Relationship Between Braden Scale Scores And Acute Kidney Injury Among Patients With Acute Coronary Syndrome: A Multicentre Retrospective Cohort Study

ABSTRACT

1. Objectives

To evaluate the impact of pressure ulcer events assessed by the Braden Scale (BS) on acute kidney injury (AKI) in patients with acute coronary syndrome (ACS).

2. Design

A multicentre retrospective cohort study.

3. Setting

Chest pain centers from seven tertiary hospitals in China.

4. Participants

We analyzed 3185 patients with ACS from the Retrospective Evaluation of Acute Chest Pain study. The patients were divided into three groups (B1, B2, and B3) according to their BS scores (≤12 vs 13–14 vs ≥15, respectively) at admission.

5. Outcome measures

AKI was defined according to the criteria of the 2012 Kidney Disease: Improving Global Outcomes. Multivariate logistic analysis was used to evaluate the relationship between the BS score and AKI.

6. Results

There were 461 patients (14.5%) with ACS who had complications of AKI. Patients with a lower score on the BS had a higher incidence of AKI (p<0.001). Multivariate logistic regression analysis showed that adjusted ORs of the BS score for AKI were 2.242 (B1 vs B3: 95% CI: 1.643 to 3.060, p<0.001) and 1.566 (B2 vs B3: 95%CI: 1.186 to 2.069, p=0.002). The receiver operating characteristic curve analysis showed that the area under the curve of the BS score was 0.719 (95% CI: 0.702 to 0.736; p<0.001) for AKI.

7. Conclusions

The BS score was independently associated with AKI. It may be a useful tool to identify those who may benefit from further prediction and prevention of AKI in patients with ACS.

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INTRODUCTION

Acute coronary syndrome (ACS), the acute manifestation of ischaemic heart disease, remains a major cause of morbidity and mortality worldwide1 and is responsible for more than 1 million hospital admissions in the USA annually.2 Although the mortality of patients with ACS has declined in recent years, the in-hospital mortality rate remains at 2.5%–4.2%.3–5 The identification of high-risk patients with ACS is important and facilitates therapeutic decision-making. 6

Acute kidney injury (AKI) is a common complication of ACS that may be due to hemodynamic impairment and the use of contrast agents.7 According to a previous study, the incidence of AKI in patients with ACS ranges from 6.3% to 36.6%,8 and AKI has a detrimental effect on the prognosis of patients, including prolonged length of hospital stay, higher incidence of cardiovascular events and twofold–threefold mortality.9–11 Given the high incidence of AKI and its negative influence on the prognosis of patients with ACS, it is crucial to identify high-risk patients who may develop AKI so that medical staff can predict and prevent the occurrence of AKI in patients with ACS.

Frailty is a clinical syndrome, which results in the decline of body recovery, reserve capacity, and stress resistance.12 The overall frailty status of patients reportedly correlated with renal functional reserve13–15 and was significantly associated with a high incidence of AKI.16 Therefore, early assessment and screening of frailty are critical to the assessment of AKI.

The Braden Scale (BS) is widely used in routine nursing evaluation programs to predict pressure ulcer events in patients.17 Because the BS examines several factors that could contribute to assessing frailty, such as nutrition, cognition, activity, and function, it was recommended as a frailty identification tool.18 In our previous study, the low BS score was reportedly associated with death in patients with acute myocardial infection19; however, the relationship between the BS scores and AKI remains unclear. Clarifying the relationship may help nurses in daily nursing services identify patients with a high risk of AKI, avoid the use of nephrotoxic drugs, limit the dosage of contrast medium, and make rational allocations of nursing management for high-risk patients with AKI.20 21 Therefore, this study aimed to evaluate the relationship between the BS score and AKI in patients with ACS undergoing primary percutaneous coronary intervention (PCI).

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MATERIALS AND METHODS

1. Study design

In this multicentre retrospective cohort study, data from the Retrospective Evaluation of Acute Chest Pain (REACP) study were analyzed to evaluate whether the BS could predict AKI in patients with ACS undergoing primary PCI. The REACP study enrolled patients with acute chest pain at chest pain centers from seven tertiary hospitals in China and registered them at www. chictr.org.cn (identifier: ChiCTR1900024657).

2. Study population

From January 2017 to February 2019, 14 460 patients visited the acute chest pain center, and 3337 adult patients were diagnosed with ACS and underwent primary PCI. Of these patients, 122 patients did not have relevant data and failed to return for follow-up, 150 patients were treated with thrombolysis and 218 patients left the hospital within 24 hours. Finally, 2847 patients were selected and divided into B1, B2, and B3 groups, according to the sum of their BS scores: ≤12, 13–14, and ≥15 on admission, respectively (figure 1).

