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1、Acute kidney injury after cardiac surgery according to Risk/Injury/Failure/Loss/End-stage, Acute Kidney Injury Network, and Kidney Disease: Improving Global Outcomes classifications, Anthony J. Bastin MRCP, PhD a, Marlies Ostermann MD, PhDb, Andrew J. Slack MRCP a, Gerhard-Paul Diller MD, PhDc, Simo
2、n J. Finney MRCP, FRCA, PhD a, Timothy W. Evans MD, PhDa aUnit of Critical Care, Imperial College, Royal Brompton Hospital, London, SW3 6NP, UK bDepartment of Nephrology and Critical Care, Kings College London, Guys and St Thomas Hospital, SE1 7EH, London, UK cAdult Congenital Heart Centre and Centr
3、e for Pulmonary Hypertension, Imperial College, Royal Brompton Hospital, SW3 6NP, London, UK Keywords: Acute kidney injury; Cardiac surgery; Renal replacement therapy; Intensive care unit; Cardiopulmonary bypass Abstract Purpose: The epidemiology of acute kidney injury (AKI) after cardiac surgery de
4、pends on the definition used. Our aims were to evaluate the Risk/Injury/Failure/Loss/End-stage (RIFLE) criteria, the AKI Network (AKIN) classification, and the Kidney Disease: Improving Global Outcomes (KDIGO) classification for AKI postcardiac surgery and to compare the outcome of patients on renal
5、 replacement therapy (RRT) with historical data. Methods: Retrospectiveanalysisof1881adultswhohadcardiacsurgerybetweenMay2006andApril2008 and determination of the maximum AKI stage according to the AKIN, RIFLE, and KDIGO classifications. Results:The incidence of AKI using the AKINand RIFLE criteriaw
6、as 25.9% and 24.9%,respectively, but individual patients were classified differently. The area under the receiver operating characteristic curve for hospital mortality was significantly higher using the AKIN compared with the RIFLE criteria (0.86 vs 0.78, P=.0009).IncidenceandoutcomeofAKIaccordingto
7、theAKINandKDIGOclassificationwereidentical. The percentage of patients who received RRT was 6.2% compared with 2.7% in 1989 to 1990. The associated hospital mortality fell from 82.9% in 1989 to 1990 to 15.6% in 2006 to 2008. Sources of funding: A.J.B. was funded by the Dunhill Medical Trust, and thi
8、s project was supported by the National Institute for Health Research (NIHR) Respiratory Disease Biomedical Research Unit at Royal Brompton and Harefield NHS Foundation Trust and Imperial College London. The funding/supporting bodies had no role in the design, collection, analysis, or interpretation
9、 of data or decision to submit for publication. Conflict of interest statement: None to declare. Corresponding author. E-mail addresses: marliesostermann.freeserve.co.uk, Marlies.Ostermanngstt.nhs.uk (M. Ostermann). 0883-9441/$ see front matter 2012 Elsevier Inc. All rights reserved. http:/dx.doi.or
10、g/10.1016/j.jcrc.2012.12.008 Journal of Critical Care (2013) xx, xxxxxx Conclusions: The AKIN classification correlated better with mortality than did the RIFLE criteria. MortalityofpatientsneedingRRTaftercardiacsurgeryhasimprovedsignificantlyduringthelast20years. 2012 Elsevier Inc. All rights reser
11、ved. 1. Introduction Acute kidney injury (AKI) after cardiac surgery is associated with increased mortality 14, a higher incidence of complications, a longer stay in the intensive care unit (ICU) and hospital, and increased health care costs 2,57. Moreover, the highest mortality and complications ar
12、e seen in patients who require renal replacement therapy (RRT). The reported incidence of AKI after cardiac surgery varies widely depending on the definition used. In AKI in general, the most commonly used definitions are the Risk/Injury/Failure/Loss/End-stage (RIFLE) criteria, which differentiate b
13、etween 3 stages (Risk, Injury, Failure) and 2 outcome categories (Loss and End-stage renal disease), and the AKI Network (AKIN) classification, which essen- tially is a modified version of the RIFLE criteria 8,9 (Table 1). The AKIN classification differs from the RIFLE criteria in several aspects: (
14、a) a lower serum creatinine threshold for the diagnosis of AKI, (b) the classification of patients requiring RRT as AKIN stage 3 independent of serum creatinine, (c) the removal of estimated glomerular filtration rate (GFR) criteria, (d) a shorter time window for diagnosing AKI (48 hours instead of
15、7 days), and (e) the elimination of an assumption that patients with missing baseline creatinine values had normal preexisting renal function. Epidemiologic studies collectively enrolling more than 500 000 patients confirmed that the RIFLE and/or AKIN criteria were valid tools to diagnose and stage
16、AKI. Joannidis et al 10 directly compared the RIFLE and AKIN criteria in 14 356 critically ill patients using changes of serum creatinine and urinary output during the first 48 hours of ICU admission without including a requirement of RRT in the analysis. Although the mortality of patients with AKI
17、classified by either RIFLE or AKIN criteria was similar, the Table 1RIFLE, AKIN, and KDIGO classifications for AKI Serum creatinine criteria a Urine output criteria RIFLE 10 RIFLE-RiskIncrease serum creatinine to 1.5- to 2-fold from baseline, or GFR decrease N25%b0.5 mL kg1h1for N6 h RIFLE-InjuryInc
