A Risk Score to Predict Acute Renal Failure in Adult Patients After Lung Transplantation

doi:10.1016/j.athoracsur.2014.07.073

The Annals of Thoracic Surgery

Volume 99, Issue 1, January 2015, Pages 251-257

https://doi.org/10.1016/j.athoracsur.2014.07.073 Get rights and content

Background

Despite the significant morbidity associated with renal failure after lung transplantation (LTx), no predictive models currently exist. Accordingly, the purpose of this study was to develop a preoperative risk score based on recipient-, donor-, and transplant-specific characteristics to predict postoperative acute renal failure in candidates for transplantation.

Methods

The United Network of Organ Sharing (UNOS) database was queried for adult patients (≥ 18 years of age) undergoing LTx between 2005 and 2012. The population was randomly divided into derivation (80%) and validation (20%) cohorts. The primary outcome of interest was new-onset renal failure. Variables predictive of acute renal failure (exploratory p value < 0.2) within the derivation cohort were incorporated into a multivariable logistic regression model. Odds ratios were used to assign values to the independent predictors of postoperative renal failure to construct the risk stratification score (RSS).

Results

During the study period, 10,963 patients underwent lung transplantation, and the incidence of renal failure was 5.5% (598 patients). Baseline recipient-, donor-, and transplant-related factors were similar between the cohorts. Eighteen covariates were included in the multivariable model, and 10 were assigned values based on their relative odds ratios (ORs). Scores were stratified into 3 groups, with an observed rate of acute renal failure of 3.1%, 5.3%, and 15.6% in the low-, moderate-, and high-risk groups, respectively. The incidence of renal failure was found to be significantly increased in the highest risk group (p < 0.001). Furthermore, the risk model’s predicted rates of renal failure highly correlated with actual rates observed in the population (r = 0.86).

Conclusions

We introduce a novel and simple RSS that is highly predictive of renal failure after LTx.

Section snippets

Study Population

The United Network of Organ Sharing (UNOS) database provided Standard Transplant Analysis and Research files with deidentified patient-level data. All patients 18 years of age or older who received single or double LTx between 2005 and 2012 were included. Patients who received simultaneous transplantation of other organs were excluded. The primary outcome was acute renal failure necessitating hemodialysis after LTx. Institutional review board approval was obtained before this study.

Data Analysis

The study

Study Population

A total of 10,963 lung transplant recipients met criteria for inclusion. The mean age of the recipients was 54.4 ± 13.3 years, and 59.0% were men (n = 6,465). The majority of patients were white (n = 9,213 [84.0%]), and the most common reason for LTx was pulmonary fibrosis (n = 4,271 [39.0%]) followed by chronic obstructive pulmonary disease (COPD) (n = 2,886 [26.3%]). The mean body mass index (BMI) of recipients was 25.0 ± 0.045 kg/m², and the mean estimated GFR (eGFR) before transplantation

Comment

The overall incidence of new-onset renal failure requiring dialysis in this population was 5.5%, which is similar to the incidence reported in other studies 5, 6. Although patient-specific factors have been previously identified, no tool exists to predict the risk of acute renal failure after LTx. Accordingly, we designed and validated an RSS composed of 10 variables to identify recipients with specific characteristics that conferred an increased risk of postoperative renal failure developing (

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Cited by (25)

