Systemic Inflammatory Response Syndrome Is Not an Indicator of Bacteremia in Hemodialysis Patients With Native Accesses: A Multicenter Study

Added value of clinical prediction rules for bacteremia in hemodialysis patients: An external validation study

Introduction

Having developed a clinical prediction rule (CPR) for bacteremia among hemodialysis (HD) outpatients (BAC-HD score), we performed external validation.

Materials & methods

Data were collected on maintenance HD patients at two Japanese tertiary-care hospitals from January 2013 to December 2015. We enrolled 429 consecutive patients (aged ≥ 18 y) on maintenance HD who had had two sets of blood cultures drawn on admission to assess for bacteremia. We validated the predictive ability of the CPR using two validation cohorts. Index tests were the BAC-HD score and a CPR developed by Shapiro et al. The outcome was bacteremia, based on the results of the admission blood cultures. For added value, we also measured changes in the area under the receiver operating characteristic curve (AUC) using logistic regression and Net Reclassification Improvement (NRI), in which each CPR was added to the basic model.

Results

In Validation cohort 1 (360 subjects), compared to a Model 1 (Basic Model) AUC of 0.69 (95% confidence interval [95% CI]: 0.59–0.80), the AUC of Model 2 (Basic model + BAC-HD score) and Model 3 (Basic model + Shapiro’s score) increased to 0.8 (95% CI: 0.71–0.88) and 0.73 (95% CI: 0.63–0.83), respectively. In validation cohort 2 (96 subjects), compared to a Model 1 AUC of 0.81 (95% CI: 0.68–0.94), the AUCs of Model 2 and Model 3 increased to 0.83 (95% CI: 0.72–0.95) and 0.85 (95% CI: 0.76–0.94), respectively. NRIs on addition of the BAC-HD score and Shapiro’s score were 0.3 and 0.06 in Validation cohort 1, and 0.27 and 0.13, respectively, in Validation cohort 2.

Conclusion

Either the BAC-HD score or Shapiro’s score may improve the ability to diagnose bacteremia in HD patients. Reclassification was better with the BAC-HD score.

External validation of the quick Sequential Organ Failure Assessment score for mortality and bacteraemia risk evaluation in Japanese patients undergoing haemodialysis: a retrospective multicentre cohort study

OBJECTIVES

We aimed to examine the validity of the quick Sequential Organ Failure Assessment (qSOFA) score for mortality and bacteraemia risk assessment in Japanese haemodialysis patients.

DESIGN

This is a retrospective multicentre cohort study.

SETTING

The six participating hospitals are tertiary-care institutions that receive patients on an emergency basis and provide primary, secondary and tertiary care. The other participating hospital is a secondary-care institution that receives patients on an emergency basis and provides both primary and secondary care.

PARTICIPANTS

This study included haemodialysis outpatients admitted for bacteraemia suspicion, who had blood drawn for cultures within 48 hours of their initial admission.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was overall in-hospital mortality. Secondary outcomes included 28-day in-hospital mortality and the incidence of bacteraemia diagnosed based on blood culture findings. The discrimination, calibration and test performance of the qSOFA score were assessed. Missing data were handled using multiple imputation.

RESULTS

Among the 507 haemodialysis patients admitted with bacteraemia suspicion between August 2011 and July 2013, the overall in-hospital mortality was 14.6% (74/507), the 28-day in-hospital mortality was 11.1% (56/507) and the incidence of bacteraemia, defined as a positive blood culture, was 13.4% (68/507). For predicting in-hospital mortality among haemodialysis patients, the area under the receiver operating characteristic curve was 0.61 (95% CI 0.56-0.67) for a qSOFA score ≥2. The Hosmer-Lemeshow χ² statistics for the qSOFA score as a predictor of overall and 28-day in-hospital mortality were 5.72 (p=0.02) and 7.40 (p<0.01), respectively.

CONCLUSION

On external validation, the qSOFA score exhibited low diagnostic accuracy and miscalibration for in-hospital mortality and bacteraemia among haemodialysis patients.