Validated contemporary risk model of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the National Cardiovascular Data Registry Cath-PCI Registry

Thomas T Tsai, Uptal D Patel, Tara I Chang, Kevin F Kennedy, Frederick A Masoudi, Michael E Matheny, Mikhail Kosiborod, Amit P Amin, William S Weintraub, Jeptha P Curtis, John C Messenger, John S Rumsfeld, John A Spertus, Thomas T Tsai, Uptal D Patel, Tara I Chang, Kevin F Kennedy, Frederick A Masoudi, Michael E Matheny, Mikhail Kosiborod, Amit P Amin, William S Weintraub, Jeptha P Curtis, John C Messenger, John S Rumsfeld, John A Spertus

Abstract

Background: We developed risk models for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI‐D) after percutaneous coronary intervention (PCI) to support quality assessment and the use of preventative strategies.

Methods and results: AKI was defined as an absolute increase of ≥0.3 mg/dL or a relative increase of 50% in serum creatinine (AKIN Stage 1 or greater) and AKI‐D was a new requirement for dialysis following PCI. Data from 947 012 consecutive PCI patients and 1253 sites participating in the NCDR Cath/PCI registry between 6/09 and 7/11 were used to develop the model, with 70% randomly assigned to a derivation cohort and 30% for validation. AKI occurred in 7.33% of the derivation and validation cohorts. Eleven variables were associated with AKI: older age, baseline renal impairment (categorized as mild, moderate, and severe), prior cerebrovascular disease, prior heart failure, prior PCI, presentation (non‐ACS versus NSTEMI versus STEMI), diabetes, chronic lung disease, hypertension, cardiac arrest, anemia, heart failure on presentation, balloon pump use, and cardiogenic shock. STEMI presentation, cardiogenic shock, and severe baseline CKD were the strongest predictors for AKI. The full model showed good discrimination in the derivation and validation cohorts (c‐statistic of 0.72 and 0.71, respectively) and identical calibration (slope of calibration line=1.01). The AKI‐D model had even better discrimination (c‐statistic=0.89) and good calibration (slope of calibration line=0.99).

Conclusion: The NCDR AKI prediction models can successfully risk‐stratify patients undergoing PCI. The potential for this tool to aid clinicians in counseling patients regarding the risk of PCI, identify patients for preventative strategies, and support local quality improvement efforts should be prospectively tested.

Figures

Figure 1.
Figure 1.
Study flow.
Figure 2.
Figure 2.
Predictors of acute kidney injury and their associated odds ratios and 95% confidence intervals. ACS indicates acute coronary syndrome; AKI, acute kidney injury; CKD, chronic kidney disease; CVD, cerebrovascular disease; NSTEMI, non‐ST elevation myocardial infarction.
Figure 3.
Figure 3.
Predictors of acute kidney injury requiring dialysis and their associated odds ratios and 95% confidence intervals. ACS indicates acute coronary syndrome; CKD, chronic kidney disease; STEMI, ST elevation myocardial infarction.
Figure 4.
Figure 4.
Comparison of predicted vs observed outcome rate for the validation cohort (A)AKI; (B)AKI+dialysis. AKI indicates acute kidney injury.
Figure 5.
Figure 5.
NCDR Prediction score card for acute kidney injury following PCI in a sample patient. AKI indicates acute kidney injury; CEA, carotid endarterectomy; CHF, chronic heart failure; eGFR, estimated glomerular filtration rate; HF, heart failure; IABP, intra‐aortic balloon pump; NCDR, National Cardiovascular Data Registry; NSTEMI, non‐ST elevation myocardial infarction; PCI, percutaneous coronary intervention.
Figure 6.
Figure 6.
NCDR prediction score for acute kidney injury requiring dialysis following PCI. HF indicates heart failure; NCDR, National Cardiovascular Data Registry; NSTEMI, non‐ST elevation myocardial infarction.

