Risk assessment of acute kidney injury in patients with acute cardiovascular disease without invasive intervention

Objective. To evaluate the prevalence, predictors, prognostic value of cardiorenal interrelations in patients with acute cardiovascular disease (CVD), and to develop an algorithm for stratification these patients at risk of acute kidney injury (AKI). Materials and methods. 566 patients (pts) were examined: 278 with acute decompensated heart failure (ADHF) and 288 with non-ST-elevation acute coronary syndrome (NSTE-ACS). The levels of electrolytes, glucose, urea, creatinine were evaluated, glomerular filtration rate (GFR) was determined according to the formula CKD-EPI. Chest x-ray, electrocardiography at admission and in dynamics, echocardiography at admission with assessment of systolic and diastolic myocardial functions were performed. Chronic kidney disease (CKD), AKI, ADHF, NSTE-ACS were diagnosed according to Russian and international Guidelines. Mann-Whitney test and multivariate logistic regression analysis were considered significant if p<0.05. Results. Different variants of cardiorenal interrelations were revealed in 366 (64.7%) pts. CKD was diagnosed in 259 (45.8%), with more than half of the cases (61%) diagnosed for the first time at this hospitalization, 62 (11%) pts had signs of kidney damage of unknown duration (which did not allow to diagnose CKD). AKI occurred in 228 (40,3%) pts, more frequently in patients with ADHF vs with NSTE-ACS (43.5 and 37.2%). In all groups stage 1 of AKI was prevalent. In-hospital mortality was significantly higher in pts with AKI vs without AKI (14.9 vs 3.6%, p<0.001). The risk of AKI was determined by kidney function and blood pressure levels at admission, and comorbidities. Conclusion. Prevalence of cardiorenal interactions in patients with acute CVD (ADHF and NSTE-ACS) was 64.7%. Development of AKI was associated with poor prognosis in both groups. Renal function and blood pressure levels on admission are the main predictors of AKI.

1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. 2012;2(1):1–138. [Av. at: http://www.nephro.ru/content/files/standards/KDIGO_GN_AKI_anemia.pdf ]

2. Lewington AJP, Cerdá J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer. Kidney International. 2013;84(3):457–67. DOI:10.1038/ki.2013.153

3. Hoste EAJ, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Medicine. 2015;41(8):1411–23. DOI:10.1007/s00134-015-3934-7

4. Kolhe NV, Muirhead AW, Wilkes SR, Fluck RJ, Taal MW. The epidemiology of hospitalised acute kidney injury not requiring dialysis in England from 1998 to 2013: retrospective analysis of hospital episode statistics. International Journal of Clinical Practice. 2016;70(4):330–9. DOI:10.1111/ijcp.12774

5. Tao Li PK, Burdmann EA, Mehta RL. Acute kidney injury: global health alert. International Journal of Organ Transplantation Medicine. 2013;4(1):1–8. DOI:10.1016/j.hkjn.2013.03.001

6. Chawla LS, Eggers PW, Star RA, Kimmel PL. Acute Kidney Injury and Chronic Kidney Disease as Interconnected Syndromes. New England Journal of Medicine. 2014;371(1):58–66. DOI:10.1056/NEJMra1214243

7. Piccinni P, Cruz DN, Gramaticopolo S, Garzotto F, Dal Santo M, Aneloni G et al. Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT). Minerva Anestesiologica. 2011;77(11):1072–83. PMID: 21597441

8. MacLeod A. NCEPOD report on acute kidney injury-must do better. The Lancet. 2009;374(9699):1405–6. DOI:10.1016/S01406736(09)61843-2

9. Kellum JA, Bellomo R, Ronco C. Kidney Attack. JAMA. 2012;307(21):2265–2266. DOI:10.1001/jama.2012.4315

10. Park S, Baek SH, Ahn S, Lee K-H, Hwang H, Ryu J et al. Impact of Electronic Acute Kidney Injury (AKI) Alerts with Automated Nephrologist Consultation on Detection and Severity of AKI: A Quality Improvement Study. American Journal of Kidney Diseases. 2018;71(1):9–19. DOI:10.1053/j.ajkd.2017.06.008

11. Cardiorenal syndromes in critical care. Ronco C, Bellomo R, McCullough PA, editors -Basel ; New York: Karger;2010. – 366 p. ISBN 978-3-8055-9472-1

12. Matsushita K, Selvin E, Bash LD, Franceschini N, Astor BC, Coresh J. Change in Estimated GFR Associates with Coronary Heart Disease and Mortality. Journal of the American Society of Nephrology. 2009;20(12):2617–24. DOI:10.1681/ASN.2009010025

13. Marenzi G, Assanelli E, Campodonico J, De Metrio M, Lauri G, Marana I et al. Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission. Critical Care Medicine. 2010;38(2):438–44. DOI:10.1097/CCM.0b013e3181b9eb3b

