美国克利夫兰诊所Crystal A. Gadegbeku团队研究了基于围手术期实验室检测的心脏手术后中重度急性肾损伤预测模型的预测精度。这一研究成果于2022年3月8日发表在《美国医学会杂志》上。

急性肾损伤（AKI）的有效治疗取决于及时诊断；然而，肾损伤后血清肌酐水平升高的滞后可能会延迟治疗的开始。

为了确定心脏手术后AKI预测模型的推导和验证，研究组基于2000年1月至2019年12月在美国学术医学中心接受心脏手术的成年患者回顾性观察队列（58526名患者），推导出一个多变量预测模型，随后在3家美国社区医院（4734名患者）的外部队列中进行验证。最后一次随访日期为2020年1月15日。

暴露因素为心脏手术后第一代谢组的围手术期血清肌酐和术后血尿素氮、血清钠、钾、碳酸氢盐和白蛋白的变化。主要观察指标为术后72小时和14天内受试者工作特征曲线下面积（AUC）和用于中重度AKI、每种肾脏疾病的补救措施：改善整体预后（KDIGO）和模型预测需要透析的AKI。

衍生队列58526名患者的中位年龄为66岁，67%为男性，91%为白人参与者；术后72小时内中重度AKI和需要透析的AKI发生率分别为4.6%和1.48%，术后14天内则分别为5.4%和1.74%。从手术结束到第一次代谢组的中间间隔（IQR）为10小时。在派生队列中，基于代谢面板的模型对手术后72小时内（AUC为0.876）和14天内（0.854）的中重度AKI以及手术后72小时内（0.916）和14天内（0.900）需要透析的AKI有很好的预测辨别力。

验证队列4734名患者的中位年龄为67岁，71%为男性，87%为白人参与者；手术后中重度AKI的模型显示72小时内AUC为0.860，14天内AUC为0.842，手术后需要透析的AKI模型72小时内AUC为0.879，14天内AUC为0.873。通过Spiegelhalter z测试评估的校准结果显示P>0.05，表明验证模型和衍生模型均已很好地校准。

研究结果表明，在接受心脏手术的患者中，基于围手术期基本代谢面板实验室值的预测模型对手术后72小时和14天内的中重度急性肾损伤具有良好的预测准确性。但仍需进一步研究来确定使用风险预测工具是否能改善临床预后。

附：英文原文

Title: Predictive Accuracy of a Perioperative Laboratory Test–Based Prediction Model for Moderate to Severe Acute Kidney Injury After Cardiac Surgery

Author: Sevag Demirjian, C. Allen Bashour, Andrew Shaw, Jesse D. Schold, James Simon, David Anthony, Edward Soltesz, Crystal A. Gadegbeku

Issue&Volume: 2022/03/08

Abstract:

Importance  Effective treatment of acute kidney injury (AKI) is predicated on timely diagnosis; however, the lag in the increase in serum creatinine levels after kidney injury may delay therapy initiation.

Objective  To determine the derivation and validation of predictive models for AKI after cardiac surgery.

Design, Setting, and Participants  Multivariable prediction models were derived based on a retrospective observational cohort of adult patients undergoing cardiac surgery between January 2000 and December 2019 from a US academic medical center (n=58526) and subsequently validated on an external cohort from 3 US community hospitals (n=4734). The date of final follow-up was January 15, 2020.

Exposures  Perioperative change in serum creatinine and postoperative blood urea nitrogen, serum sodium, potassium, bicarbonate, and albumin from the first metabolic panel after cardiac surgery.

Main Outcomes and Measures  Area under the receiver-operating characteristic curve (AUC) and calibration measures for moderate to severe AKI, per Kidney Disease: Improving Global Outcomes (KDIGO), and AKI requiring dialysis prediction models within 72 hours and 14 days following surgery.

Results  In a derivation cohort of 58526 patients (median [IQR] age, 66 [56-74] years; 39173 [67%] men; 51503 [91%] White participants), the rates of moderate to severe AKI and AKIrequiring dialysis were 2674 (4.6%) and 868 (1.48%) within 72 hours and 3156 (5.4%) and 1018 (1.74%) within 14 days after surgery. The median (IQR) interval to first metabolic panel from conclusion of the surgical procedure was 10 (7-12) hours. In the derivation cohort, the metabolic panel–based models had excellent predictive discrimination for moderate to severe AKI within 72 hours (AUC, 0.876 [95% CI, 0.869-0.883]) and 14 days (AUC, 0.854 [95% CI, 0.850-0.861]) after the surgical procedure and for AKI requiring dialysis within 72 hours (AUC, 0.916 [95% CI, 0.907-0.926]) and 14 days (AUC, 0.900 [95% CI, 0.889-0.909]) after the surgical procedure. In the validation cohort of 4734 patients (median [IQR] age, 67 (60-74) years; 3361 [71%] men; 3977 [87%] White participants), the models for moderate to severe AKI after the surgical procedure showed AUCs of 0.860 (95% CI, 0.838-0.882) within 72 hours and 0.842 (95% CI, 0.820-0.865) within 14 days and the models for AKI requiring dialysis and 14 days had an AUC of 0.879 (95% CI, 0.840-0.918) within 72 hours and 0.873 (95% CI, 0.836-0.910) within 14 days after the surgical procedure. Calibration assessed by Spiegelhalter z test showed P >.05 indicating adequate calibration for both validation and derivation models.

Conclusions and Relevance  Among patients undergoing cardiac surgery, a prediction model based on perioperative basic metabolic panel laboratory values demonstrated good predictive accuracy for moderate to severe acute kidney injury within 72 hours and 14 days after the surgical procedure. Further research is needed to determine whether use of the risk prediction tool improves clinical outcomes.

DOI: 10.1001/jama.2022.1751

Source: https://jamanetwork.com/journals/jama/article-abstract/2789659