessed the timing of AKI onset and the prognostic impact on long-term outcomes in patients hospitalized with AMI.

Methods

The present study enrolled consecutive AMI survivors who had undergone successful percutaneous coronary interventions at admission. AKI was defined as an increase in the serum creatinine level of ≥0.3 mg/dL above the admission value within 7 days of hospitalization. AKI patients were further divided into two subgroups (early-phase AKI: within 3 days vs. late-phase AKI: 4 to 7 days after AMI onset). The primary endpoint was all-cause death.

Results

In total, 506 patients were included in this study, with 385 men and a mean age of 69.5 ± 13.5 years old. The mean follow-up duration was 1289.5 ± 902.8 days. AKI developed in 127 patients (25.1%). Long-term mortality was significantly higher in the AKI group than in the non-AKI group (log-rank p < 0.001). Early-phase AKI developed in 98 patients (19.3%), and late-phase AKI developed in 28 patients (5.5%). In the multivariable analysis, early-phase AKI was significantly associated with all-cause mortality (HR 2.83, 95% CI [1.51–5.29], p = 0.0012), while late-phase AKI was not.

Conclusion

Early-phase AKI but not late-phase AKI was associated with poor long-term mortality. Careful clinical attention and intensive care are needed when AKI is observed within 3 days of AMI onset.

Neutrophil gelatinase-associated lipocalin (NGAL) for the prediction of acute kidney injury in chronic kidney disease patients treated with primary percutaneous coronary intervention

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Chronic kidney disease (CKD) patients may demonstrate elevated NGAL levels reflecting chronic impairment condition.

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We evaluated plasma NGAL level for identification of AKI superimposed on CKD vs. “de novo” AKI among (STEMI) patients undergoing primary PCI.

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NGAL is a useful tool for the identification of patients with CKD in high risk for AKI following primary PCI. However, Different cutoff values of plasma NGAL for “de novo” AKI and AKI superimposed on CKD may be necessary for Table 1, Table 2, Table 3 diagnosis.

Introduction

Elevated plasma levels of neutrophil gelatinase-associated lipocalin (NGAL) is a marker of tubular damage and aid in the early identification of acute kidney injury (AKI). We evaluated NGAL levels for identification of AKI superimposed on chronic kidney disease (CKD) vs. “de novo” AKI among ST elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI).

Methods

217 STEMI patients treated with PCI were prospectively included, 34 (16%) had baseline CKD. Plasma NGAL levels were drawn 24 h following PCI. Receiver-operator characteristic (ROC) methods were used to identify optimal sensitivity and specificity for the observed NGAL range in AKI patients with and without CKD.

Results

Overall AKI incidence was 13%. NGAL levels were significantly higher for patients with AKI compared to no-AKI, irrespective of CKD. Different optimal cutoff value for NGAL to predict AKI were found for patients with CKD (133 ng/ml, sensitivity of 73% and specificity of 75%; AUC: 0.837, p < 0.001) and for non-CKD (104 ng/ml with sensitivity of 79% and specificity of 82%; AUC: 0.844, p < 0.001). In a multivariate logistic regression model, NGAL levels were independently associated with AKI in patients with and without CKD (HR 1.04, 95% CI: 1.01–1.08; p = 0.024; and HR 1.03, 95% CI: 1.01–1.04; p = 0.001), respectively.

Conclusions

Elevated plasma NGAL levels identify patients who are at high-risk to develop AKI following primary PCI. Determining different cutoff values of plasma NGAL for de novo AKI and AKI superimposed on CKD may be necessary for accurate AKI diagnosis and risk stratification.

Reduced glutathione does not further reduce contrast-induced nephropathy in elderly patients with diabetes receiving percutaneous coronary intervention

Objective

To investigate the preventive effect of hydration combined with reduced glutathione on contrast-induced nephropathy (CIN) after coronary intervention therapy in elderly Chinese patients with diabetes.

Methods

Patients with diabetes aged ≥65 years, who received percutaneous coronary intervention (PCI) between 1 August 2016 and 31 December 2018, were enrolled and randomized into two groups: patients treated with hydration combined with reduced glutathione (treatment group) and patients who received hydration alone (controls). Serum creatinine and creatinine clearance levels were measured in all patients before PCI and then daily for 3 days after PCI. Occurrence of CIN (the primary endpoint) was defined as serum creatinine value 25% or 44.2 mmol/l (0.5 mg/dl) above baseline at 72 h after an exposure to contrast medium.

