Abstract
BackgroundAlthough urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance.Material and methodsA total of 177 consecutive patients who underwent cardiac surgery were enrolled. Clinical characteristics, prognostic model scores, and outcomes were assessed. Urinary NGAL were examined within 6 hours after cardiac surgery. Patients were stratified according to preoperative ACEF scores, and comparisons were made using the area under the receiver operator characteristic curve (AUROC) for the prediction of AKI.ResultsA total of 45.8% (81/177) of the patients had AKI. As expected, patients with ACEF scores ≥ 1.1 were older and more likely to have class III or IV heart failure. They were also more likely to have diabetes mellitus, myocardial infarction, and peripheral arterial disease. Urinary NGAL alone moderately predicted AKI, with an AUROC of 0.732. Risk stratification by ACEF scores ≥ 1.1 substantially improved the AUROC of urinary NGAL to 0.873 (95% confidence interval, 0.784–0.961; P < .001).ConclusionsRisk stratification by preoperative ACEF scores ≥ 1.1, followed by postoperative urinary NGAL, provides more satisfactory risk discrimination than does urinary NGAL alone for the early detection of AKI after cardiac surgery. Future studies should investigate whether this strategy could improve the outcomes and cost-effectiveness of care in patients undergoing cardiac surgery.
Highlights
Acute kidney injury (AKI) occurs in 10%–50% of patients undergoing cardiac surgery.[1,2,3,4,5] This statistical variation is largely due to heterogeneous study populations and the use of different criteria to define AKI
Comorbidities were evaluated according to the following definitions: myocardial infarction was defined according to the 2007 Expert Consensus Document of Circulation, European Heart Journal; Peripheral arterial disease (PAD) was defined as a confirmed ankle–brachial index < 0.9, diagnosis established through duplex ultrasonography, and need for medication; and chronic obstructive pulmonary disease was confirmed through a spirometer test or a medical history and need for treatment
We demonstrated the performance characteristics of a two-step diagnostic framework, combined risk assessment through ACEF scores first and urinary neutrophil gelatinase-associated lipocalin (NGAL) test, a urinary biomarker of tubular injury measured within 6 hours after cardiac surgery, for detecting subsequent AKI
Summary
Acute kidney injury (AKI) occurs in 10%–50% of patients undergoing cardiac surgery.[1,2,3,4,5] This statistical variation is largely due to heterogeneous study populations and the use of different criteria to define AKI. Urinary neutrophil gelatinase-associated lipocalin (NGAL) has emerged as a promising biomarker for the early detection of kidney injury, previous studies of adult patients who underwent cardiac surgery have reported only moderate discrimination. The age, creatinine, and ejection fraction (ACEF) score is a preoperative validated risk model with satisfactory accuracy for predicting AKI following cardiac surgery. It remains unknown whether combining preoperative risk assessment through ACEF scores followed by urinary NGAL test in a population of high-risk individuals is an optimal approach with improved predictive performance
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