PDF(Pubmed)
Abstract：
BACKGROUND: The Revised Cardiac Risk Index (RCRI) is a six-parameter model that is commonly used in assessing individual 30-day perioperative cardiovascular risk before general surgery, but its use in patients on chronic kidney replacement therapy (KRT) is unvalidated. This study aimed to externally validate RCRI in this patient group over a 15-year period.
METHODS: Data linkage was used between the the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admisisons data across Australia and New Zealand to identify all incident and prevalent patients on chronic KRT between 2000 and 2015 who underwent elective abdominal surgery. Chronic KRT was categorised as haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD) and kidney transplant. The outcome of interest was major adverse cardiovascular event (MACE) which was defined as nonfatal myocardial infarction, nonfatal stroke, non-fatal cardiac arrest and cardiovascular mortality at 30 days. Logistic regression was used with the RCRI score included as a continuous variable to estimate discrimination by area under the receiver operating curve (AUROC). Calibration was evaluated using a calibration plot. Clinical utility was assessed using a decision curve analysis to determine the net benefit.
RESULTS: A total of 5094 elective surgeries were undertaken, and MACE occurred in 153 individuals (3.0%). Overall, RCRI had poor discrimination in patients on chronic KRT undergoing elective surgery (AUROC 0.67), particularly in patients aged greater than 65 years (AUROC 0.591). A calibration plot showed that RCRI overestimated risk of MACE. The expected-to-observed outcome ratio was 6.0, 5.1 and 2.5 for those with RCRI scores of 1, 2 and ≥ 3, respectively. Discrimination was moderate in patients under 65 years and in kidney transplant recipients, with AUROC values of 0.740 and 0.718, respectively. Overestimation was common but less so for kidney transplant recipients. Decision curve analysis showed that there was no net benefit of using the tool in neither the overall cohort nor patients under 65 years, but a slight benefit associated with threshold probability > 5.5% in kidney transplant recipients.
CONCLUSIONS: The RCRI tool performed poorly and overestimated risk in patients on chronic dialysis, potentially misinforming patients and clinicians about the risk of elective surgery. Further research is needed to define a more comprehensive means of estimating risk in this unique population.
METHODS: Data linkage was used between the the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry and jurisdictional hospital admisisons data across Australia and New Zealand to identify all incident and prevalent patients on chronic KRT between 2000 and 2015 who underwent elective abdominal surgery. Chronic KRT was categorised as haemodialysis (HD), peritoneal dialysis (PD), home haemodialysis (HHD) and kidney transplant. The outcome of interest was major adverse cardiovascular event (MACE) which was defined as nonfatal myocardial infarction, nonfatal stroke, non-fatal cardiac arrest and cardiovascular mortality at 30 days. Logistic regression was used with the RCRI score included as a continuous variable to estimate discrimination by area under the receiver operating curve (AUROC). Calibration was evaluated using a calibration plot. Clinical utility was assessed using a decision curve analysis to determine the net benefit.
RESULTS: A total of 5094 elective surgeries were undertaken, and MACE occurred in 153 individuals (3.0%). Overall, RCRI had poor discrimination in patients on chronic KRT undergoing elective surgery (AUROC 0.67), particularly in patients aged greater than 65 years (AUROC 0.591). A calibration plot showed that RCRI overestimated risk of MACE. The expected-to-observed outcome ratio was 6.0, 5.1 and 2.5 for those with RCRI scores of 1, 2 and ≥ 3, respectively. Discrimination was moderate in patients under 65 years and in kidney transplant recipients, with AUROC values of 0.740 and 0.718, respectively. Overestimation was common but less so for kidney transplant recipients. Decision curve analysis showed that there was no net benefit of using the tool in neither the overall cohort nor patients under 65 years, but a slight benefit associated with threshold probability > 5.5% in kidney transplant recipients.