Results

A total of 396 patients were included (treatment group, n = 204; and controls, n = 192). The CIN occurrence rate in the treatment and control group was 5.88% and 6.77%, respectively, with no statistically significant between-group difference.

Conclusion

In elderly patients with diabetes receiving PCI, the risk of CIN was not effectively lowered by hydration combined with reduced glutathione.

Effect of N-acetylcysteine on prevention of contrast-associated acute kidney injury in patients with STEMI undergoing primary percutaneous coronary intervention: a systematic review and meta-analysis of randomised controlled trials

OBJECTIVE

Several studies evaluating the preventive effect of N-acetylcysteine (NAC) on contrast-associated acute kidney injury (CA-AKI) among patients with ST segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) have suggested inconsistent results and that a systematic review and meta-analysis should be performed.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, MEDLINE, EMBASE, ClinicalTrials.gov and the Cochrane Central databases were searched from inception to 15 November 2019.

ELIGIBILITY CRITERIA

Randomised controlled trials assessing use of NAC compared with non-use of NAC (eg, placebo) in preventing CA-AKI in patients with STEMI following PPCI were included.

DATA SYNTHESIS

Relative risks with 95% CIs were pooled using a random-effects model. Evidence level of conclusions was assessed by Cochrane GRADE measure.

RESULTS

Seven trials including 1710 patients were identified. Compared with non-use of NAC, use of NAC significantly reduced the incidence of CA-AKI by 49% (risk ratio (RR) 0.51, 95% CI 0.31 to 0.82, p<0.01) and all-cause in-hospital mortality by 63% (RR 0.37, 95% CI 0.17 to 0.79, p=0.01). The estimated effects on the requirement for dialysis (RR 0.61, 95% CI 0.11 to 3.38, p=0.24) were not statistically significant. Trial sequential analysis confirmed the true positive of NAC in reducing risk of CA-AKI. Subgroup analyses suggested that the administration of NAC had greater benefits in patients with renal dysfunction and in those receiving oral administration and higher dosage of NAC.

CONCLUSIONS

NAC intake reduces the risk of CA-AKI and all-cause in-hospital mortality in patients with STEMI undergoing PPCI. The estimated potential benefit of NAC in preventing dialysis was ambiguous, and further high-quality studies are needed.

PROSPERO REGISTRATION NUMBER

CRD42020155265.

Impact of renal function on patients with acute coronary syndromes: 15,593 patient-years study

Introduction

Coexistence of chronic kidney disease (CKD) in the case of acute coronary syndromes (ACS) significantly worsens the outcomes.

Aim

The aim of our study was to assess renal function impact on mortality among patients with ACS.

Materials and methods

The study was based on records of 21,985 patients hospitalized in the Medical University of Bialystok in 2009–2015. Inclusion criteria were ACS. Exclusion criteria were: death within 24 h of admission, eGFR <15 ml/min/1.73 m², hemodialysis. Mean observation time was 2296 days.

Results

Criteria were met by 2213 patients. CKD occurred in 24.1% (N = 533) and more often affected those with NSTEMI (26.2 (337) vs. 21.2 (196), p = .006). STEMI patients had higher incidence of post-contrast acute kidney injury (PC-AKI) (5 (46) vs. 4.1 (53), p < .001). During the study, 705 people died (31.9%), more often with NSTEMI (33.2% (428) vs. 29.95% (277), p < .001). However, from a group of patients suffering from PC-AKI 57.6% died. The risk of PC-AKI increased with creatinine concentration (RR: 2.990, 95%CI: 1.567–5.721, p < .001), occurrence of diabetes mellitus (RR: 2.143, 95%CI: 1.029–4.463, p = .042), atrial fibrillation (RR: 2.289, 95%CI: 1.056–4.959, p = .036). Risk of death was greater with an increase in postprocedural creatinine concentration (RR: 2.254, 95%CI: 1.481–3.424, p < .001).

Conclusion

PC-AKI is a major complication in patients with ACS, occurs more frequently in STEMI and may be a prognostic marker of long-term mortality in patients undergoing percutaneous coronary intervention (PCI). More attention should be given to the prevention and diagnosis of PC-AKI but necessary PCI should not be withheld in fear of PC-AKI.

Neutrophil Gelatinase-Associated Lipocalin for the Early Prediction of Acute Kidney Injury in ST-Segment Elevation Myocardial Infarction Patients Treated with Primary Percutaneous Coronary Intervention

INTRODUCTION AND OBJECTIVE

Neutrophil gelatinase-associated lipocalin (NGAL), a glycoprotein released by renal tubular cells, can be used as a marker of early tubular damage. We evaluated plasma NGAL level utilization for the identification of acute kidney injury (AKI) among ST-elevation myocardial infarction (STEMI) patients undergoing primary coronary intervention (PCI).

