Development and Validation of an Acute Kidney Injury Risk Index for Patients Undergoing General Surgery: Results from a National Data Set
ABSTRACT The authors sought to identify the incidence, risk factors, and mortality impact of acute kidney injury (AKI) after general surgery using a large and representative national clinical data set.
The 2005-2006 American College of Surgeons-National Surgical Quality Improvement Program participant use data file is a compilation of outcome data from general surgery procedures performed in 121 US medical centers. The primary outcome was AKI within 30 days, defined as an increase in serum creatinine of at least 2 mg/dl or acute renal failure necessitating dialysis. A variety of patient comorbidities and operative characteristics were evaluated as possible predictors of AKI. A logistic regression full model fit was used to create an AKI model and risk index. Thirty-day mortality among patients with and without AKI was compared.
Of 152,244 operations reviewed, 75,952 met the inclusion criteria, and 762 (1.0%) were complicated by AKI. The authors identified 11 independent preoperative predictors: age 56 yr or older, male sex, emergency surgery, intraperitoneal surgery, diabetes mellitus necessitating oral therapy, diabetes mellitus necessitating insulin therapy, active congestive heart failure, ascites, hypertension, mild preoperative renal insufficiency, and moderate preoperative renal insufficiency. The c statistic for a simplified risk index was 0.80 in the derivation and validation cohorts. Class V patients (six or more risk factors) had a 9% incidence of AKI. Overall, patients experiencing AKI had an eightfold increase in 30-day mortality.
Approximately 1% of general surgery cases are complicated by AKI. The authors have developed a robust risk index based on easily identified preoperative comorbidities and patient characteristics.
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- "Various studies are investigating the risk factors associated with the development of adult AKI, both patient and procedure related. Consistent risk factors for AKI were cardiac and noncardiac surgery. Patient-related risk factors are age, hypertension, diabetes mellitus, cardiac failure, peripheral vascular disease, cerebrovascular disease and preexisting chronic kidney disease. "
ABSTRACT: The recent standardization and validation of definitions of pediatric acute kidney injury (pAKI) has ignited new dimensions of pAKI epidemiology and its risk factors. pAKI causes increased morbidity and mortality in critically ill-children. Among the hospitalized patients incidence of pAKI ranges from 1% to 31%, while mortality ranges from 28% to 82%, presenting a broad range due to lack of uniformly acceptable pAKI definition. In addition, cumulative data regarding the progression of pAKI to chronic kidney disease in children is rising. Despite these alarming figures, treatment modalities have failed to deliver significantly. In this review, we will summarize the latest developments of pAKI and highlight important aspects of pAKI management.Indian Journal of Critical Care Medicine 08/2014; 18(8):518-26. DOI:10.4103/0972-5229.138156
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- "Free text, which is allowed in all fields, was left to interpretation by the research team. Despite these data collection limitations, such data have been used frequently to develop models in the literature and have correlated with data that were prospectively collected by dedicated research staff [17-19]. Additionally, the method of data collection regarding tidal volumes differed between the two anesthesia machines and was not able to be corrected for. "
ABSTRACT: Background The impact of anesthetic equipment on clinical practice parameters associated with development of acute respiratory distress syndrome (ARDS) has not been extensively studied. We hypothesized a change in anesthesia machines would be associated with parameters associated with lower rates of ARDS. Methods We performed a retrospective cohort study on a subset of data used to evaluate intraoperative ventilation. Patients included adults receiving a non-cardiac, non-thoracic, non-transplant, non-trauma, general anesthetic between 2/1/05, and 3/31/09 at the University of Michigan. Existing anesthesia machines (Narkomed IIb, Drager) were exchanged for new equipment (Aisys, General Electric). The initial subset compared the characteristics of patients anesthetized between 12/1/06 and 1/31/07 (pre) with those between 4/1/07 and 5/30/07 (post). An extended subset examined cases two years pre and post exchange. Using the standard predicted body weight (PBW), we calculated and compared the tidal volume (total Vt and mL/kg PBW) as well as positive end-expiratory pressure (PEEP), peak inspiratory pressure (PIP), Delta P (PIP-PEEP), and FiO2. Results A total of 1,414 patients were included in the 2-month pre group and 1,635 patients included in the post group. Comparison of ventilation characteristics found statistically significant differences in median (pre v post): PIP (26 ± 6 v 21 ± 6 cmH2O,p < .001), Delta P (24 ± 6 v 19 ± 6 cmH2O, p < .001), Vt (588 ± 139 v 562 ± 121 ml, p < 0.001; 9.3 ± 2.2 v 9.0 ± 1.9 ml/kg predicted body weight, p < .001), FiO2 (0.57 ± 0.17 v 0.52 ± 0.18, p < .001). Groups did not differ in age, ASA category, PBW, or BMI. The two year subgroup had similar parameters. Risk adjustment resulted in minimal differences in the analysis. New anesthesia machines were associated with a non-statistically significant reduction in postoperative ARDS. Conclusions In this study, a change in ventilator management was associated with an anesthesia machine exchange. The smaller Vt and lower PIP noted in the post group may imply a lower risk of volutrauma and barotrauma, which may be significant in at-risk populations. However, there was not a statistically significant reduction in the incidence of post-operative ARDS.BMC Anesthesiology 06/2014; 14(1):44. DOI:10.1186/1471-2253-14-44 · 1.33 Impact Factor
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- "CKD is considered to be the most important risk factor for AKI [7,10]. However, the majority of previous studies did not account for CKD in their analyses [8,11,37,40,41,44-46]. "
ABSTRACT: Some studies but not others suggest angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) use prior to major surgery associates with a higher risk of postoperative acute kidney injury (AKI) and death. We conducted a large population-based retrospective cohort study of patients aged 66 years or older who received major elective surgery in 118 hospitals in Ontario, Canada from 1995 to 2010 (n = 237,208). We grouped the cohort into ACEi/ARB users (n = 101,494) and non-users (n = 135,714) according to whether the patient filled at least one prescription for an ACEi or ARB (or not) in the 120 days prior to surgery. Our study outcomes were acute kidney injury treated with dialysis (AKI-D) within 14 days of surgery and all-cause mortality within 90 days of surgery. After adjusting for potential confounders, preoperative ACEi/ARB use versus non-use was associated with 17% lower risk of post-operative AKI-D (adjusted relative risk (RR): 0.83; 95% confidence interval (CI): 0.71 to 0.98) and 9% lower risk of all-cause mortality (adjusted RR: 0.91; 95% CI: 0.87 to 0.95). Propensity score matched analyses provided similar results. The association between ACEi/ARB and AKI-D was significantly modified by the presence of preoperative chronic kidney disease (CKD) (P value for interaction < 0.001) with the observed association evident only in patients with CKD (CKD - adjusted RR: 0.62; 95% CI: 0.50 to 0.78 versus No CKD: adjusted RR: 1.00; 95% CI: 0.81 to 1.24). In this cohort study, preoperative ACEi/ARB use versus non-use was associated with a lower risk of AKI-D, and the association was primarily evident in patients with CKD. Large, multi-centre randomized trials are needed to inform optimal ACEi/ARB use in the peri-operative setting.BMC Nephrology 04/2014; 15(1):53. DOI:10.1186/1471-2369-15-53 · 1.52 Impact Factor