14. Hillege HL. Renal Function as a Predictor of Outcome in a Broad Spectrum of Patients with Heart Failure. Circulation. 2006;113(5):671– 8. DOI:10.1161/CIRCULATIONAHA.105.580506

15. Cowie MR, Komajda M, Murray-Thomas T, Underwood J, Ticho B. Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH). European Heart Journal. 2006;27(10):1216–22. DOI:10.1093/eurheartj/ehi859

16. Vyalkina Yu.A., Shalaev S.V. Renal dysfunction in predicting the risk of cardiovascular death and myocardial infarction in patients with acute coronary syndrome without ST-segment elevation (based on annual observation). CardioSomatics. 2011;2(2):11–3. [Russian]

17. Avdoshina S.V., Pigareva Yu.A., Villevalde S.V., Ezhova L.G., Kobalava Zh.D. Prevalence, types and prognostic significance of acutekidney injury in patienths with non-ST-elevation acute coronary syndrome. Clinical Pharmacology and Therapy. 2013;22 (3):30–6. [Russian]

18. Klimenko A.S., Villevalde S.V., Kobalava Zh.D. Clinical variants of acute kidney injury in decompensated chronic heart failure: prevalence, severity and outcomes. Clinical Nephrology. 2013;5:19–26. [Russian]

19. Scientific society of nephrologists of Russia. Clinical guidelines for the diagnosis and treatment of acute kidney injury. 2014. [Russian] http://nonr.ru/?page_id=3115

20. Authors/Task Force Members, McMurray JJV, Adamopoulos S, Anker SD, Auricchio A, Bohm M et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. European Heart Journal. 2012;33(14):1787– 847. DOI:10.1093/eurheartj/ehs104

21. Mareev V.Yu., Ageev F.T., Arutyunov G.P., Koroteev A.V., Mareev Yu.V., Ovchinnikov A.G. et al. SEHF, RSC and RSMSIM national guidelines on CHF diagnostics and treatment (fourth revision) Approved at the SEHF Congress on December 7, 2012, at the SEHF Board of Directors meeting on March 31, 2013, and at the RSC Congress on September 25, 2013. Russian Heart Failure Journal. 2013;14(7):379–472. [Russian]

22. Ruda M.Ya., Golitsin S.P., Gratsiansky N.A., Komarov N.A., Panchenko E.P., Staroverov I.I. et al. Diagnosis and treatment of patients with acute myocardial infarction with ST-segment elevation ECG. Russian recomendations. Cardiovascular Therapy and Prevention. 2007;6(8 S1):415–500. [Russian]

23. Hemmelgarn BR, Manns BJ, Tonelli M. A Decade After the KDOQI CKD Guidelines: A Perspective From Canada. American Journal of Kidney Diseases. 2012;60(5):723–4. DOI:10.1053/j.ajkd.2012.08.026

24. Smirnov A.V. National recommendations. Chronic illness of kidneys: main principles of screening, diagnostics, preventive maintenance and approaches to treatment. – St. Petersburg: Levsha; 2012. – 54 p. [Russian]. ISBN 978-5-93356-129-3

25. Moiseev V.S., Mukhin N.A., Smirnov A.V., Kobalava Zh.D., Bobkova I. N., Villevalde S. V. et al. Cardiovascular risk and chronic kidney disease: cardio-nephroprotection strategies. Russian Journal of Cardiology. 2014;19 (8):7–37. [Russian]. DOI:10.15829/1560-4071-2014-8-7-37

26. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney International Supplements. 2012;2(1):1–141. [Available at: https://kdigo.org/wp-content/uploads/2016/10/KDIGO-2012-AKI-Guideline-English.pdf ]

27. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, Feldman HI et al. A new equation to estimate glomerular filtration rate. Annals of Internal Medicine. 2009;150(9):604–12. DOI:10.7326/0003-4819-150-9-200905050-00006

28. Forman DE, Butler J, Wang Y, Abraham WT, O’Connor CM, Gottlieb SS et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. Journal of the American College of Cardiology. 2004;43(1): 61–7. DOI:10.1016/j.jacc.2003.07.031

29. Makeeva E. R., Menzorov M. V., Shutov A. M., Serov V. A., Saen-ko Yu. V., Strakhov A. A. Effect of acute kidney injury on progno-sisin patients with acute decompensation of chronic heart. Russian Heart Failure Journal. 2014;15 (1):33–8. [Russian]

30. Menzorov M.V., Shutov A.M., Makeeva E.R., Serov V.A., Mikhaĭlo-va  E.V., Parfenova E.A. Problems in the diagnosis of acute kidney injury in patients with ST-segment elevation myocardial infarction. Therapeutic Archive. 2014;86(4):25–9. [Russian]

31. Takagi A, Iwama Y, Yamada A, Aihara K, Daida H. Estimated glo merular filtration rate is an independent predictor for mor-tality of patients with acute heart failure. Journal of Cardiology. 2010;55(3):317–21. DOI:10.1016/j.jjcc.2009.12.005

