Acute Kidney Injury
Risk Factors for Acute Kidney Injury Following Cardiac Catheterisation Michael E Matheny,1
Edward D Siew,1 Josh F Peterson1 Frederic S Resnic,1 Theodore Speroff,2 and Jeremiah R Brown3
1. Assistant Professor of Medicine, Section of Interventional Cardiology, Brigham and Women’s Hospital and Harvard Medical School; 2. Professor, Geriatric Research and Education Clinical Centre, Tennessee Valley Health System, Veteran’s Administration; 3. Assistant Professor of Health Policy and Clinical Practice, The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth Medical School
Abstract
Acute kidney injury (AKI) is a frequent complication following cardiac catheterisation and percutaneous coronary intervention (PCI). Contrast-induced AKI is commonly defined as a 25 % or 0.5 mg/dl increase in serum creatinine within 48 hours of the procedure. Numerous studies have developed prediction models for contrast-induced AKI from large-scale databases and clinical trials. In this review, we discuss the clinical importance of AKI and the patient, clinical, and procedural risk factors for determining the risk of AKI to the patient undergoing a cardiac catheterisation or PCI. These risk factors can be incorporated into routine patient risk assessments and used for patient and provider education and institutional surveillance of patient safety.
Keywords
Acute kidney injury, contrast-induced nephropathy, cardiac catheterisation, percutaneous coronary intervention, angioplasty, risk prediction, outcomes, patient safety
Disclosure: Michael E Matheny is supported by the Veterans Administration Health Services Research and Development (VA HSR&D), grant number CDA-08-020. Edward D Siew is supported by the Vanderbilt Clinical and Translational Research Scholarship Award (5-KL2-RR-24977-03). Josh F Peterson is supported by the National Library of Medicine (NLM), grant number LM-009965-03. Jeremiah R Brown is supported by the Agency for Healthcare Research and Quality (AHRQ), grant number K01-HS-018443. The content is solely the responsibility of the authors and does not necessarily represent the official views of VA HSR&D, NLM, or AHRQ. Received: 10 June 2011 Accepted: 31 July 2011 Citation: European Nephrology, 2011;5(2):116–20 Correspondence: Jeremiah R Brown, HB 7505 DHMC, One Medical Center Drive, Lebanon, NH 03756, US. E:
jbrown@dartmouth.edu
Acute kidney injury (AKI) is a frequent complication following cardiac catheterisation and is associated with elevated morbidity,1–3 higher short- and long-term mortality,4–6 and higher overall costs.8,9
increased length of stay7 Contrast-induced nephropathy (CIN)4,10–13
causes the majority of post-procedural AKI, but other acute medical conditions such as renal atheroembolism,14–16
chronic medical
conditions such as diabetes and chronic kidney disease (CKD) and medication or medical device exposures can cause or contribute to renal injury. CIN and vascular volume derangements generally occur between 24 and 72 hours following the procedure, while renal atheroembolism can occur at any point up to three to four weeks following the procedure. Definitive causation cannot be determined without renal biopsy; an invasive procedure rarely pursued in this setting. For this reason, AKI is the preferred term to refer to the spectrum of post-procedural renal dysfunction.
Several risk prediction models have been developed to predict the occurrence of AKI following cardiac catheterisation. Some of these models focused on pre-procedural variables to determine the relative contribution of demographics, co-morbidity status and clinical settings to the risk of developing AKI.19 also included procedural variables in order to demonstrate and
Others 116
While there are no effective treatments for established AKI in this setting other than supportive care, prophylactic measures exist, which can potentially reduce risk. Consequently, proactive identification of high-risk individuals is of paramount clinical relevance.17,18
adjust for the relative contribution of contrast load or other physiological characteristics to the risk of AKI.20,21
However,
including procedural information results in models that predict patient risk following the procedure and these models cannot be used for evaluating patients for prophylaxis prior to the procedure. Patients can be risk stratified by calculating risk for individual patients and high-risk patients can be targeted for pre-procedural therapies to reduce their risk of AKI following the procedure. Model results and recommendations for pre-procedural prophylaxis can be delivered by integration into electronic health record clinical decision support.22,23
Development of risk stratification models also serves an important public health need by providing risk stratification and risk adjustment in institutional and provider profiling. Models can also provide important risk adjustment in medication and medical device post-marketing surveillance. High-quality mandatory registries, such as those in the coronary artery bypass grafting surgery and cardiac catheterisation registries of Massachusetts and New York,24,25
have strong surveillance
networks because of high-quality data and established manual and automated surveillance protocols.26–28
In fact, surveillance in the
Massachusetts registry detected outliers, which achieved reduced adverse outcomes after notification and quality improvement initiatives.29
incorporation of relevant risk factors into the observational cohort confounding adjustment.
© TOUCH BRIEFINGS 2011 All of these activities rely on identification and
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