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

Long-Term Effects of Acute Kidney Injury Following Endovascular Femoropopliteal Intervention: Insights From a Multicenter Trial

PURPOSE

To examine the association between acute kidney injury (AKI) severity and duration with cardiovascular mortality, following endovascular treatment of femoropopliteal disease, and whether it is AKI in itself that confers an increased risk of cardiovascular mortality.

METHODS

A retrospective analysis of prospectively collected data obtained between 2014 and 2019 from 3 vascular centers. Renal function was followed up for a minimum of 90 days. Electronic records were queried to establish a cause of death, where applicable. Patients were excluded if unable to provide written informed consent or if presenting with acute limb ischemia. Primary outcomes were the hazard ratios for cardiovascular death (AKI patients vs no AKI; no AKI vs stage 1 AKI vs stage 3 AKI; and no AKI vs transient AKI vs established AKI). Propensity score-matched analysis was used to establish whether developing AKI, in patients with similar demographics and procedural characteristics, is associated with a higher risk of cardiovascular death.

RESULTS

Overall 239 patients developed AKI, and this was associated with an increased risk of cardiovascular mortality (hazard risk [HR]: 4.3, 95% confidence intervals [CIs]: 2.1-6.8, pairwise comparison p value=0.006]. This was dependent on the severity of the AKI stage (HR 5.4, 95% CI: 2.4-7.3, pairwise comparison p value=0.01) and duration (HR 4.2, 95% CI: 2.3-6.2, pairwise comparison p value=0.04). The propensity score-matched analysis showed that even when patients are matched for comorbidity and procedural characteristics, AKI confers an increased risk of mortality (p=0.04).

CONCLUSIONS

Acute kidney injury is common after femoropopliteal endovascular therapy. It confers an increased risk of long-term cardiovascular mortality, which is still present when renal decline is transient, and highest for patients with established decline in renal function.

CLINICAL IMPACT

This is the first study in the setting of peripheral arterial disease to show that acute kidney injury has an adverse effect on cardiovascular mortality, in the long-term, that is dependent on its severity, and present even when the AKI is transient. We have also shown that this difference in cardiovascular mortality becomes more pronounced from the medium-term, and thus closer follow-up of these patients is required.

Predictive Value of the Naples Prognostic Score for Acute Kidney Injury in ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention

The purpose of this investigation was to investigate whether there was an association between the Naples prognostic score and the development of acute kidney injury (AKI) in ST-elevation myocardial infarction (STEMI) patients following primary percutaneous coronary intervention (pPCI). The study comprised 2901 consecutive STEMI patients who had pPCI. For each patient, the Naples prognostic score was determined. To evaluate the predictive performance of the Naples score (which included either continuous and categorical variables), we developed a Nested model and a nested model combined with the Naples score. The Naples prognostic score was the most significant predictor of AKI occurrence after admission creatinine, age, and contrast volume. The continuous Naples prognostic score model provided the best prediction performance and discriminative ability. The C-index of the Nested and full models with continuous Naples prognostic score were significantly higher than that of the Nested model. The decision curve analysis found that the overall model had a higher full range of probability of clinical net benefit than the baseline model, with a 10% AKI likelihood. The present study found that the Naples prognostic score may be useful to predict the risk of AKI in STEMI patients undergoing pPCI.

Analyzing predictors of in-hospital mortality in patients with acute ST-segment elevation myocardial infarction using an evolved machine learning approach

