RESUMEN
BACKGROUND: It has been recently mathematically demonstrated that the percentage increase in serum creatinine (SCr) can delay acute kidney injury (AKI) diagnosis in patients with previous chronic kidney disease (CKD). Based on creatinine (Cr) kinetics, it was suggested a new AKI classification using absolute increase in SCr elevation over specified time periods. However, this classification has not been evaluated in clinical studies. METHODS: A prospective cohort study evaluated myocardial infarction patients during the first 7 days of hospital stay with daily SCr measurements. They were classified using Kidney Disease Improving Global Outcomes (KDIGO) and Cr kinetics systems. Both classifications were compared by net reclassification improvement (NRI) and area under the receiver operator characteristic (AuROC) curve regarding hospital mortality. RESULTS: A total of 584 patients were included, of which 34.1% had previous CKD. Patients had more AKI by KDIGO than by Cr kinetics criteria (25.7 versus 18.0%, P < 0.001) and 81 patients (13.9%) had different AKI severity classification. Patients with AKI by KDIGO criteria and non-AKI by Cr kinetics had higher hospital mortality rates than patients with non-AKI using both classifications [adjusted mortality odds ratios (ORs): 4.753; 95% confidence interval (CI): 1.119-9.023, P = 0.014]. In patients with previous CKD, NRI analysis was 6.2% favoring Cr kinetics criteria. However, there was no difference using the AuROC curve analysis. In patients with no previous CKD, NRI analysis was 33.0%, favoring KDIGO, and this was in accordance with a better AuROC curve (0.828 versus 0.664, P < 0.05). CONCLUSIONS: AKI classification proposed by a Cr kinetics model can be superior when diagnosing patients with previous CKD. However, KDIGO had a better performance in patients with no previous CKD.
Asunto(s)
Lesión Renal Aguda/diagnóstico , Creatinina/metabolismo , Mortalidad Hospitalaria , Infarto del Miocardio/complicaciones , Insuficiencia Renal Crónica/complicaciones , Lesión Renal Aguda/clasificación , Lesión Renal Aguda/etiología , Lesión Renal Aguda/mortalidad , Anciano , Área Bajo la Curva , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Humanos , Cinética , Tiempo de Internación , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Prospectivos , Curva ROC , Insuficiencia Renal Crónica/diagnóstico , Factores de TiempoRESUMEN
INTRODUCTION: Acute kidney injury (AKI) is common in acute myocardial infarction (AMI) patients and has serious prognostic implications. The early identification of patients at risk of developing AKI at the emergency department (ED) can reduce its incidence. METHODS: Patients with ST-segment elevation myocardial infarction (STEMI) at the ED were included. Associated factors playing a role at ED presentation and during hospitalization were collected, and independent risk factors of developing AKI were assessed. RESULTS: Mean age among patients (n = 406, 69.7% male) was 62.5 ± 12.5 years. At ED admission, the mean glomerular filtration rate (GFR) was 70.5 ± 28.1 mL/min per 1.73 m(2), and 140 (34.5%) patients had a GFR <60 mL/min per 1.73 m(2). Eighty-three patients (20.4%) developed AKI: 47 (11.6%) with stage 1, 26 (6.4%) with stage 2 and 10 (2.5%) with stage 3. Mortality was 11.8% and was higher in patients with AKI (34.9% vs 5.9%, P < .0001). Univariate analysis disclosed age, reduced GFR at presentation, severe Killip class, heart rate and longer door-to-needle time as risk factors to develop AKI. Moreover, these patients received less ß-blocker and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker in the ED. Multivariate analysis revealed that age, Killip class, heart rate, door-to-needle time, and ß-blocker non-use were independent factors associated with AKI. These factors provided the ED physician with good accuracy in identifying patients at high risk of developing AKI. CONCLUSION: Factors associated with AKI in STEMI patients allowed physicians to identify patients at high risk in the ED. Moreover, reduced door-to-needle time and ß-blocker use were associated with renal protection in AMI patients.