Incidence and Perioperative Risk Factors of Acute Kidney Injury Among Lung Transplant Recipients
2022, Transplantation Proceedings
Acute kidney injury (AKI) is a significant burden in an early postoperative period after lung transplantation (LT). The development of severe AKI, including a need for continuous renal replacement therapy (CRRT), is associated with increased mortality among lung transplant recipients. Evaluation of AKI incidence and predictive factors related to the development of severe AKI and with the use of CRRT in the early postoperative period after LT.
Retrospective study of 73 consecutive patients after LT operated between 2015 and 2018 in our center. We noted the stage of AKI according to KDIGO guidelines in the 7 postoperative days.
We noted AKI among 62 lung transplant recipients (84.9%). We recognized the first and second stages of AKI in 21 patients (28.8%) and 19 patients 26%, respectively (group A). We identified severe AKI (group C) in 22 recipients (30.1%), 9 of whom needed CRRT postoperatively. There was a nonsignificant difference between groups in baseline serum creatinine (0.69 ± 0.22 mg/dL vs 0.84 ± 0.34; P = .073). Group C subjects statistically more often suffered from pulmonary hypertension (P < .001) and diabetes (P < .001). In both groups, the duration of the procedure was comparable, but, among patients with severe AKI, procedures were performed more often with the use of extracorporeal circulation (50% vs 68%; P = .194)
Pulmonary hypertension and diabetes could be significant risk factors of high-grade AKI development after LT. Identification of factors modifying renal insufficiency development in lung transplant recipients needs further investigations.
A prediction and interpretation framework of acute kidney injury in critical care
2021, Journal of Biomedical Informatics
Citation Excerpt :
Logistic regression is widely used in risk factor identification and risk prediction score development. For example, Grimm et al. [31] construct a risk stratification score system to predict acute renal failure in adult patients after lung transplantation based on the odds ratio of logistic regression. Malhotra et al. [32] use logistic regression to develop and validate an AKI risk prediction score for ICU patients.
Acute kidney injury (AKI) is a common clinical condition with high mortality and resource consumption. Early identification of high-risk patients to achieve an appropriate allocation of limited clinical resources and timely interventions is of significant importance, which has attracted substantial research to develop prediction models for AKI risk stratification. However, most available AKI prediction models have moderate performance and lack of interpretability, which limits their applicability in supporting care intervention. In this paper, a machine learning-based framework for AKI prediction and interpretation in critical care is presented. First, an ensemble model is developed to predict a patient’s risk of AKI within 72 h of admission to the intensive care units. Next, the model is interpreted both globally and locally. For the global interpretation, the important predictors are pinpointed and the detailed relationships between AKI risk and these predictors are illustrated. For the local interpretation, patient-specific analysis is presented to provide a visualized explanation for each individual prediction. Experimental results show that such a prediction and interpretation framework can lead to good prediction and interpretation performance, which has the potential to provide effective clinical decision support.
Combined Single Lung and Liver Transplantation in a Cystic Fibrosis Patient With Previous Contralateral Pneumonectomy: A Case Report
2020, Transplantation Proceedings
Citation Excerpt :
Jacques et al [14] identified the use of aprotinin and bipulmonary transplantation as predictive factors for developing acute renal failure. Other predictive factors such as effective volume contraction, ventricular dysfunction, acute tubular necrosis, sepsis, hypotension, or extracorporeal membrane oxygenation before lung transplantation are found in the literature [16,17]. However, data on intraoperative renal replacement therapy during lung or combined lung-liver transplantation are not specifically reported but have been studied for liver transplantation.
Combined lung-liver transplantation is a rare life-saving procedure to treat concomitant end-stage lung and liver failure. In this report, we describe the first published case of single lung and liver transplantation in a cystic fibrosis patient who had previously undergone a pneumonectomy for the treatment of an infected and destroyed right lung. We detail the lung first, sequential transplant procedure and surgical difficulties due to mediastinal shift. Emergent intraoperative renal replacement therapy was carried out before liver transplantation to overcome pulmonary edema in the transplanted lung. After fluid balance equilibration, liver transplantation was performed in good conditions. The patient is currently alive with no signs of rejection 8 years after the procedure.
Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation
2017, American Journal of Transplantation
Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.
Hospital length of stay after lung transplantation: Independent predictors and association with early and late survival
2017, Journal of Heart and Lung Transplantation
Duration of index hospitalization after lung transplantation (LTx) is an important variable that has not received much attention. We sought to determine independent predictors of prolonged hospital length of stay (LOS) and its association with early and late outcomes.
The United Network of Organ Sharing database was queried for adult patients undergoing LTx between 2006 and 2014 (N = 14,320). Patients with dual organ or previous transplantation and patients who died during the first 25 days after LTx were excluded (n = 12,647, mean age 55.2 years ± 13.1). Primary outcome was prolonged LOS (>25 days) (3,251/12,647; 25.7%). Donor, recipient, and procedure-related variables were analyzed as potential predictors of prolonged LOS. Association of prolonged LOS with 1-year and 5-year survival was evaluated using Cox proportional hazards analysis.
Independent predictors of prolonged LOS included serum albumin, lung allocation score, functional status, and need of extracorporeal membrane oxygenation or ventilator support at the time of transplant; donor age >40 years; gender mismatch (female donor to male recipient); donor body mass index; African American ethnicity; ischemic time >6 hours; and double LTx. Prolonged LOS was independently associated with increased mortality at 1 year (hazard ratio, 3.96; 95% confidence interval, 3.48–4.50; p < 0.001) and 5 years (hazard ratio, 2.00; 95% confidence interval, 1.79–2.25; p < 0.001).
A significant proportion of patients have a prolonged LOS after LTx, and several recipient, donor, and procedure-related variables are independent predictors of this outcome. Patients with prolonged LOS after LTx have significantly increased risk of death at 1 year and 5 years.
Thoracoscopic Mesh Repair of Diaphragmatic Defects in Hepatic Hydrothorax: A 10-Year Experience
2016, Annals of Thoracic Surgery
Citation Excerpt :
The combination of hepatic failure and renal insufficiency on surgical stress adversely affected postoperative management, resulting in fluid imbalance and the development of gastrointestinal bleeding and hepatic encephalopathy. Strategies aimed at decreasing postoperative mortality should include careful assessment of renal function and predisposition to fluid balance [26–30]. Therefore we systematically searched for new evidence to determine risk factors to allow for further selection of suitable patients for surgical repair [29, 31, 32].
The objective was to analyze the outcomes of thoracoscopic mesh repair for hepatic hydrothorax (HH) at our institution during the past 10 years.
A total of 63 patients with refractory HH who underwent thoracoscopic mesh onlay reinforcement to repair diaphragmatic defects from January 2005 to December 2014 were included in the study. Mesh covering alone was used in 47 patients and mesh with suturing was used in 16 patients. Patient demographics, Child-Pugh class, and model for end-stage liver disease (MELD) score were evaluated to predict morbidity and mortality.
Of the patients (mean age, 60.4 ± 15 years; 31 men and 32 women), 14.3% had concomitant underlying diseases of renal insufficiency, 34.9% had diabetes mellitus, and 4.8% had pneumonia. Diaphragmatic blebs were the most common diaphragmatic defects (29 of 63 [46%]). After a median 20.5 months of follow-up examinations, 4 patients experienced recurrence. The 1-month mortality rate was 9.5% (6 of 63 patients). On multivariable analysis, underlying impaired renal function (p = 0.039) and MELD scores (p = 0.048) were associated with increased 3-month mortality in 16 patients. Contrary to the rising Child-Pugh score (p = 0.058), rising MELD scores represented an increase in kidney or liver failure and mortality. The main causes of 3-month mortality were septic shock (n = 6), acute renal insufficiency (n = 4), gastrointestinal bleeding (n = 4), hepatic encephalopathy (n = 1), and ischemic bowel (n = 1).
Thoracoscopic mesh repair for refractory HH improves symptoms and lowers the recurrence rate.

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Original articleGeneral thoracicA Risk Score to Predict Acute Renal Failure in Adult Patients After Lung Transplantation

Background

Methods

Results

Conclusions

Section snippets

Study Population

Data Analysis

Study Population

Comment

Am J Transplant

Ann Thorac Surg

Kidney Int

Am J Kidney Dis

Am J Transplant

J Heart Lung Transplant

Chest

Ann Thorac Surg

Am J Transplant

J Am Coll Surg

J Am Coll Surg

J Gastrointest Surg

Original article
General thoracic
A Risk Score to Predict Acute Renal Failure in Adult Patients After Lung Transplantation