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当代简单风险评分可有效预测PCI后造影剂相关急性肾损伤的风险
作者:小柯机器人 发布时间:2021/11/21 23:53:56

美国西奈山伊坎医学院Roxana Mehran团队研究了预测经皮冠状动脉介入术后造影剂相关急性肾损伤的当代简单风险评分。该项研究成果发表在2021年11月15日出版的《柳叶刀》杂志上。

经皮冠状动脉介入治疗(PCI)后可发生造影剂相关急性肾损伤。预测造影剂相关的急性肾损伤风险对于个性化定制的预防和缓解策略非常重要。研究组试图建立一个简单的风险评分,根据一个大的当代PCI队列来估计造影剂相关的急性肾损伤风险。

研究组招募2012年1月1日至2020年12月31日在一家大型三级医疗中心接受PCI的连续就诊患者,术前和术后48小时内均进行肌酐检测;仅排除慢性透析患者。2012-2017年间接受治疗的患者构成衍生队列,2018-2020年间接受治疗的患者构成验证队列。主要终点是造影剂相关性急性肾损伤,根据急性肾损伤网络定义。

造影剂相关急性肾损伤的独立预测因子来自多变量logistic回归分析。模型1仅包括手术前变量,模型2还包括手术变量。根据每个独立变量的疗效估计,使用加权整数得分来计算每个患者的最终风险得分。研究组还评估了造影剂相关急性肾损伤对1年死亡的影响。

医院共施行了32378次PCI手术,对其进行筛选,以纳入本分析。排除未进行配对肌酐检测、接受慢性透析和多次手术的患者后,14616名患者被纳入衍生队列(平均年龄66.2岁,女性占29.2%),5606名患者被纳入验证队列(平均年龄67.0岁,女性占26.4%)。

860例(4.3%)患者出现造影剂相关性急性肾损伤。模型1中造影剂相关急性肾损伤的独立预测因子包括:临床症状、估计肾小球滤过率、左室射血分数、糖尿病、血红蛋白、基础血糖、充血性心力衰竭和年龄。模型2中的其他独立预测因子包括:造影剂体积、围手术期出血、术后无血流或血流缓慢以及复杂的PCI解剖结构。

衍生队列中造影剂相关急性肾损伤的发生率在两种模型的四个风险评分组中从最低风险到最高风险逐渐增加(模型1为2.3%至34.9%,模型2为2.0%至38.8%)。在模型中纳入术中变量仅略微改善了风险评分的区别(衍生队列中的C-统计:模型1为0.72,模型2为0.74;验证队列中:模型1为0.84,模型2为0.86)。造影剂相关急性肾损伤患者1年死亡的风险显著增加(10.2%对2.5%),大多数为超过30天的死亡。

研究结果表明,基于PCI患者现今变量的当代简单风险评分可以准确识别造影剂相关急性肾损伤的风险,该风险与后续死亡密切相关。

附:英文原文

Title: A contemporary simple risk score for prediction of contrast-associated acute kidney injury after percutaneous coronary intervention: derivation and validation from an observational registry

Author: Roxana Mehran, Ruth Owen, Mauro Chiarito, Usman Baber, Samantha Sartori, Davide Cao, Johny Nicolas, Carlo Andrea Pivato, Matteo Nardin, Prakash Krishnan, Annapoorna Kini, Samin Sharma, Stuart Pocock, George Dangas

Issue&Volume: 2021-11-15

Abstract:

Background

Contrast-associated acute kidney injury can occur after percutaneous coronary intervention (PCI). Prediction of the contrast-associated acute kidney injury risk is important for a tailored prevention and mitigation strategy. We sought to develop a simple risk score to estimate contrast-associated acute kidney injury risk based on a large contemporary PCI cohort.

Methods

Consecutive patients undergoing PCI at a large tertiary care centre between Jan 1, 2012, and Dec 31, 2020, with available creatinine measurements both before and within 48 h after the procedure, were included; only patients on chronic dialysis were excluded. Patients treated between 2012 and 2017 comprised the derivation cohort and those treated between 2018 and 2020 formed the validation cohort. The primary endpoint was contrast-associated acute kidney injury, defined according to the Acute Kidney Injury Network. Independent predictors of contrast-associated acute kidney injury were derived from multivariate logistic regression analysis. Model 1 included only pre-procedural variables, whereas Model 2 also included procedural variables. A weighted integer score based on the effect estimate of each independent variable was used to calculate the final risk score for each patient. The impact of contrast-associated acute kidney injury on 1-year deaths was also evaluated.

Findings

32378 PCI procedures were performed and screened for inclusion in the present analysis. After the exclusion of patients without paired creatinine measurements, patients on chronic dialysis, and multiple procedures, 14616 patients were included in the derivation cohort (mean age 66·2 years, 29·2% female) and 5606 were included in the validation cohort (mean age 67·0 years, 26·4% female). Contrast-associated acute kidney injury occurred in 860 (4·3%) patients. Independent predictors of contrast-associated acute kidney injury included in Model 1 were: clinical presentation, estimated glomerular filtration rate, left ventricular ejection fraction, diabetes, haemoglobin, basal glucose, congestive heart failure, and age. Additional independent predictors in Model 2 were: contrast volume, peri-procedural bleeding, no flow or slow flow post procedure, and complex PCI anatomy. The occurrence of contrast-associated acute kidney injury in the derivation cohort increased gradually from the lowest to the highest of the four risk score groups in both models (2·3% to 34·9% in Model 1, and 2·0% to 38·8% in Model 2). Inclusion of procedural variables in the model only slightly improved the discrimination of the risk score (C-statistic in the derivation cohort: 0·72 for Model 1 and 0·74 for model 2; in the validation cohort: 0·84 for Model 1 and 0·86 for Model 2). The risk of 1-year deaths significantly increased in patients with contrast-associated acute kidney injury (10·2% vs 2·5%; adjusted hazard ratio 1·76, 95% CI 1·31–2·36; p=0·0002), which was mainly due to excess 30-day deaths.

Interpretation

A contemporary simple risk score based on readily available variables from patients undergoing PCI can accurately discriminate the risk of contrast-associated acute kidney injury, the occurrence of which is strongly associated with subsequent death.

DOI: 10.1016/S0140-6736(21)02326-6

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02326-6/fulltext

期刊信息

LANCET:《柳叶刀》,创刊于1823年。隶属于爱思唯尔出版社,最新IF:59.102
官方网址:http://www.thelancet.com/
投稿链接:http://ees.elsevier.com/thelancet