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also after cardiac valve operations. The observed increased mortality risk substantially below the threshold of the AKI definition for stage 1 [1] in the whole spectrum of cardiac operations carries several important implications.First, the study urges improvement in the AKI definition, detection of CSA-AKI earlier, and delivery of targeted interventions to high-risk subgroups.Second, these endeavors should not dwell solely on creatininederived definitions, because an important proportion of patients with potentially deleterious outcomes could be missed. Essentially, the study of Bouma and colleagues [1] supports the concept of subclinical CSA-AKI, defined as being not always clinically expressed nevertheless strongly predicting adverse outcomes.To better describe subclinical CSA-AKI and the potential of its acute clinical worsening, we proposed a combination of conventional creatinine, relative creatinine dynamic changes, neutrophil gelatinase-associated lipocalin to depict acute tubular injury, and cystatin C as a glomerular filtration rate marker [2]. Acknowledging that even a minimal (up to 10%) creatinine rise identifies patients at higher risk of CSA-AKI, it has been largely unknown that the subclinical increase of creatinine after cardiac surgery in the range of 10% to 25% translates into substantially higher long-term mortality [1].Applying care bundles, however, reverses the progression of CSA-AKI compared with standard postoperative care [3]. We believe that a composite biomarker panel could help us overcome the gap, presented in the current report, whereby 10% to 25% patients with initially subclinical and undetected AKI presented with substantially higher late mortality [1].Finally, we congratulate the authors for the carefully executed study, underlying the inadequacy of the present CSA-AKI creatinine-based definition to reliably assess long-term mortality after cardiac operations, therewith advocating that future development of evidence-based composite biomarker panel with reference values for early detection of (ir-)reversible CSA-AKI corresponds to putting an additional horse before the cart rather than putting a cart before the horse.
also after cardiac valve operations. The observed increased mortality risk substantially below the threshold of the AKI definition for stage 1 [1] in the whole spectrum of cardiac operations carries several important implications.First, the study urges improvement in the AKI definition, detection of CSA-AKI earlier, and delivery of targeted interventions to high-risk subgroups.Second, these endeavors should not dwell solely on creatininederived definitions, because an important proportion of patients with potentially deleterious outcomes could be missed. Essentially, the study of Bouma and colleagues [1] supports the concept of subclinical CSA-AKI, defined as being not always clinically expressed nevertheless strongly predicting adverse outcomes.To better describe subclinical CSA-AKI and the potential of its acute clinical worsening, we proposed a combination of conventional creatinine, relative creatinine dynamic changes, neutrophil gelatinase-associated lipocalin to depict acute tubular injury, and cystatin C as a glomerular filtration rate marker [2]. Acknowledging that even a minimal (up to 10%) creatinine rise identifies patients at higher risk of CSA-AKI, it has been largely unknown that the subclinical increase of creatinine after cardiac surgery in the range of 10% to 25% translates into substantially higher long-term mortality [1].Applying care bundles, however, reverses the progression of CSA-AKI compared with standard postoperative care [3]. We believe that a composite biomarker panel could help us overcome the gap, presented in the current report, whereby 10% to 25% patients with initially subclinical and undetected AKI presented with substantially higher late mortality [1].Finally, we congratulate the authors for the carefully executed study, underlying the inadequacy of the present CSA-AKI creatinine-based definition to reliably assess long-term mortality after cardiac operations, therewith advocating that future development of evidence-based composite biomarker panel with reference values for early detection of (ir-)reversible CSA-AKI corresponds to putting an additional horse before the cart rather than putting a cart before the horse.
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