32. Sileanu FE, Murugan R, Lucko N, Clermont G, Kane-Gill SL, Handler SM et al. AKI in Low-Risk versus High-Risk Patients in Intensive Care. Clinical Journal of the American Society of  Nephrology. 2015;10(2):187–96. DOI:10.2215/CJN.03200314

33. Perinel S, Vincent F, Lautrette A, Dellamonica J, Mariat C, Zeni  F et al. Transient and Persistent Acute Kidney Injury and the Risk of  Hospital Mortality in Critically Ill Patients: Results of a Multicenter Cohort Study. Critical Care Medicine. 2015;43(8): e269–75. DOI:10.1097/CCM.0000000000001077

34. Liang KV, Williams AW, Greene EL, Redfield MM. Acute decom-pensated heart failure and the cardiorenal syndrome: Critical Care Medicine. 2008;36(1 Suppl): S75–88. DOI:10.1097/01.CCM.0000296270.41256.5C

35. Adams KF, Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR, Abraham WT et al. Characteristics and outcomes of patients hospi-talized for heart failure in the United States: Rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). American Heart Journal. 2005;149(2):209–16. DOI:10.1016/j.ahj.2004.08.005

36. Mahon NG, Blackstone EH, Francis GS, Starling RC, Young JB, Lauer MS. The prognostic value of estimated creatinine clear-ance alongside functional capacity in ambulatory patients with chronic congestive heart failure. Journal of the American College of Cardiology. 2002;40(6):1106–13. DOI:10.1016/S0735-1097(02)02125-3

37. Kearney MT, Fox KAA, Lee AJ, Prescott RJ, Shah AM, Batin PD et al. Predicting death due to progressive heart failure in patients with mild-to-moderate chronic heart failure. Journal of the American College of Cardiology. 2002;40(10):1801–8. DOI:10.1016/S0735-1097(02)02490-7

38. Efremova E.V., Shutov A.M., Borodulina E.O. Problem of comor-bidity in chronic heart failure. Ulyanovsk medico-biological journal. 2015; 4:46–52. [Russian]

39. Zaitseva V.P., Nanchikeeva M.L., Kozlovskaja L.V., Fomin V.V., Bulanov N.M., Ю. В. Красоткина. Prospects of contemporary diag-nostics of acute kidney injury in patients with acute coronary syn-drome. Clinical Nephrology. 2015;2–3:11–6. [Russian]

40. Zaitseva V.P., Bulanova M.L., Bulanov N.M., Krasotkina Yu.V., Shashkov E.L., Bulanov M.N. Acute Kidney Injury in Patients with Acute Myocardial Infarction. Modern Approach to Diagnostics. Ultrasound and functional diagnostics. 2015;3:56–65. [Russian]

41. Menzorov M.V., Shutov A.M., Serov V.A., Mikhailova E.V. Acute Kidney Injury in Patients With Myocardial Infarction and Efficacy of Thrombolytic Therapy. Kardiologiia. 2012;52(5):8–12. [Russian]

42. Tomilina N.A., Podkorytova O.L. Acute renal failure. Nephrology and Dialysis. 2009;11(1):4–20. [Russian]

43. Al-Aly Z, Balasubramanian S, McDonald JR, Scherrer JF, O’Hare AM. Greater variability in kidney function is associated with an increased risk of death. Kidney International. 2012;82(11):1208–14. DOI:10.1038/ki.2012.276

44. Steyerberg EW, Vickers AJ, Cook NR, Gerds T, Gonen M, Obuchowski N et al. Assessing the Performance of Prediction Models: A Framework for Traditional and Novel Measures. Epidemiology. 2010;21(1):128–38. DOI:10.1097/EDE.0b013e3181c30fb2

45. Cheng H, Chen Y. Clinical Prediction Scores for Type 1 Cardiorenal Syndrome Derived and Validated in Chinese Cohorts. Cardiorenal Medicine. 2015;5(1):12–9. DOI:10.1159/000369479

46. Kristovic D, Horvatic I, Husedzinovic I, Sutlic Z, Rudez I, Baric D et al. Cardiac surgery-associated acute kidney injury: risk fac-tors analysis and comparison of prediction models. Interactive CardioVascular and Thoracic Surgery. 2015;21(3):366–73. DOI:10.1093/icvts/ivv162

47. Inohara T, Kohsaka S, Abe T, Miyata H, Numasawa Y, Ueda I et  al. Development and Validation of a Pre-Percutaneous Coronary Intervention Risk Model of Contrast-Induced Acute Kidney Injury with an Integer Scoring System. The American Journal of Cardiology. 2015;115(12):1636–42. DOI:10.1016/j.amjcard.2015.03.004

48. Matheny ME, Miller RA, Ikizler TA, Waitman LR, Denny JC, Schildcrout JS et al. Development of Inpatient Risk Stratification Models of Acute Kidney Injury for Use in Electronic Health Records. Medical Decision Making. 2010;30(6):639–50. DOI:10.1177/0272989X10364246