Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: Do we have to revise current definitions of acute renal failure?*

Lassnigg, Andrea; Schmid, Edith R.; Hiesmayr, Michael; Falk, Christian; Druml, Wilfred; Bauer, Péter; Schmidlin, Daniel

doi:10.1097/ccm.0b013e318169181a

Cited by 288 publications

(229 citation statements)

References 24 publications

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“…Although we used a standardized definition of AKI, it is possible that the inclusion of absolute increases in creatinine as small as 0.3 mg/dl or restricting creatinine rise to within 48 hours postoperatively may have contributed to the observed impact of preoperative eGFR on the NGAL-AKI relationship. However, large studies confirm the clinical significance of small absolute increases in serum creatinine after cardiac surgery (26,27). Waikar and Bonventre (28) further demonstrated that the rate of the rise of absolute serum creatinine after acute reduction in GFR is relatively constant across a range of baseline renal function, making misclassification bias in patients with impaired baseline function unlikely.…”

Section: Discussionmentioning

confidence: 99%

Neutrophil Gelatinase-Associated Lipocalin and Acute Kidney Injury after Cardiac Surgery

McIlroy¹,

Wagener²,

Lee³

2010

Clinical Journal of the American Society of Nephrology

180

102

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Background and objectives: Neutrophil Gelatinase-Associated Lipocalin (NGAL) is rapidly released by renal tubules after injury, potentially allowing early identification of acute kidney injury (AKI) after cardiac surgery. However, the diagnostic performance of NGAL has varied widely in clinical studies, and it remains unknown what factors modify the relationship between NGAL and AKI. We hypothesized the relationship between urinary NGAL and AKI would vary with baseline renal function, allowing a stratified analysis to improve diagnostic performance of this novel biomarker.Design, setting, participants, & measurements: We performed a prospective observational study in 426 adult cardiac surgical patients. Urinary NGAL was serially determined, commencing preoperatively and continuing 24 hours postoperatively. AKI was defined as increase in serum creatinine from baseline by either >50% or >0.3 mg/dl within 48 hours postoperatively. Patients were stratified by baseline estimated GFR (eGFR). NGAL levels were compared between patients with and without AKI and diagnostic characteristics determined according to baseline eGFR.Results: In patients with baseline eGFR >60 ml/min, urinary NGAL was higher at all postoperative time points in patients who developed AKI compared with those who did not. In patients with baseline eGFR <60 ml/min, urinary NGAL did not differ at any time between those who did and those who did not develop AKI. Postoperative NGAL best identified AKI in patients with baseline eGFR 90 to 120 ml/min. Conclusions: The relationship between urinary NGAL and AKI after cardiac surgery varies with baseline renal function, with optimal discriminatory performance in patients with normal preoperative function.

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Section: Discussionmentioning

confidence: 99%

Neutrophil Gelatinase-Associated Lipocalin and Acute Kidney Injury after Cardiac Surgery

McIlroy¹,

Wagener²,

Lee³

2010

Clinical Journal of the American Society of Nephrology

180

102

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“…1 -4,6 However, there is interest in applying a different outcome other than dialysis and/or death in assessing efficacy in clinical trials of AKI prevention, because growing evidence suggests that inhospital AKI not requiring dialysis may identify patients with increased long-term morbidity and mortality. 7,12 In fact, AKI has been reported to increase the risk for ESRD, 13,14 and even small changes in SCr level during hospitalization were associated with an independent higher risk of ESRD and death. 8 In CV surgery patients, deterioration of immediate postoperative renal function has been reported to predict in-hospital mortality and longterm survival.…”

Section: Discussionmentioning

confidence: 99%

Long‐term Outcome of Patients Treated With Prophylactic Nesiritide for the Prevention of Acute Kidney Injury Following Cardiovascular Surgery

