Can We Really Predict Postoperative Acute Kidney Injury after Aortic Surgery? Diagnostic Accuracy of Risk Scores Using Gray Zone Approach

Abstract

Background Several risk scores have been developed to predict acute kidney injury (AKI) after cardiac surgery. We evaluated the accuracy of eight prediction models using the gray zone approach in patients who underwent aortic surgery.

Patients and Methods We retrospectively applied the risk scores of Palomba, Wijeysundera, Mehta, Thakar, Brown, Aronson, Fortescue, and Rhamanian to 375 consecutive adult patients undergoing aortic surgery with cardiopulmonary bypass. The area under the receiver operating characteristic curve (AUC) and gray zone approach were used to evaluate the accuracy of the eight models for prediction of AKI, as defined by the RIFLE criteria.

Results The incidence of AKI was 29% (109/375). The AUC for predicting AKI requiring dialysis ranged from 0.66 to 0.84, excluding the score described by Brown et al (0.50). The AUC for predicting the RIFLE criteria of risk and higher ranged from 0.57 to 0.68. The application of gray zone approach resulted in more than half of the patients falling in the gray zone: 275 patients (73%) for Palomba, 221 (59%) for Wijeysundera, 292 (78%) for Mehta, 311 (83%) for Thakar, 329 (88%) for Brown, 291 (78%) for Aronson, 205 (54%) for Fortescue, and 308 (82%) for Rhamanian.

Conclusion More than half of the patients in our study sample were in the gray zone of eight scoring models for AKI prediction. The two cutoffs of the gray zone can be used when using risk models. A surgery-specific and more accurate prediction model with a smaller gray zone is required for patients undergoing aortic surgery.