CONCLUSIONS: The RCRI tool performed poorly and overestimated risk in patients on chronic dialysis, potentially misinforming patients and clinicians about the risk of elective surgery. Further research is needed to define a more comprehensive means of estimating risk in this unique population.
摘要：
背景：修订的心脏风险指数（RCRI）是一种六参数模型，通常用于评估普外科手术前30天围手术期的心血管风险，但其在接受慢性肾脏替代疗法(KRT)的患者中的应用尚未得到验证.这项研究旨在在15年内从外部验证该患者组中的RCRI。
方法：在澳大利亚和新西兰的透析和移植（ANZDATA）注册与澳大利亚和新西兰的管辖医院调查数据之间使用了数据链接，以识别所有在2000年至2015年间接受选择性腹部手术的慢性KRT的事件和流行患者。慢性KRT被归类为血液透析（HD），腹膜透析(PD),家庭血液透析（HHD）和肾脏移植。感兴趣的结果是主要不良心血管事件（MACE），其定义为非致死性心肌梗死，非致命性中风,非致死性心脏骤停和30天心血管死亡率。使用Logistic回归，将RCRI评分作为连续变量，以通过受试者工作曲线下面积（AUROC）来估计区别。使用校准图评估校准。使用决策曲线分析评估临床效用以确定净收益。
结果：总共进行了5094次选择性手术，153例(3.0%)发生MACE。总的来说,RCRI在接受择期手术的慢性KRT患者中的区别性较差（AUROC0.67），特别是年龄大于65岁的患者（AUROC0.591）。校准图显示RCRI高估了MACE的风险。RCRI评分为1、2和≥3的患者的预期与观察结果比分别为6.0、5.1和2.5。在65岁以下的患者和肾移植受者中，歧视是中等程度的，AUROC值分别为0.740和0.718。高估是常见的，但对于肾移植受者则较少。决策曲线分析表明，在整个队列和65岁以下患者中都没有使用该工具的净收益。但在肾移植受者中，与阈值概率>5.5%相关的轻微益处。
结论：RCRI工具在接受慢性透析的患者中表现差且高估了风险，可能误导患者和临床医生关于择期手术的风险。需要进一步的研究来定义一种更全面的方法来估计这一独特人群的风险。
方法：在澳大利亚和新西兰的透析和移植（ANZDATA）注册与澳大利亚和新西兰的管辖医院调查数据之间使用了数据链接，以识别所有在2000年至2015年间接受选择性腹部手术的慢性KRT的事件和流行患者。慢性KRT被归类为血液透析（HD），腹膜透析(PD),家庭血液透析（HHD）和肾脏移植。感兴趣的结果是主要不良心血管事件（MACE），其定义为非致死性心肌梗死，非致命性中风,非致死性心脏骤停和30天心血管死亡率。使用Logistic回归，将RCRI评分作为连续变量，以通过受试者工作曲线下面积（AUROC）来估计区别。使用校准图评估校准。使用决策曲线分析评估临床效用以确定净收益。
结果：总共进行了5094次选择性手术，153例(3.0%)发生MACE。总的来说,RCRI在接受择期手术的慢性KRT患者中的区别性较差（AUROC0.67），特别是年龄大于65岁的患者（AUROC0.591）。校准图显示RCRI高估了MACE的风险。RCRI评分为1、2和≥3的患者的预期与观察结果比分别为6.0、5.1和2.5。在65岁以下的患者和肾移植受者中，歧视是中等程度的，AUROC值分别为0.740和0.718。高估是常见的，但对于肾移植受者则较少。决策曲线分析表明，在整个队列和65岁以下患者中都没有使用该工具的净收益。但在肾移植受者中，与阈值概率>5.5%相关的轻微益处。
结论：RCRI工具在接受慢性透析的患者中表现差且高估了风险，可能误导患者和临床医生关于择期手术的风险。需要进一步的研究来定义一种更全面的方法来估计这一独特人群的风险。
