Use of postoperative creatinine to predict sustained kidney injury in patients undergoing mesothelioma surgery

Our plain-English summary of Use of postoperative creatinine to predict sustained kidney injury in patients undergoing mesothelioma surgery, by K.A. Mizuguchi, A. Mitani, S.S. Waikar, et al (Clinical Journal of the American Society of Nephrology, 2012).

The study

• Authors: K.A. Mizuguchi, A. Mitani, S.S. Waikar, P. Ireland, C. Panizales, G. Deluke, D.J. Sugarbaker, J.V. Bonventre, G. Frendl
• Journal: Clinical Journal of the American Society of Nephrology
• Published: 2012;7(7):1071-8
• Cited by: 9 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background And Objectives: AKI leads to increased morbidity and mortality and progression to chronic kidney injury is a frequent consequence of AKI. Surgical treatment of mesothelioma is associated with increased risk for kidney injury. However, sustained kidney injury may limit therapeutic options for treating residual cancer. This study hypothesized that patients with significant serum creatinine (sCr) elevation within 48 hours of surgery would be at risk for sustained kidney injury. The goal was to determine the best acute sCr measure predictive of sustained kidney injury defined as a 50% increase in sCr from baseline measured 2-4 weeks after surgery.

Design, Setting, Participants, & Measurements: In a prospective, observational cohort of surgical patients with mesothelioma, receiver operator characteristic curves were generated for the 24- and 48-hour absolute difference and relative sCr change over baseline in the derivation cohort (n=279). The prediction was tested in a validation cohort (n=207). The ability of various other AKI definitions to predict sustained kidney injury was evaluated.

Results: Sustained kidney injury occurred in 9.8% of patients in the derivation cohort. A ≥59% increase in sCr 48 hours after surgery was most predictive of sustained kidney injury (c statistic=0.78). Among other AKI definitions, a sCr increase of 0.3 mg/dl in 24 hours or 0.5 mg/dl increase in 48 hours (Waikar and Bonventre criteria) also reliably predicted sustained kidney injury.

Conclusions: Development of clinically significant sustained kidney injury can be predicted by acute postoperative sCr elevation in patients treated for mesothelioma.

In plain English

This study looked at kidney function in patients who had extrapleural pneumonectomy for malignant pleural mesothelioma at a Boston hospital between 1998 and 2009. It did not study asbestos exposure. Some patients had heated cisplatin chemotherapy washed into the chest during surgery. Sustained kidney injury was defined as a doubling of blood creatinine from its pre-surgery level, measured 2 to 4 weeks after surgery or at the latest test before discharge. The authors used 279 patients operated on in 1998–2004 to find the early creatinine rise that best predicted this. They then tested it on 207 patients from 2005–2008. Sustained injury occurred in 25 patients (8.9%) in the first group and 21 (10.1%) in the second. A 59% rise in creatinine 48 hours after surgery predicted it best. In the second group it correctly identified 15 of 21 patients who developed sustained injury and 164 of 186 who did not. The authors concluded that sustained kidney injury can be predicted by an early rise in creatinine after surgery. They noted that their estimates were unadjusted and may not apply to other patient groups.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Cohort study of surgical patients, split by year of surgery into a derivation group and a validation group. The discussion calls it retrospective and database-driven; the abstract calls it a prospective, observational cohort.
• Who was studied: Patients undergoing extrapleural pneumonectomy for malignant pleural mesothelioma at Brigham and Women's Hospital, Boston. The derivation cohort was operated on in 1998–2004 (n=279) and the validation cohort in 2005–2008 (n=207). Two patients who died within 48 hours of surgery were excluded.
• Exposure: Not asbestos. The study examined the surgery (extrapleural pneumonectomy) and the optional intraoperative intracavitary heated cisplatin lavage (225 mg/m2). The predictors tested were early changes in serum creatinine at 24 and 48 hours after surgery.
• Main results:
  • The outcome, sustained kidney injury, was defined as doubling of creatinine relative to the preoperative baseline. It was measured during the 2- to 4-week period after surgery or at the latest creatinine value before discharge.
  • Sustained kidney injury occurred in 8.9% (n=25) of the derivation cohort and 10.1% (n=21) of the validation cohort.
  • In the derivation cohort, a 59% (1.59-fold) increase in creatinine at 48 hours had the highest area under the ROC curve (0.798), with 68% sensitivity and 87% specificity.
  • In the validation cohort, the 59% increase correctly predicted 15 of 21 patients who had sustained kidney injury and 164 of 186 who did not (71% sensitivity, 88% specificity). The positive predictive value was 41% and the negative predictive value was 96%.
  • Compared with the RIFLE risk criterion (1.5-fold increase at 48 hours; c statistic 0.73), the 1.59-fold rule had a c statistic of 0.78. The difference was statistically significant (P less than 0.001).
  • On net reclassification index and integrated discrimination improvement, the authors' criterion and the Waikar and Bonventre criteria (0.3 mg/dl rise in 24 hours or 0.5 mg/dl rise in 48 hours) performed equally well.
  • In the derivation cohort, patients who developed sustained kidney injury more often had received intracavitary cisplatin (16 of 25, 64.0%, versus 97 of 254, 38.2%; P=0.01). They also more often required renal replacement therapy.
  • Patients meeting the 1.59-fold criterion had a significantly longer intensive care unit stay. Length of hospital stay was not significantly different.
• The authors' conclusion: The authors concluded that clinically significant sustained kidney injury can be predicted by an acute rise in serum creatinine after surgery in patients treated for mesothelioma. They also concluded that the Waikar and Bonventre criteria could be useful as an early predictive tool when a population-specific rule cannot be built.
• Limitations the authors state:
  • Because the study was retrospective, the authors could not determine which perioperative factor was most responsible for sustained kidney injury. The estimates presented are unadjusted.
  • Some patients may have had reduced kidney reserve, from earlier chemotherapy or other conditions, that their baseline creatinine did not show.
  • The rule may not reliably predict sustained kidney injury at time points other than 2–4 weeks after surgery.
  • The authors did not address whether the rule applies to patients with pre-existing kidney disease.
  • The results are specific to this cohort and may not generalize to other cohorts or other types of acute kidney injury, such as septic AKI.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma.

Medical terms in this study, explained in our Lexicon: Mesothelioma.

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