METHODS

131 STEMI patients treated with PCI were prospectively included. Plasma NGAL levels were drawn prior to PCI (0 h) and 24 h afterwards. AKI was defined per KDIGO criteria of serum creatinine increase. Receiver-operating characteristic (ROC) methods were used to identify optimal sensitivity and specificity for the observed NGAL range.

RESULTS

Overall AKI incidence was 14%. NGAL levels were significantly higher for patients with AKI at both 0 h (164 ± 42 vs. 95 ± 30; p < 0.001) and 24 h (142 ± 41 vs. 93 ± 36; p < 0.001). Per ROC curve analysis, an optimal cutoff value of NGAL (>120 ng/mL) predicted AKI with 80% sensitivity and specificity (AUC 0.881, 95%, CI 0.801-0.961, p < 0.001). In a multivariate logistic regression model, NGAL levels were independently associated with AKI at 0 h (OR 1.044, 95% CI 1.013-1.076; p = 0.005) and 24 h (OR 1.018, 95% CI 1.001-1.036; p = 0.04).

CONCLUSIONS

Elevated NGAL levels, suggesting renal tubular damage, are independently associated with AKI in STEMI patients undergoing primary PCI.

Outcome in Patients Resuscitated following Myocardial Infarction with Acute Kidney Injury

Background: Data on acute kidney injury (AKI) in patients with myocardial infarction (MI) who underwent percutaneous coronary intervention (PCI) after cardiac arrest are scarce. The prevalence of AKI, as classified by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria; and its possible association with 30-day mortality were assessed. Methods: Data on 6387 patients with MI, 342 (5.3%) with out-of-hospital cardiac arrest or arrest immediately after admission before PCI, were retrospectively analyzed. The AKI and no-AKI groups were compared. The 30-day mortality was determined. Results: Ninety-three (27.2%) patients suffered AKI. AKI KDIGO stages 1, 2 and 3 occurred in 45 (13.2%), 8 (2.3%) and 40 (11.7%) patients, respectively. Higher mortality was found in AKI patients [56 (60.2%) vs. no-AKI patients 32 (12.9%); p<0.0001]. More patients died in the higher AKI KDIGO stages. In AKI KDIGO stages 1/2 and stage 3, 20 (37.7%) patients and 36 (90.0%) patients died, respectively compared to 32 (12.9%) no-AKI patients; p<0.0001. AKI was the strongest predictor of 30-day mortality (adjusted OR 6.98; 95% CI 3.42 to 14.23; p<0.0001). Other predictors were bleeding, cardiogenic shock, contrast volume-to-glomerular filtration rate ratio, and female sex. The adjusted OR for AKI KDIGO stages 1/2 and stage 3 were 3.68; 95% CI 1.53 to 8.32; p=0.002 and 29.10; 95% CI 8.31 to 101.88; p<0.0001, respectively. Conclusion: In patients resuscitated after MI undergoing PCI, AKI had a deleterious impact on the prognosis. A graded increase in the severity of AKI according to the KDIGO definition was associated with a progressively increased risk of 30-day mortality.

Contrast Volume to Glomerular Filtration Ratio and Acute Kidney Injury among ST-Segment Elevation Myocardial Infarction Patients Treated with Primary Percutaneous Coronary Intervention

INTRODUCTION

The ratio of contrast media volume to glomerular filtration rate (contrast/GFR) has been shown to correlate with the occurrence of contrast-induced acute kidney injury (CI-AKI) in unselected patient populations who underwent percutaneous coronary intervention (PCI).

OBJECTIVE

We evaluated the possible utilization of this marker and optimal cutoff among ST-elevation myocardial infarction (STEMI) patients undergoing primary PCI.

METHODS

We retrospectively included 419 patients with STEMI treated with primary PCI. The occurrence of CI-AKI was defined by the KDIGO criteria as an increase in serum creatinine of ≥0.3 mg/dL within 48 h following PCI. A receiver-operator characteristic (ROC) curve was used to identify the optimal cutoff value of contrast/GFR ratio to predict CI-AKI. This value was then assessed using multivariable logistic regression.