Lingegowda¹,

Van²,

Shimada³

et al. 2010

Clinical Cardiology

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Background: Previously, we reported that the prophylactic use of nesiritide did not reduce the incidence of dialysis or death following cardiovascular (CV) surgery despite reducing the incidence of acute kidney injury (AKI) in the immediate postoperative period. Therefore, we investigated whether the observed renal benefits of nesiritide had any long-term impact on cumulative patient survival and renal outcomes. Methods: Participants of the Nesiritide Study, a previously reported prospective, double-blind, placebocontrolled, randomized clinical trial investigating the effect of nesiritide on the incidence of dialysis or death at 21 days in adult patients undergoing high-risk CV surgery, were included in the study. Data of the participants' most recent health and renal function status were obtained using institutional review board-approved patient questionnaires, medical records, and the database of the Social Security Administration. Results: Data on all 94 patients from the Nesiritide Study were obtained. The mean follow-up period was 20.8 ± 10.4 months. No differences in cumulative survival between the groups were noted at follow-up (nesiritide 77.7% vs placebo 81.6%, P = 0.798). Patients with in-hospital incidence of AKI had a higher rate of mortality than those with no AKI (AKI 41.4% vs no AKI 10.7%, P = 0.002). However, differences in survival time were not significant between the groups when the analysis was restricted to patients with AKI (nesiritide 16.8 ± 4 months vs placebo 18.5 ± 2.3 months, P = 0.729). Conclusions: Renoprotection provided by nesiritide in the immediate postoperative period was not associated with improved long-term survival in patients undergoing high-risk CV surgery. IntroductionEvidence for the renoprotective effect of natriuretic peptides in clinical settings remains controversial. 1 -4 Previously, we reported in a retrospective study that the use of the B-type natriuretic peptide (BNP) nesiritide (Natrecor) in patients with impaired renal function (serum creatinine [SCr]>1 mg/dL) who were undergoing cardiovascular (CV) surgery was associated with a dramatic reduction in 21-day dialysis-free survival (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.14-0.87, P = 0.024). 5 However, in a follow-up prospective, randomized clinical trial (the Nesiritide Study), we could not demonstrate a benefit for prophylactic use of nesiritide as related to the incidence of 21-day dialysis and/or death in patients undergoing high-risk CV surgery (nesiritide 6.6% vs control 6.1%; P = 0.914). 6 The study did demonstrate that the prophylactic use of nesiritide was associated with reduced incidence

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“…In addition, we determined the accuracy of the estimated bSCr for classifying postoperative AKI using Kidney Disease Improving Global Outcomes (KDIGO) criteria (17), and subsequent patient mortalities. Finally, we compared our results with a cohort of similar patients at the University Hospital of Zurich, Switzerland to validate our findings (18).…”

Section: Introductionmentioning

confidence: 91%

“…For comparison, AKI diagnosis was performed on 3123 adult patients who underwent cardiac surgery at the University Hospital of Zurich, Switzerland. This cohort of patients has previously been compared with our patient cohort and used for validation of data (18,22).…”

Section: Aki Diagnosis and Validationmentioning

confidence: 99%

Serum Creatinine Back-Estimation in Cardiac Surgery Patients

Bernardi¹,

Schmidlin

Ristl

et al. 2016

Clinical Journal of the American Society of Nephrology

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Background and objectives A knowledge of baseline serum creatinine (bSCr) is mandatory for diagnosing and staging AKI. With often missing values, bSCr is estimated by back-calculation using several equations designed for the estimation of GFR, assuming a "true" GFR of 75 ml/min per 1.73 m 2 . Using a data set from a large cardiac surgery cohort, we tested the appropriateness of such an approach and compared estimated and measured bSCr. Moreover, we designed a novel data-driven model (estimated serum creatinine [eSCr]) for estimating bSCr. Finally, we analyzed the extent of AKI and mortality rate misclassifications.Design, setting, participants, & measurements Data for 8024 patients (2833 women) in our cardiac surgery center were included from 1997 to 2008. Measured and estimated bSCr were plotted against age for men and women. Patients were classified to AKI stages defined by the Kidney Disease Improving Global Outcomes (KDIGO) group. Results were compared with data from another cardiac surgery center in Zurich, Switzerland.Results The Modification of Diet in Renal Disease and the Chronic Kidney Disease Epidemiology Collaboration formulae describe higher estimated bSCr values in younger patients, but lower values in older patients compared with the measured bSCr values in both centers. The Pittsburgh Linear Three Variables formula correctly describes the increasing bSCr with age, however, it underestimates the overall bSCr level, being in the range of the 25% quantile of the measured values. Our eSCr model estimated measured bSCr best. AKI stage 1 classification using all formulae, including our eSCr model, was incorrect in 53%-80% of patients in Vienna and in 74%-91% in Zurich; AKI severity (according to KDIGO stages) and also mortality were overestimated. Mortality rate was higher among patients falsely classified into higher KDIGO stages by estimated bSCr.Conclusions bSCr values back-estimated using currently available eGFR formulae are inaccurate and cannot correctly classify AKI stages. Our model eSCr improves the prediction of AKI but to a still inadequate extent.

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Impact of minimal increases in serum creatinine on outcome in patients after cardiothoracic surgery: Do we have to revise current definitions of acute renal failure?*

Cited by 288 publications

References 24 publications

Neutrophil Gelatinase-Associated Lipocalin and Acute Kidney Injury after Cardiac Surgery

Neutrophil Gelatinase-Associated Lipocalin and Acute Kidney Injury after Cardiac Surgery

Long‐term Outcome of Patients Treated With Prophylactic Nesiritide for the Prevention of Acute Kidney Injury Following Cardiovascular Surgery

Serum Creatinine Back-Estimation in Cardiac Surgery Patients

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