Acute ST-segment elevation myocardial infarction (STEMI) is a severe cardiac ailment characterized by the sudden complete blockage of a portion of the coronary artery, leading to the interruption of blood supply to the myocardium. This study examines the medical records of 3205 STEMI patients admitted to the coronary care unit of the First Affiliated Hospital of Wenzhou Medical University from January 2014 to December 2021. In this research, a novel predictive framework for STEMI is proposed, incorporating evolutionary computational methods and machine learning techniques. A variant algorithm, AGCOSCA, is introduced by integrating crossover operation and observation bee strategy into the original Sine Cosine Algorithm (SCA). The effectiveness of AGCOSCA is initially validated using IEEE CEC 2017 benchmark functions, demonstrating its ability to mitigate the deficiency in local mining after SCA random perturbation. Building upon this foundation, the AGCOSCA approach has been paired with Support Vector Machine (SVM) to forge the predictive framework referred to as AGCOSCA-SVM. Specifically, AGCOSCA is employed to refine the selection of predictors from a substantial feature set before SVM is utilized to forecast the occurrence of STEMI. In our analysis, we observed that SVM excels at managing nonlinear data relationships, a strength that becomes particularly prominent in smaller datasets of STEMI patients. To assess the effectiveness of AGCOSCA-SVM, diagnostic experiments were conducted based on the STEMI sample data. Results indicate that AGCOSCA-SVM outperforms traditional machine learning methods, achieving superior Accuracy, Sensitivity, and Specificity values of 97.83 %, 93.75 %, and 96.67 %, respectively. The selected features, such as acute kidney injury (AKI) stage, fibrinogen, mean platelet volume (MPV), free triiodothyronine (FT3), diuretics, and Killip class during hospitalization, are identified as crucial for predicting STEMI. In conclusion, AGCOSCA-SVM emerges as a promising model framework for supporting the diagnostic process of STEMI, showcasing potential applications in clinical settings.

Acute Kidney Injury in Acute Myocardial Infarction and Its Outcome at 3 and 6 Months

Epidemiological data on the prevalence of acute kidney injury (AKI) in acute coronary syndrome are sparse, with most studies having been conducted retrospectively. This study prospectively analyzed the incidence of AKI in patients with acute myocardial infarction (AMI) and to identify the risk factors for AKI and their renal outcome at 3 and 6 months. This was a prospective and observational study, which enrolled 120 patients presenting with their first episode of AMI to our hospital and consented to the study. Renal function tests were performed at admission, at 48 h, and at follow-up at 3 and 6 months. The majority of the patients underwent a percutaneous coronary intervention (59.2%), 21.7% received thrombolytic therapy, and 19.2% were managed conservatively. At 48 h, 11 patients had AKI. At 3 months, 8 patients had died, and renal dysfunctions were seen in 9 out of 112 patients. At 6 months, 12 patients out of 112 had renal dysfunction. There was no difference in the incidence of AKI in patients with an estimated glomerular filtration rate above and below 60 mL/min/1.73 m2. Killip Class 4 and diabetes mellitus were associated with an increased incidence of renal dysfunction in AMI patients. The type of treatment and the use of a contrast agent in the coronary intervention did not affect the development of AKI. According to this study, if indicated, a percutaneous coronary intervention should not be denied to patients for fear of developing AKI. This needs to be examined in larger randomized trials.

Impact of contrast-induced acute kidney injury on long-term major adverse cardiovascular events and kidney function after percutaneous coronary intervention: insights from a territory-wide cohort study in Hong Kong

BACKGROUND

The impact of contrast-induced acute kidney injury (CI-AKI) on long-term major adverse cardiovascular events (MACE) remains controversial.

METHOD

This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between 2004 and 2017. Severe CI-AKI was defined as an increase in serum creatinine of >50% from the baseline value, an absolute increase of >1 mg/dL (88 μmol/L) or requiring dialysis after percutaneous coronary intervention (PCI). Mild CI-AKI was defined as an increase in serum creatinine of >25% from the baseline value or an absolute increase of >0.5 mg/dL (44 μmol/L) after PCI but not fulfilling the criteria for severe CI-AKI. The primary endpoint was MACE, defined as a composite outcome of all-cause mortality, non-fatal myocardial infarction after hospital discharge, stroke or any unplanned coronary revascularization, in a time-to-first-event analysis up to 5 years after PCI. The secondary endpoints were individual components of MACE and cardiovascular mortality.