References

    1. Bartholomew BA, Harjai KJ, Dukkipati S, Boura JA, Yerkey MW, Glazier S, Grines CL, O'Neill WW. Impact of nephropathy after percutaneous coronary intervention and a method for risk stratification. Am J Cardiol. 2004; 93:1515-1519.
    1. Brown JR, DeVries JT, Piper WD, Robb JF, Hearne MJ, Ver LP, Kellet MA, Watkins MW, Ryan TJ, Silver MT, Ross CS, MacKenzie TA, O'Connor GT, Malenka DJ. Serious renal dysfunction after percutaneous coronary interventions can be predicted. Am Heart J. 2008; 155:260-266.
    1. Conen D, Buerkle G, Perruchoud AP, Buettner HJ, Mueller C. Hypertension is an independent risk factor for contrast nephropathy after percutaneous coronary intervention. Int J Cardiol. 2006; 110:237-241.
    1. Dangas G, Iakovou I, Nikolsky E, Aymong ED, Mintz GS, Kipshidze NN, Lansky AJ, Moussa I, Stone GW, Moses JW, Leon MB, Mehran R. Contrast‐induced nephropathy after percutaneous coronary interventions in relation to chronic kidney disease and hemodynamic variables. Am J Cardiol. 2005; 95:13-19.
    1. Freeman RV, O'Donnell M, Share D, Meengs WL, Kline‐Rogers E, Clark VL, DeFranco AC, Eagle KA, McGinnity JG, Patel K, Maxwell‐Eward A, Bondie D, Moscucci M. Nephropathy requiring dialysis after percutaneous coronary intervention and the critical role of an adjusted contrast dose. Am J Cardiol. 2002; 90:1068-1073.
    1. Brown JR, Robb JF, Block CA, Schoolwerth AC, Kaplan AV, O'Connor GT, Solomon RJ, Malenka DJ. Does safe dosing of iodinated contrast prevent contrast‐induced acute kidney injury? Circ Cardiovasc Interv. 2010; 3:346-350.
    1. Klima T, Christ A, Marana I, Kalbermatter S, Uthoff H, Burri E, Hartwiger S, Schindler C, Breidthardt T, Marenzi G, Mueller C. Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium‐induced nephropathy: a randomized controlled trial. Eur Heart J. 2012; 33:2071-2079.
    1. Marenzi G, Assanelli E, Campodonico J, Lauri G, Marana I, De Metrio M, Moltrasio M, Grazi M, Rubino M, Veglia F, Fabbiocchi F, Bartorelli AL. Contrast volume during primary percutaneous coronary intervention and subsequent contrast‐induced nephropathy and mortality. Ann Intern Med. 2009; 150:170-177.
    1. Mueller C, Buerkle G, Buettner HJ, Petersen J, Perruchoud AP, Eriksson U, Marsch S, Roskamm H. Prevention of contrast media‐associated nephropathy: randomized comparison of 2 hydration regimens in 1620 patients undergoing coronary angioplasty. Arch Intern Med. 2002; 162:329-336.
    1. Mehran R, Aymong ED, Nikolsky E, Lasic Z, Iakovou I, Fahy M, Mintz GS, Lansky AJ, Moses JW, Stone GW, Leon MB, Dangas G. A simple risk score for prediction of contrast‐induced nephropathy after percutaneous coronary intervention: development and initial validation. J Am Coll Cardiol. 2004; 44:1393-1399.
    1. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty‐first Century. 2001Washington: National Academy Press
    1. Lloyd‐Jones DM. Cardiovascular risk prediction: basic concepts, current status, and future directions. Circulation. 2010; 121:1768-1777.
    1. Marso SP, Amin AP, House JA, Kennedy KF, Spertus JA, Rao SV, Cohen DJ, Messenger JC, Rumsfeld JSNational Cardiovascular Data R. Association between use of bleeding avoidance strategies and risk of periprocedural bleeding among patients undergoing percutaneous coronary intervention. JAMA. 2010; 303:2156-2164.
    1. Arnold SV, Decker C, Ahmad H, Olabiyi O, Mundluru S, Reid KJ, Soto GE, Gansert S, Spertus JA. Converting the informed consent from a perfunctory process to an evidence‐based foundation for patient decision making. Circ Cardiovasc Qual Outcomes. 2008; 1:21-28.
    1. Moussa I, Hermann A, Messenger JC, Dehmer GJ, Weaver WD, Rumsfeld JS, Masoudi FA. The NCDR cathpci registry: a US national perspective on care and outcomes for percutaneous coronary intervention. Heart. 2013; 99:297-303.
    1. Amin AP, Spertus JA, Cohen DJ, Chhatriwalla A, Kennedy KF, Vilain K, Salisbury AC, Venkitachalam L, Lai SM, Mauri L, Normand SL, Rumsfeld JS, Messenger JC, Yeh RW. Use of drug‐eluting stents as a function of predicted benefit: clinical and economic implications of current practice. Arch Intern Med. 2012; 172:1145-1152.
    1. Peterson ED, Dai D, DeLong ER, Brennan JM, Singh M, Rao SV, Shaw RE, Roe MT, Ho KK, Klein LW, Krone RJ, Weintraub WS, Brindis RG, Rumsfeld JS, Spertus JA. Contemporary mortality risk prediction for percutaneous coronary intervention: results from 588,398 procedures in the National Cardiovascular Data Registry. J Am Coll Cardiol. 2010; 55:1923-1932.
    1. Mehta SK, Frutkin AD, Lindsey JB, House JA, Spertus JA, Rao SV, Ou FS, Roe MT, Peterson ED, Marso SPNational Cardiovascular Data R. Bleeding in patients undergoing percutaneous coronary intervention: the development of a clinical risk algorithm from the national cardiovascular data registry. Circ Cardiovasc Interv. 2009; 2:222-229.