Keywords

anesthesia - aneurysm - aorta/aortic

• References

• 1 Hobson CE, Yavas S, Segal MS , et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation 2009; 119 (18) 2444-2453
• 2 Ried M, Haneya A, Kolat P , et al. Acute renal dysfunction does not develop more frequently among octogenarians compared to septuagenarians after cardiac surgery. Thorac Cardiovasc Surg 2012; 60 (1) 51-56
• 3 Andersson LG, Ekroth R, Bratteby LE, Hallhagen S, Wesslén O. Acute renal failure after coronary surgery—a study of incidence and risk factors in 2009 consecutive patients. Thorac Cardiovasc Surg 1993; 41 (4) 237-241
• 4 Koning HM, Leusink JA, Nas AA , et al. Renal function following open heart surgery: the influence of postoperative artificial ventilation. Thorac Cardiovasc Surg 1988; 36 (1) 1-4
• 5 Arnaoutakis GJ, Bihorac A, Martin TD , et al. RIFLE criteria for acute kidney injury in aortic arch surgery. J Thorac Cardiovasc Surg 2007; 134 (6) 1554-1560 , discussion 1560–1561
• 6 Englberger L, Suri RM, Greason KL , et al. Deep hypothermic circulatory arrest is not a risk factor for acute kidney injury in thoracic aortic surgery. J Thorac Cardiovasc Surg 2011; 141 (2) 552-558
• 7 Augoustides JG, Pochettino A, Ochroch EA , et al. Renal dysfunction after thoracic aortic surgery requiring deep hypothermic circulatory arrest: definition, incidence, and clinical predictors. J Cardiothorac Vasc Anesth 2006; 20 (5) 673-677
• 8 Kowalik MM, Lango R, Klajbor K , et al. Incidence- and mortality-related risk factors of acute kidney injury requiring hemofiltration treatment in patients undergoing cardiac surgery: a single-center 6-year experience. J Cardiothorac Vasc Anesth 2011; 25 (4) 619-624
• 9 Rosner MH, Okusa MD. Acute kidney injury associated with cardiac surgery. Clin J Am Soc Nephrol 2006; 1 (1) 19-32
• 10 Thakar CV, Arrigain S, Worley S, Yared JP, Paganini EP. A clinical score to predict acute renal failure after cardiac surgery. J Am Soc Nephrol 2005; 16 (1) 162-168
• 11 Mehta RH, Grab JD, O'Brien SM , et al; Society of Thoracic Surgeons National Cardiac Surgery Database Investigators. Bedside tool for predicting the risk of postoperative dialysis in patients undergoing cardiac surgery. Circulation 2006; 114 (21) 2208-2216 , quiz 2208
• 12 Palomba H, de Castro I, Neto AL, Lage S, Yu L. Acute kidney injury prediction following elective cardiac surgery: AKICS Score. Kidney Int 2007; 72 (5) 624-631
• 13 Wijeysundera DN, Karkouti K, Dupuis JY , et al. Derivation and validation of a simplified predictive index for renal replacement therapy after cardiac surgery. JAMA 2007; 297 (16) 1801-1809
• 14 Aronson S, Fontes ML, Miao Y, Mangano DT ; Investigators of the Multicenter Study of Perioperative Ischemia Research Group; Ischemia Research and Education Foundation. Risk index for perioperative renal dysfunction/failure: critical dependence on pulse pressure hypertension. Circulation 2007; 115 (6) 733-742
• 15 Brown JR, Cochran RP, Leavitt BJ , et al; Northern New England Cardiovascular Disease Study Group. Multivariable prediction of renal insufficiency developing after cardiac surgery. Circulation 2007; 116 (11, Suppl): I139-I143
• 16 Fortescue EB, Bates DW, Chertow GM. Predicting acute renal failure after coronary bypass surgery: cross-validation of two risk-stratification algorithms. Kidney Int 2000; 57 (6) 2594-2602
• 17 Rahmanian PB, Kwiecien G, Langebartels G, Madershahian N, Wittwer T, Wahlers T. Logistic risk model predicting postoperative renal failure requiring dialysis in cardiac surgery patients. Eur J Cardiothorac Surg 2011; 40 (3) 701-707
• 18 Kim WH, Lee SM, Choi JW , et al. Simplified clinical risk score to predict acute kidney injury after aortic surgery. J Cardiothorac Vasc Anesth 2013; 27 (6) 1158-1166
• 19 Kiers HD, van den Boogaard M, Schoenmakers MC , et al. Comparison and clinical suitability of eight prediction models for cardiac surgery-related acute kidney injury. Nephrol Dial Transplant 2013; 28 (2) 345-351
• 20 Candela-Toha A, Elías-Martín E, Abraira V , et al. Predicting acute renal failure after cardiac surgery: external validation of two new clinical scores. Clin J Am Soc Nephrol 2008; 3 (5) 1260-1265
• 21 Englberger L, Suri RM, Li Z , et al. Validation of clinical scores predicting severe acute kidney injury after cardiac surgery. Am J Kidney Dis 2010; 56 (4) 623-631
• 22 Heise D, Sundermann D, Braeuer A, Quintel M. Validation of a clinical score to determine the risk of acute renal failure after cardiac surgery. Eur J Cardiothorac Surg 2010; 37 (3) 710-716
• 23 Coste J, Pouchot J. A grey zone for quantitative diagnostic and screening tests. Int J Epidemiol 2003; 32 (2) 304-313
• 24 Feinstein AR. The inadequacy of binary models for the clinical reality of three-zone diagnostic decisions. J Clin Epidemiol 1990; 43 (1) 109-113
• 25 Cannesson M, Le Manach Y, Hofer CK , et al. Assessing the diagnostic accuracy of pulse pressure variations for the prediction of fluid responsiveness: a “gray zone” approach. Anesthesiology 2011; 115 (2) 231-241
• 26 Ray P, Le Manach Y, Riou B, Houle TT. Statistical evaluation of a biomarker. Anesthesiology 2010; 112 (4) 1023-1040
• 27 Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D ; Modification of Diet in Renal Disease Study Group. A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation. Ann Intern Med 1999; 130 (6) 461-470
• 28 Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 1982; 143 (1) 29-36
• 29 DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: a nonparametric approach. Biometrics 1988; 44 (3) 837-845
• 30 Leshnower BG, Myung RJ, Kilgo PD , et al. Moderate hypothermia and unilateral selective antegrade cerebral perfusion: a contemporary cerebral protection strategy for aortic arch surgery. Ann Thorac Surg 2010; 90 (2) 547-554
• 31 Roh GU, Lee JW, Nam SB, Lee J, Choi JR, Shim YH. Incidence and risk factors of acute kidney injury after thoracic aortic surgery for acute dissection. Ann Thorac Surg 2012; 94 (3) 766-771
• 32 Geirsson A, Szeto WY, Pochettino A , et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg 2007; 32 (2) 255-262
• 33 Concato J, Feinstein AR, Holford TR. The risk of determining risk with multivariable models. Ann Intern Med 1993; 118 (3) 201-210