RESULTS

A total of 34 576 patients were analysed. After adjustment for cardiovascular risk factors, procedural characteristics and medication use, the risk of MACE at 5 years was significantly higher with mild CI-AKI {hazard ratio [HR], 1.18 [95% confidence interval (CI) 1.12-1.26); P < 0.001} and severe CI-AKI [HR 1.92 (95% CI 1.78-2.07); P < 0.001]. Severe CI-AKI was associated with higher adjusted risks of each secondary end point and the risks monotonically accrued over time.

CONCLUSIONS

Among patients undergoing a first-ever PCI, CI-AKI of any severity was associated with a higher adjusted risk of MACE at 5 years. Severe CI-AKI has a stronger association with MACE and its individual components, with an excess of early and late events.

Association Between Radial Versus Femoral Access for Percutaneous Coronary Intervention and Long-Term Mortality

Background

Percutaneous coronary intervention with radial arterial access has been associated with fewer occurrences of major bleeding. However, published data on the long‐term mortality and major adverse cardiac events after percutaneous coronary intervention with radial or femoral arterial access are inconclusive.

Method and Results

This was a territory‐wide retrospective cohort study including 26 022 patients who underwent first‐ever percutaneous coronary intervention between January 1, 2010 and December 31, 2017 in Hong Kong. Among the 14 614 patients matched by propensity score (7307 patients in each group), 558 (7.6%) and 787 (10.8%) patients died during the observation period in the radial group and femoral group, respectively, resulting in annualized all‐cause mortality rates of 2.69% and 3.87%, respectively. The radial group had a lower risk of all‐cause mortality compared with the femoral group up to 3 years after percutaneous coronary intervention (hazard ratio [HR], 0.70; 95% CI, 0.63–0.78; P<0.001). Radial access was associated with a lower risk of major adverse cardiac events (HR, 0.78; 95% CI, 0.73–0.83, P<0.001), myocardial infarction after hospital discharge (HR, 0.78; 95% CI, 0.70–0.87, P<0.001), and unplanned revascularization (HR, 0.76; 95% CI, 0.68–0.85, P<0.001). The risks of stroke were similar across the 2 groups (HR, 0.96; 95% CI, 0.82–1.13, P=0.655).

Conclusions

Radial access was associated with a significant reduction in all‐cause mortality at 3 years compared with femoral access. Radial access was associated with reduced risks of myocardial infarction and unplanned revascularization, but not stroke. The benefits were sustained beyond the early postoperative period.

Acute Kidney Injury in Cardiogenic Shock: An Updated Narrative Review

Acute myocardial infarction with cardiogenic shock (AMI-CS) is associated with high mortality and morbidity despite advancements in cardiovascular care. AMI-CS is associated with multiorgan failure of non-cardiac organ systems. Acute kidney injury (AKI) is frequently seen in patients with AMI-CS and is associated with worse mortality and outcomes compared to those without. The pathogenesis of AMI-CS associated with AKI may involve more factors than previously understood. Early use of renal replacement therapies, management of comorbid conditions and judicious fluid administration may help improve outcomes. In this review, we seek to address the etiology, pathophysiology, management, and outcomes of AKI complicating AMI-CS.

Evaluation of prognosis and nephrotoxicity in patients treated with colistin in intensive care unit

Introduction

Nephrotoxicity is the most important adverse effect of colistin therapy. We investigated the frequency of nephrotoxicity, risk factors related to nephrotoxicity, and its relationship with mortality in patients who received intravenous colistin in intensive care units (ICUs).

Materials and methods

We retrospectively reviewed the data of patients who received intravenous colistin in ICUs between 2011 and 2017. Acute kidney injury (AKI) diagnosis and staging were made based on the Kidney Disease Improving Global Outcome criteria.