RESULTS

The overall incidence of CI-AKI was 9%. The contrast/GFR ratio was significantly higher among patients with CI-AKI (2.7 ± 1.2 vs. 1.9 ± 0.9; p < 0.001). According to the ROC curve analysis, the optimal cutoff value of contrast/GFR ratio to predict AKI was measured as ≥2.13, with 70% sensitivity and 60% specificity (AUC 0.65, 95% CI 0.56-0.74; p = 0.002). In a multivariate logistic regression model, contrast/GFR ratio ≥2.13 was independently associated with CI-AKI (OR 2.46, 95% CI 1.09-5.57; p = 0.03).

CONCLUSIONS

Among STEMI patients undergoing primary PCI, contrast/GFR ratio ≥2.13 was independently associated with CI-AKI.

Acute kidney injury as an independent predictor of infection and malignancy: the NARA-AKI cohort study

BACKGROUND

Acute kidney injury (AKI) is associated with higher mortality and cardiovascular events. However, association between AKI and non-cardiac events such as infection or malignancy is largely unknown.

METHODS

This is a retrospective cohort study. Inclusion criteria were adults who underwent non-cardiac surgery from 2007 to 2011 at Nara Medical University Hospital. Exclusion criteria were urological surgery, obstetric surgery, missing creatinine values peri-operatively, and pre-operative dialysis. The end of observation period was at the end of 2015 or loss to follow-up. A predictor was AKI defined by KDIGO criteria within 1-week post-operatively. Outcomes were hospitalization for infection or diagnoses of malignancy. Associations between AKI and outcomes were examined by Cox regression models.

RESULTS

Among 6692 subjects, 445 (6.6%) developed AKI. During median follow-up of 4.0 years, there were 485 hospitalizations for infection and 1138 diagnoses of malignancy (2.0 and 5.1 events/100 patient-years, respectively). After adjustment for potential confounders, AKI was independently associated with hospitalization for infection and diagnoses of malignancy (Hazard ratio [95% confidence interval]: 1.64 [1.23-2.20] and 1.31 [1.06-1.61], respectively). Excluding recurrence of malignancy from outcomes and analyses limited to those who recover renal function by the time of discharge yielded similar results. Absolute lymphocyte counts were significantly lower and neutrophil-to-lymphocyte ratios were significantly higher among those with AKI.

CONCLUSIONS

AKI was significantly associated with hospitalization for infection and development of malignancy during long-term follow-up. Those with AKI might be in persistent immunosuppressed state.

Routine iso-osmolar contrast media use and acute kidney injury following percutaneous coronary intervention for ST elevation myocardial infarction

BACKGROUND

Temporal changes in contrast-induced acute kidney injury (CI-AKI) incidence following primary percutaneous coronary intervention (PPCI) are poorly defined. Additionally, the benefits of iso-osmolar contrast media (IOCM) compared to low osmolar CM (LOCM) are uncertain.

METHODS

Using data from a regional PPCI service, temporal changes in baseline risk and annual incidence of CI-AKI were studied. A CM protocol change occurred in 2013 allowing a comparison of the incidence of CI-AKI between LOCM (2012-13) and IOCM (2013-15).

RESULTS

Between 2012 and 2015, 208 of 1310 patients experienced CI-AKI (15.9%). The Mehran AKI risk score did not change during the study period although there was an increase in the incidence of CI-AKI in later study years (P<0.001 for trend) when IOCM was used. Factors independently associated with CI-AKI were IOCM use (OR=1.96, [95% CI: 1.39-2.75]), age per year (OR=1.02, 95% CI: 1.01-1.04), baseline creatinine per µmol/L (OR=1.006, 95% CI: 1.003-1.01) and contrast volume per milliliter (OR=1.002, 95% CI: 1.001-1.004). The baseline characteristics of patients treated using IOCM (N.=783) vs. LOCM (N.=527) were similar (Mehran Score 6.6 vs. 6.9, P=0.173) but CI-AKI occurred more frequently with IOCM compared to LOCM (19.2% vs. 11.2%, P<0.001). Use of IOCM was independently associated with CI-AKI (OR=1.98, 95% CI: 1.339-2.774, P<0.001) with consistency across all sub-groups of age, gender, baseline creatinine, contrast volume, shock and diabetes. The adjusted in-hospital mortality was increased with IOCM compared to LOCM (OR=3.03, 95% CI: 1.313-6.994, P=0.009).

CONCLUSIONS

IOCM use was observed to be associated with an increased occurrence of CI-AKI, and an increase in in-hospital mortality after primary PCI.