    1. Rao SC, Chhatriwalla AK, Kennedy KF, Decker CJ, Gialde E, Spertus JA, Marso SP. Pre‐procedural estimate of individualized bleeding risk impacts physicians' utilization of bivalirudin during percutaneous coronary intervention. J Am Coll Cardiol. 2013; 61:1847-1852.
    1. Brindis RG, Fitzgerald S, Anderson HV, Shaw RE, Weintraub WS, Williams JF. The American College of Cardiology‐National Cardiovascular Data Registry (ACC‐NCDR): building a national clinical data repository. J Am Coll Cardiol. 2001; 37:2240-2245.
    1. Weintraub WS, McKay CR, Riner RN, Ellis SG, Frommer PL, Carmichael DB, Hammermeister KE, Effros MN, Bost JE, Bodycombe DP. The american college of cardiology national database: progress and challenges. American college of cardiology database committee. J Am Coll Cardiol. 1997; 29:459-465.
    1. Messenger JC, Ho KK, Young CH, Slattery LE, Draoui JC, Curtis JP, Dehmer GJ, Grover FL, Mirro MJ, Reynolds MR, Rokos IC, Spertus JA, Wang TY, Winston SA, Rumsfeld JS, Masoudi FA, Science NQuality Oversight Committee Data Quality Workgroup. The National Cardiovascular Data Registry (NCDR) Data Quality Brief: the NCDR Data Quality Program in 2012. J Am Coll Cardiol. 2012; 60:1484-1488.
    1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute kidney injury network: report of an initiative to improve outcomes in acute kidney injury. Crit Care. 2007; 11:R31.
    1. Krumholz HM, Brindis RG, Brush JE, Cohen DJ, Epstein AJ, Furie K, Howard G, Peterson ED, Rathore SS, Smith SC, Jr, Spertus JA, Wang Y, Normand SLAmerican Heart Association, Quality of Care and Outcomes Research Interdisciplinary Writing Group, Council on Epidemiology and Prevention, Stroke Council, American College of Cardiology Foundation. Standards for statistical models used for public reporting of health outcomes: an American Heart Association Scientific Statement from the Quality of Care and Outcomes Research Interdisciplinary Writing Group: cosponsored by the Council on Epidemiology and Prevention and the Stroke Council. Endorsed by the American College of Cardiology Foundation. Circulation. 2006; 113:456-462.
    1. Fe H. Regression Modeling Strategies With Applications to Linear Models, Logistic Regression, and Survival Analysis. 2001New York: Springer
    1. Pencina MJ, D'Agostino RB, Sr, D'Agostino RB, Jr, Vasan RS. Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med. 2008; 27:157-172.
    1. Sullivan LM, Massaro JM, D'Agostino RB., Sr Presentation of multivariate data for clinical use: the framingham study risk score functions. Stat Med. 2004; 23:1631-1660.
    1. Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol. 2005; 16:3365-3370.
    1. Oldemeyer JB, Biddle WP, Wurdeman RL, Mooss AN, Cichowski E, Hilleman DE. Acetylcysteine in the prevention of contrast‐induced nephropathy after coronary angiography. Am Heart J. 2003; 146:E23.
    1. Forman DE, Butler J, Wang Y, Abraham WT, O'Connor CM, Gottlieb SS, Loh E, Massie BM, Rich MW, Stevenson LW, Young JB, Krumholz HM. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 2004; 43:61-67.
    1. Gupta R, Gurm HS, Bhatt DL, Chew DP, Ellis SG. Renal failure after percutaneous coronary intervention is associated with high mortality. Catheter Cardiovasc Interv. 2005; 64:442-448.
    1. Iakovou I, Dangas G, Mehran R, Lansky AJ, Ashby DT, Fahy M, Mintz GS, Kent KM, Pichard AD, Satler LF, Stone GW, Leon MB. Impact of gender on the incidence and outcome of contrast‐induced nephropathy after percutaneous coronary intervention. J Invasive Cardiol. 2003; 15:18-22.
    1. McCullough PA, Wolyn R, Rocher LL, Levin RN, O'Neill WW. Acute renal failure after coronary intervention: incidence, risk factors, and relationship to mortality. Am J Med. 1997; 103:368-375.
    1. Marenzi G, Lauri G, Assanelli E, Campodonico J, De Metrio M, Marana I, Grazi M, Veglia F, Bartorelli AL. Contrast‐induced nephropathy in patients undergoing primary angioplasty for acute myocardial infarction. J Am Coll Cardiol. 2004; 44:1780-1785.
    1. King SB, III, Smith SC, Jr, Hirshfeld JW, Jr, Jacobs AK, Morrison DA, Williams DO, Feldman TE, Kern MJ, O'Neill WW, Schaff HV, Whitlow PL, Adams CD, Anderson JL, Buller CE, Creager MA, Ettinger SM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Page RL, Riegel B, Tarkington LG, Yancy CW. 2007 focused update of the ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice guidelines. J Am Coll Cardiol. 2008; 51:172-209.
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky PAcute Dialysis Quality Initiative workgroup. Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004; 8:R204-R212.
    1. Tsai TT, Patel UD, Chang TI, Kennedy KF, Masoudi FA, Matheny ME, Kosiborod M, Amin AP, Messenger JC, Rumsfeld JS, Spertus JA. Contemporary incidence, predictors, and outcomes of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the NCDR cath‐PCI registry. JACC Cardiovasc Interv. 2014; 7:1-9.

Source: PubMed

Sponsorer och medarbetare

Medicinska tillstånd

Läkemedelsinterventioner

3
Prenumerera