Results

There were 149 patients included in the study with 61% being male. The mean age was 58.7 ± 20.3 years. AKI was detected in 96 (64.4%) patients. There were 25 patients with AKI stage 1 (16.8%) and 71 patients with AKI stage 2 or 3 (47.7%). Advanced age (65.0 vs. 47.4 years; p < .001), diabetes mellitus (p < .001), heart failure (p = .01), high APACHE II score (31.7 vs. 28.08, p = .019), and inotrope usage (p = .01) were found as risk factors for AKI. The 14-day mortality rate was higher in the AKI group (p = .027).

Discussion

Higher AKI and mortality rates are observed in patients with diabetes, heart failure, advanced age and the hemodynamically impaired. However, it is a fact that there are no alternative therapies other than colistin in the treatment of multidrug-resistant Gram-negative bacterial infections. Therefore, the development of AKI in this patient group should not be considered a sufficient reason for discontinuing colistin treatment. Understanding the risk factors in this potential nephrotoxic treatment can provide a more careful patient follow-up.

An obesity paradox in patients with myocardial infarction undergoing percutaneous intervention

BACKGROUND AND AIMS

Data concerning the relationship between body mass index (BMI) and outcome in myocardial infarction (MI) patients are inconclusive. Long-term data on the influence of BMI on survival in patients with MI who have undergone percutaneous intervention (PCI) are lacking. We aimed to assess the effect of different categories of BMI on long-term mortality.

METHODS AND RESULTS

A single-center retrospective study of 6496 patients with MI who underwent PCI was performed. Patients were divided into six categories according to their BMI and these were compared. All-cause mortality was assessed over a median period of 6.0 years. An inverse J-shaped relationship was observed between BMI and long-term mortality. The lowest mortality was observed in patients with class I obesity. The patients with a BMI below 25.0 kg/m² were more likely to die than patients with class I obesity. A gradual decrease in BMI below 25.0 kg/m² was associated with a progressively increased risk of dying, with underweight patients showing a 2.18-fold increase in mortality risk. An obesity paradox was present. In addition, the patients with class III obesity had a more than 70% higher long-term mortality risk as compared to the reference group. Both lower and higher degrees of BMI were found to be harmful in patients with MI who underwent PCI.

CONCLUSION

The obesity paradox was present in a very long-term follow-up of patients with MI who underwent PCI. However, both lower and higher BMI values are harmful, and an inverse J-shaped relationship between BMI and outcome was observed.

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT

OBJECTIVES

This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

BACKGROUND

The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

METHODS

This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

RESULTS

Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

CONCLUSIONS

Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.

Brain Natriuretic Peptide for Predicting Contrast-Induced Acute Kidney Injury in Patients with Acute Coronary Syndrome Undergoing Coronary Angiography: A Systematic Review and Meta-Analysis

Objective

To assess the diagnostic value of B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide (NT-proBNP) for contrast-induced acute kidney injury (CI-AKI) in patients with acute coronary syndrome (ACS) undergoing coronary angiography.

Background

ACS remains a major cause of death worldwide. Patients with ACS undergoing coronary angiography are more likely to develop CI-AKI, which correlates highly with poor clinical outcomes. Early diagnosis of CI-AKI remains a challenge. Many recent studies have suggested that BNP or NT-proBNP may be a useful biomarker for the early diagnosis of CI-AKI.

Methods

We searched databases (PubMed, EMBASE, and Cochrane Library) to identify eligible studies. Two authors independently screened the studies and extracted data. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) criteria to assess the methodological quality of the included studies and STATA to perform all statistical analyses.

Results

Nine studies including 2832 patients were identified. The pooled sensitivity of 0.73 (95% CI 0.65–0.79), specificity of 0.79 (95% CI 0.70–0.85), and area under the summary receiver operating characteristic curve of 0.81 (95% CI 0.77–0.84) suggested that BNP or NT-proBNP had a good diagnostic value for CI-AKI in patients with ACS undergoing coronary angiography.