18、rease serum creatinine to N2-fold to 3-fold from baseline, or GFR decrease N50%b0.5 mL kg1h1for N12 h RIFLE-FailureIncrease serum creatinine to N3-fold from baseline, or serum creatinine to 354 mol/L with an acute rise of at least 44 mol/L, or GFR decrease N75% b0.3 mL kg1h1for 24 h or anuria for 12
19、 h RIFLE-LossComplete loss of kidney function for N4 wk End-stage kidney disease End-stage kidney disease N3 mo AKIN 11Definition: an abrupt (within 48 h) reduction in kidney function defined as an absolute increase in serum creatinine of either 0.3 mg/dL (26.4 mol/L) or a percentage increase of 50%
20、 (1.5-fold from baseline) or a reduction in urine output (after exclusion of hypovolemia and obstruction) Stage 1Increase serum creatinine 26 mol/L (N0.3 mg/dL) or increase to more than or equal to 1.5- to 2-fold from baseline b0.5 mL kg1h1for N6 h Stage 2Increase serum creatinine to more than 2- to
21、 3-fold from baselineb0.5 mL kg1h1for N12 h Stage 3Increase serum creatinine to more than 3-fold from baseline, or serum creatinine to 354 mol/L with an acute rise of at least 44 mol/L b0.3 mL kg1h1for 24 h or anuria for 12 h Individuals who receive RRT are considered to have met the criteria for st
22、age 3, irrespective of the stage they are in at the time of RRT. KDIGO 13Definition: AKI is diagnosed if serum creatinine 26.5 mol/L for 48 h, or rises to 1.5-fold from baseline, which is known or presumed to have occurred in the preceding 7 d. Stage 1Rise in serum creatinine 26.5 mol/L in 48 h, or
23、rise 1.5-1.9 times from baselineb0.5 mL kg1h1for 6-12 h Stage 2Rise in serum creatinine 2.0-2.9 times from baselineb0.5 mL kg1h1for 12h Stage 3Rise in serum creatinine 3 times from baseline, or increase in serum creatinine to 353.6 mol/L, or initiation of RRT irrespective of serum creatinine b0.3 mL
24、 kg1h1for 24 h or anuria for 12 h a Acute kidney injury diagnosis based on change between 2 creatinine values within a 48-hour period for AKIN classification and within a 1-week window for RIFLE criteria. 2A.J. Bastin et al. 2 classifications classified individual patients differently. The percentag
25、e of patients who were identified as non-AKI bythe AKIN classification but fulfilled the RIFLEcriteria for AKI was 10.5%. By contrast, 3.5% of patients were classified as non-AKI according to the RIFLE criteria but fulfilled the AKIN criteria for AKI. Mortality of this group of patients was nearly t
26、wice that of patients who did not have AKI by both criteria (25.2% vs 12.9%). These results suggest that both RIFLE and AKIN criteria are useful tools to identify patients with AKI despite their differences. In an attempt to standardize the definition of AKI, the Kidney Disease: Improving Global Out
27、comes (KDIGO) initiative recently produced the KDIGO classification, which essen- tially combines the RIFLE and AKIN criteria 11 (Table 1). To date, this classification has not been validated in critically ill patients, including patients postcardiac surgery. The aims of this study were, first, to a
28、ssess and compare the use of the AKIN and RIFLE criteria in patients post cardiac surgery; second, to compare the AKIN and RIFLE criteria with the KDIGO classification; and third, to compare the epidemiology of patients with severe AKI requiring RRT with that from 10 and 20 years earlier. 2. Methods
29、 2.1. Study design, setting, and population We retrospectively analyzed data from patients older than 16 years who underwent cardiac surgery necessitating cardiopulmonary bypass (CPB) in a tertiary referral center in London, UK, over a 2-year period from May 2006 to April 2008 inclusive. Patients we
30、re excluded if there was a need for a ventricular assist device or extracorporeal membrane oxygenation, cardiac transplantation, need for more than 1 episodeof CPB during thesame admission, a requirement for RRT before surgery, or death within 24 hours of surgery. These exclusions were selected to p
31、ermit direct comparison with previously published data from our institution 15. Cardiopulmonary bypass was carried out using a calibrated roller pump (Stckert, Munich, Germany) at a flow rate of 2.4 L min1m2at 28C to 32C 12. Mean arterial pressure during CPB was maintained between 60 and 65 mm Hg us
32、ing vasoactive agents, if necessary. Venous oxygen saturation was maintained in excess of 65%. Shed mediastinal blood was washed (Cell Saver, Haemonetics, Mass) and returned. Patient exposure to free hemoglobin was minimized by checking occlusion pressures on roller pumps before each case and by wee
33、kly quality control of cell salvage equipment. Patients undergoing coronary artery bypass grafting (CABG) received antibiotic prophylaxis with cefuroxime for a total of 4 doses. For surgery involving valve replacement or repair, teicoplanin was added and the duration of therapy extended until remova
