Risk Factors for Acute Kidney Injury Following Cardiac Catheterisation
Table 1: Acute Kidney Injury Outcome Definitions According to the Acute Kidney Injury Network and Acute Dialysis Quality Initiative Group
AKIN Definition36 Stage 1
Stage 2 Stage 3
Cr ≥50 % or ↑Cr ≥0.3 mg/dl, or urine output <0.5 ml/kg/hr for 6 hours
Cr ≥100 % or urine output <0.5 ml/kg/hr for >12 hours
Cr ≥200 % or Cr ≥4 mg/dl with acute rise of ≥0.5 mg/dl, or
urine output <0.3 ml/kg/hr for 24 hours or aneuria for 12 hours
Loss ESRD
RIFLE Definition35 Risk
Injury Failure
Cr ≥50 % or ↓GFR ≥25 % and urine output <0.5 ml/kg/hr for 6 hours
Cr ≥100 % or ↓GFR ≥50 % and urine output <0.5 ml/kg/hr for 12 hours
Cr ≥200 % or ↓GFR ≥75 % or Cr ≥4 mg/dl with acute rise of ≥0.5 mg/dl and urine output <0.3 ml/kg/hr or aneuria for 12 hours
Persistent need for renal replacement >4 weeks Need for renal replacement therapy >3 months
AKIN = Acute Kidney Injury Network; Cr = serum creatinine; ESRD = end stage renal disease; GFR = glomerular filtration rate; RIFLE = Risk, Injury, Failure, Loss, and End Stage Kidney Disease Criteria for Acute Renal Dysfunction (Acute Dialysis Quality Initiative).
Table 2: Summary of the Acute Kidney Injury Risk Prediction Models Following Percutaneous Coronary Interventions
Bartholomew20 Mehran21 Freeman43 Brown19 Maioli44
MuCullough11, 12 Marenzi50 Lindsay2 Gruberg37 Gupta33 Rihal6
Dangas51 Madsen45 Conen81 Conen81
Fukumoto82 Iakovou38 Neyra39
Centres 1 1 8
10 1 1 1 1 1 1 1 1 1 1 1
11 1 1
Time Period 1993–2002 ~1997–2002 1997–2000 2003–2005 2003–2004 1993–1995 2001–2003 1994–2000 1994–1998 1997–2001 1996–2000 ~1999–2003 1994–2002 1998–1999 1998–1999 1998–1999 1994–1999 2008–2009
AKI Outcome Definition ↑Cr ≥1 mg/dl
↑Cr ≥25 % or ↑Cr ≥0.5 mg/dl Dialysis
Dialysis or ↑Cr ≥50 % or ↑Cr ≥2 mg/dl ↑Cr ≥0.5 mg/dl Dialysis
↑Cr ≥0.5 mg/dl ↑ Cr ≥50 % Dialysis
↑Cr ≥1 mg/dl ↑Cr ≥0.5 mg/dl
↑Cr ≥25 % or ↑Cr ≥0.5 mg/dl ↑Cr ≥0.5 mg/dl ↑Cr ≥0.5 mg/dl ↑Cr ≥25 %
Embolism* or ↑Cr ≥50 % ↑Cr ≥25 %
↑Cr ≥25 % or ↑Cr ≥0.5 mg/dl or ↓eGFR ≥25 %
Outcome Window n Inpatient 2 Days
Inpatient Inpatient 5 Days
Inpatient Inpatient Inpatient Inpatient 1 Day
2 Days 2 Days
Inpatient 2 Days 2 Days
14 Days 2 Days 3 Days
Event Rate 20,479 2 %
8,357 13.3 % 16,592 0.4 % 11,141 0.7 % 1,218 9.4 % 1,869
208 19 % 5,967 3.5 % 7,741 0.7 % 9,067 1.6 % 7,586 3.3 % 7,230 14.7 % 5,256 11.2 % 1,383 0.7 % 1,383 10 % 1,786 1.4 % 8,628 16.5 % 1,211 16.3 %
* Post-procedural new onset livedo reticularis, blue toe syndrome, or digital gangrene. AKI = acute kidney injury; Cr = serum creatinine; eGFR = estimated glomerular filtration rate.
A clear understanding of the known risk factors, existing risk prediction models and the outcome heterogeneity following cardiac catheterisation is critical to improving patient care. In this review, we describe a summary of the known risk factors consistently identified in observational cohorts and randomised control trial data and describe the limitations and challenges of the outcome definition variation due to threshold and time window differences.
Outcome Definitions
The heterogeneous application of different thresholds in the former carry different sensitivity and specificity limitations, which have contributed to wide variation in the reported event rates and have made it difficult to adequately compare patterns of disease across cohorts.30–33
Furthermore, changes in
functional markers often require information on baseline kidney function, which are not always readily available.
EUROPEAN NEPHROLOGY
The study of AKI has been challenging due to multiple and competing clinical definitions of the outcome. In addition to lexicographical variability (e.g., acute renal failure/injury), most have relied on changes in functional markers, including serum creatinine and/or urine output, while a few others have focused on the need for clinical intervention, including dialysis or nephrology consultation.4,11,12
The most commonly used definition for CIN is a ≥25 % increase or ≥0.5 mg/dl increase in serum creatinine from baseline within 48 hours of exposure.3,12,18,34
However, in recent years, the
development and widespread acceptance in the nephrology community of the Acute Dialysis Quality Initiative Group35 Kidney Injury Network (AKIN),36
and Acute generalised AKI outcome definitions
have emerged (see Table 1). The guidelines focused exclusively on changes in creatinine/glomerular filtration rate (GFR) and urine output to make the determination and further stratify levels according to severity of injury. The significant outcome variation can be observed in the summary table of multivariable analyses of observational cohorts in Table 2.
Multivariate Acute Kidney Injury Risk Factors There are many studies performing multivariate analysis of risk factors for AKI following cardiac catheterisation. The main results from these studies are summarised in Table 2. Significant outcome variation can be observed between the studies from the previously mentioned definition heterogeneity. A summary of all variables that retained significance after multivariable analysis are shown in Table 3, and some of these risk factors are discussed in more detail below.
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