Conclusions

Our findings suggest that BNP or NT-proBNP may be an effective predictive marker for CI-AKI. However, additional high-quality studies are required to find the optimal cutoff value and the diagnostic value of BNP or NT-proBNP in combination with other biomarkers.

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.

Activation of the Nitric Oxide Pathway and Acute Myocardial Infarction Complicated by Acute Kidney Injury

BACKGROUND/AIMS

The pathophysiology of acute kidney injury (AKI) in ST-elevation myocardial infarction (STEMI) patients remains poorly explored. The involvement of the nitric oxide (NO) pathway has been demonstrated in experimental ischemic AKI. The aim of this study was to assess the predictive value of circulating biomarkers of the NO pathway for AKI in STEMI patients.

METHODS

Four hundred and twenty-seven STEMI patients treated with primary percutaneous coronary intervention were included. The primary end point was AKI. Biomarkers of the NO pathway (plasma superoxide dismutase [SOD], uric acid, nitrite/nitrate [NOx], neopterin) as well as cardiac biomarkers (B-type natriuretic peptide [BNP] and troponin) were sampled 12 h after admission. The predictive value of circulating biomarkers was evaluated in addition to the multivariate clinical model.

RESULTS

AKI developed in 8.9% of patients. The 3-month mortality was significantly higher in patients with AKI (34.2 vs. 4.1%; p < 0.001). SOD, uric acid, NOx, neopterin, BNP and troponin were significantly associated with the development of AKI (area under curve [AUC]-receiver operating curve [ROC] ranging between 0.70 and 0.81). In multivariate analysis cardiogenic shock, neopterin, NOx and troponin were independent predictors of AKI. AUC-ROC of the association of multibiomarkers and clinical model was 0.90 and outperformed the predictive value of the clinical model alone. OR of NOx ≥45 µmol/L was 8.0 (95% CI 3.1-20.6) for AKI.

CONCLUSION

Biomarkers of the NO pathway are associated with the development of AKI in STEMI patients. These results provide insights into the pathophysiology of AKI and may serve at developing preventing strategies for AKI targeting this pathway.

Clinical efficacy and safety of percutaneous coronary intervention for acute myocardial infarction complicated with chronic renal insufficiency: A protocol of systematic review and meta-analysis

BACKGROUND

The aim of this research is to further evaluate the efficacy and safety of percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) complicated with chronic renal insufficiency (CRI) by meta-analysis, to provide scientific and effective medical evidence for PCI in patients with AMI complicated with CRI, and to support the clinical application of PCI.

METHODS

Electronic databases will be searched, including PubMed, Cochrane Library, Embase, CNKI, CBM, VIP, and Wanfang Data. Patients with AMI complicated by renal insufficiency treated with PCI will be included. The retrieval time is from inception to January 2019. The inclusion and exclusion criteria are formulated to search only the relevant literature. Endnote software management for literature will be adopted. The literature will be independently screened by 2 researchers. Excel 2016 will be applied to extract literature data with the "Research Information Registration Form." The final selected literature will be assessed for bias risk. Stata 12.0 software will be used for the meta-analysis.

RESULTS

The systematic evaluation and meta-analysis will be carried out strictly in accordance with the requirements of the Cochrane System Evaluator Manual 5.3 on meta-analyses, which will provide a high-quality evaluation of the clinical efficacy and safety of PCI in patients with AMI and CRI.

ETHICS AND DISSEMINATION

This study belongs to the category of systematic reviews, not clinical trials. Therefore, it does not require ethical approval. The results of this study will be published in influential international academic journals related to this topic.

CONCLUSION

PCI is an effective and safe treatment for patients with AMI and CRI. This study will provide a definite evidence-based medical conclusion and provide a scientific basis for the clinical treatment of patients with AMI and CRI.

PROSPERO REGISTRATION NUMBER

CRD42019131367.