Figure 1 Study flow chart. PCI, percutaneous coronary intervention.

3. Data collection and definition

We obtained data from the database of the REACP study. Data on vital signs, medical history, coronary angiography, medications, laboratory examination, and imaging findings were collected by the physicians. Bedside echocardiography was performed by a professional technician within 24 hours after admission, and the left ventricular ejection fraction (LVEF) was calculated using the biplane Simpson method (Philips E33 Medical Systems, Bothell, Washington, USA). The Global Registry of Acute Coronary Events (GRACE) score and Gensini score were calculated according to previous studies.22–25 The Mehran risk score includes hypotension, use of intra-aortic balloon pump, congestive heart failure, age, anemia, diabetes mellitus, contrast media volume, and estimated glomerular filtration rate (eGFR).26 All data were reviewed by two trained clinical research coordinators.

At the emergency room, the protocol for the nurse is to use the BS on each patient at admission with a re-evaluation every 24 hours. Six subscales constitute the BS, which includes sensation, communication, water, activity, nutrition and friction, and shear force. Each subscale has 1–4 points, excluding friction and shear force which have 1–3 points. Based on this scoring system, the total points can range from 6 to 23.17 According to the scientific interpretation of the BS in 2005, to identify the patient’s risk of developing pressure ulcers, the scores were as follows: 15–23, mild or no risk; 13–14, moderate risk; and ≤12, high risk.27

Staging of AKI was based on the criterion of Kidney Disease: Improving Global Outcomes.28 AKI stage 1 criteria are serum creatinine level >26.5 mmol/L (0.3 mg/dL) within 48 hours, an increase in serum creatinine to 1.5-fold–1.9-fold of the baseline value, or urine output <0.5 mL/kg/hour for 6–12 hours. The criteria for AKI stage 2 are increased serum creatinine to 2.0-fold–2.9-fold of the baseline value or urine output <0.5 mL/kg/hour for 12 hours. AKI stage 3 criteria are serum creatinine level >353.6 mmol/L (4.0 mg/dL), an increase in serum creatinine more than 3.0-fold of the baseline value, urine output <0.3 mL/kg/hour for 24 hours or anuria for 12 hours. The first serum creatinine value measured on admission is the baseline serum creatinine.

4. Endpoint and follow-up

The study population underwent a median of 11.9 months (5.0–20.4 months) of follow-up. Trained physicians interviewed patients using structured telephone questionnaires. The primary endpoint was AKI.

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5. Statistical analysis

The categorical variables were presented as numbers (percentages) and compared by the χ2 test. The continuous variables were reported as medians (25th– 75th) or means±SDs, according to non-normal and normal distribution, and compared using the Mann-Whitney U test or analysis of variance, respectively. The logistic regression model was used to evaluate whether BS scores are associated with AKI. All variables were included in a univariate model, and the significant variables were re-entered into a multivariable model. The area under the receiver operating characteristic (ROC) curves was established to evaluate the ability of the BS scores to predict AKI. The cumulative survival rates among the three groups of patients (B1 vs B2 vs B3) with or without AKI were compared by the Kaplan-Meier curve. To explore the indirect effect of the BS scores on all-cause mortality through the bypath of AKI, path analysis established by structural equation modeling was performed.29 The results of the path analysis were analyzed by standardized regression coefficients (β) to describe the direct and indirect effects on all-cause mortality, and the proportion of the mediating effect was calculated by dividing the regression coefficient of the indirect path by the total regression coefficient. A two-tailed p-value of <0.05 was considered significant. Data were analyzed using SPSS Statistics V.20.0 and R for Windows V.3.5.0.

6. Patient and public involvement

The patients were not involved in the design of or data collection in this study.

CONCLUSIONS

The BS score at admission was independently associated with AKI for patients with ACS. The BS may be a useful and simple tool to identify the risk of AKI among patients with ACS. In addition, more than 30% of the effects of the BS score on mortality were mediated by AKI, which suggests that frailty and AKI are two important intervention targets to improve the prognosis of patients with ACS.

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Zhichao Li ,1,2 Bofu Liu,1 Dongze Li,1 Yu Jia,1 Lei Ye,1 Xiaoyang Liao,3 Zhi Zeng,1 Zhi Wan 1

1 Department of Emergency Medicine, West China School of Nursing, West China Hospital, Sichuan University, Chengdu, China

2 Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China

3 Department of General Practice and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China