34、l of intravascular and urinary catheters. Gentamicin prophylaxis was reserved for penicillin-allergic patients. The need for RRT was established by the consultant intensivist in charge of the patients care. Modality of choice was continuous venovenous hemodiafiltration (Prisma CFM; Hospal, Lyon, Fra
35、nce) using AN69 membranes (surface area 1 m2) via a 12Fr double-lumen catheter (Dualyse; Vygon, Ecouen, France) inserted into the internal jugular or femoral vein. The blood pump speed was set at 150 mL/min, aiming for ultrafiltration and dialysate rates totalling approximately 2 L/h. Unfractionated
36、 heparin was used routinely for anticoagulation. In patients with contraindications to hepa- rin, epoprostenol and/or nonpharmacologic measures were used to keep the circuit patent. Detailsofpatientdemographics,typeofsurgery,laboratory data, and preoperative, perioperative, and postoperative managem
37、ent were retrieved from an automated, prospectively collected database (CareVue; Phillips, Groeningen, the Netherlands). The highest AKIN, RIFLE, and KDIGO stages in the first 7 days after surgery were calculated and recorded (Table 1). Glomerular filtration rate was estimated using the Modification
38、 of Diet in Renal Disease formula 13. Baseline renal function was determined by using the most recent serum creatinine, which was either the creatinine value taken in preadmission clinic or on admission to hospital. Urine output criteria were not used because our database did not contain 6- or 12-ho
39、urly urine output data for all patients. Postoperative day 1 was defined as the period up to 8AMon the day after surgery, day 2 as the period until 8AMon the subsequent day, and so on. Length of stay in ICU and hospital were expressed in days, rounded up to a whole integer. 2.2. Ethics The need for
40、individual informed consent was waived because this was a retrospective analysis of data collected prospectively for routine care, and there was no breach of privacyoranonymity (UK National ResearchEthics Service). 2.3. Statistical analysis Data were analyzed using GraphPad Prism version 4.02 (Graph
41、Pad Software, San Diego, CA, USA). Data were tested for normality using the Kolmogorov-Smirnov test. Normally distributed data were expressed as mean and SD, and nonnormally distributed data were expressed as median and interquartile range. Logistic regression analysis includ- ing calculation of odd
42、s ratio (OR) and 95% confidence intervals (CIs) and receiver operating characteristics curves were used to assess the association between maximum stage of AKI and hospital mortality. Areas under the receiver operating characteristics curve (AUC) were calculated, and differences between AUCs were com
43、pared using a nonpara- metric algorithm 14. The relationship between maximum stage of AKI and length of stay in ICU and hospital was assessed by a negative binomial regression model. P values were calculated 2 sided, and analyses were performed using 3Acute kidney injury after cardiac surgery accord
44、ing to RIFLE, AKIN and KDIGO R version 2.12.2 (R Foundation for Statistical Computing, Vienna, Austria) and Medcalc version 12.0.4 (MedCalc Software, Ostend, Belgium). Current data on the incidence and outcome of patients treated with RRT were compared with data from 1989 to 1990 14 and 1997 to 1998
45、 data 15 using Fisher exact test or a 1-sample t test, respectively. 3. Results 3.1. Baseline characteristics During the 24-month study period, 1922 adult patients underwent cardiac surgery with CPB. We excluded patients who received a ventricular assist device (n = 8), had treatment with extracorpo
46、real membrane oxygenation (n = 2), required RRT preoperatively (n = 7), had more than 1 episode of CPB during the same admission (n = 5), and who died within 24 hours of surgery (n = 19). The remaining 1881 patients were included in the analysis. Baseline characteris- tics and operative details are
47、shown in Table 2. One third of patients had a preoperative estimated GFR of less than 60 mL min11.73 m2consistent with the diagnosis of chronic kidney disease stage 3 or worse. 3.2. Incidence of AKI The incidence of AKI after cardiac surgery according to the AKIN and RIFLE criteria was 25.9% and 24.
48、9%, respectively (Table 3). Most patients with AKI had maximum AKI stage on the second day postsurgery, but more than 40% of episodes of AKI occurred later (Fig. 1). The proportion of patients with AKIN stage 1 and RIFLE- Risk was also similar at 16.9% and 17.9%, respectively. However, there was a g
49、reater proportion of patients with AKIN stage 3 compared with RIFLE-Failure, mainly because of all patients on RRT were classified as having AKIN stage 3 independent of serum creatinine results. When applying the RIFLE criteria to this cohort, the proportion of patients in each RIFLEstage was 42/336 (12.5%) for RIFLE- Risk, 41/98 (41.8%) for RIFLE-Injury, and 35/35 (100%) for RIFLE-Failure, respectively. The number of patients who received RRT in each of the RIFLE categories was 42/336 (12.5%) for RIFLE-Risk, 40/98 (40.8%) for RIFLE-Injury, and 17/35 (48.6%) for RIFLE-Failure. Renal