C-reactive protein velocity and the risk of acute kidney injury among ST elevation myocardial infarction patients undergoing primary percutaneous intervention

BACKGROUND

Elevated C-reactive protein (CRP) was shown to be associated with an increased risk for acute kidney injury (AKI) in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), however, the optimal time frame to measure CRP for risk stratification is not known. We evaluated the relation between the change in CRP over time (CRP velocity-CRPv) and AKI among STEMI patients treated with primary PCI.

METHODS

We included 801 STEMI who presented between 2007 and 2017 and had their CRP measured with a wide range assay (wr-CRP) at least twice during the 24 h after admission. CRPv was defined as the change in wr-CRP concentration (mg/l) divided by the change in time (in h) between the two measurements. Patient's medical records were reviewed for occurrence of AKI.

RESULTS

Mean age was 62 ± 16 and 80% were males. Patients with AKI had significantly higher CRPv (1.47 versus 0.4 mg/l/h, p < 0.001). In a multivariate regression model CRPv was independently associated with AKI (OR 1.03, 95% CI 1.01-1.0 5, p = 0.001). On receiver operating characteristic (ROC) curve the optimal cutoff value of CRPv to predict AKI was measured as more than 0.8 mg/l/h, with 70% sensitivity and 65% specificity (AUC 0.712, 95% CI 0.64-0.78, p < 0.001).

CONCLUSION

CRPv might be an independent and rapidly measurable biomarker for AKI following primary PCI in STEMI patients.

Acute kidney injury in patients with myocardial infarction undergoing percutaneous coronary intervention using radial versus femoral access

BACKGROUND

Data on radial access (RA) as an independent risk factor for acute kidney injury (AKI) in myocardial infarction (MI) patients are conflicting. Our aim was to assess how RA influences the incidence of AKI in MI patients undergoing percutaneous coronary intervention (PCI).

METHODS

Data from 3842 MI patients undergoing PCI at our institution from January 2011 to December 2016, of which 35.8% were performed radially, were retrospectively analyzed. A propensity-matched analysis was performed to adjust for differences in the baseline characteristics between the RA and femoral access (FA) groups. The effect of RA on the incidence of AKI was observed.

RESULTS

In the unmatched cohort, AKI occurred less often in the RA group [77 (5.6%) patients in the RA group compared to 250 (10.1%) patients in the FA group; p = 0.001]. After propensity-matched adjustment, the incidence of AKI was similar in the two groups. After adjustment for potential confounders, RA was not identified as an independent predictive factor for AKI in either the unmatched or the propensity-matched cohort. Bleeding, heart failure, age ≥ 70 years, renal dysfunction, and the contrast volume/GFR ratio predicted AKI in both cohorts. Additionally, diabetes, contrast volume, and hypertension were predictive of AKI in the unmatched cohort.

CONCLUSION

The access site was not independently associated with the incidence of AKI in patients with MI in both a non-matched and a propensity-matched cohort. Our study result suggests that the lower incidence of AKI in patients treated with RA in an unmatched cohort might be substantially influenced by confounding factors, especially bleeding.

Impact of KDIGO-Defined Acute Kidney Injury on Mortality after Percutaneous Coronary Intervention for Acute Myocardial Infarction

BACKGROUND

There are limited data regarding the incidence and long-term impact of acute kidney injury (AKI) according to the KDIGO guidelines on the outcome in patients with myocardial infarction (MI) treated with percutaneous coronary intervention (PCI). The aim of the study was to evaluate the prevalence of AKI, as classified by the KDIGO criteria, and its association with long-term mortality.

METHODS

Data from 5,859 MI patients undergoing PCI at our institution were analyzed. We compared the group without and with AKI according to the KDIGO criteria in relation to long-term mortality.

RESULTS

AKI was documented in 499 (8.5%) patients. AKI stage 1 occurred in 6.2% of patients, AKI stage 2 in 0.9% of patients, and AKI stage 3 in 1.5% of patients. Patients with AKI had a higher long-term mortality (57.3 vs. 20.6%; p < 0.0001). The mortality was 50.3% in AKI stage 1, 56.9% in AKI stage 2, and 87.2% in AKI stage 3. The hazard ratios for all-cause mortality for AKI stages 1-3 were 1.77, 1.85, and 6.30 compared to patients with no AKI. Cardiogenic shock, bleeding, heart failure, age, renal dysfunction, diabetes, hyperlipidemia, ST-elevation MI, contrast volume/glomerular filtration ratio, P2Y12 receptor antagonists, and radial access were associated with the development of AKI.

CONCLUSION

A slight increase in serum creatinine was associated with a progressive increase in long-term mortality in patients with AKI according to the KDIGO definition.