The clinical outcomes of acute kidney injury substages based on serum cystatin C in pediatric patients undergoing cardiac surgery

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Abstract Background Multiple biomarkers have been identified by previous studies to diagnose acute kidney injury (AKI). Moreover, combination of biomarkers with conventional criteria to define AKI substages so that we can identify high-risk patients and improve diagnostic accuracy were recommended. Our study aimed to explore the incidence of AKI substages defined by serum cystatin C (CysC), determine whether AKI substages were associated with worse outcomes. Methods We prospectively included 2519 pediatric patients (<16yrs) undergoing cardiac surgery with cardiopulmonary bypass in our cohort between March 2022 to February 2023 in Fuwai Hospital. Demographic and clinical variables we collected. To define AKI substages, Kidney Disease: Improving Global Outcomes AKI definition (based on SCr or CysC) was used. The association between AKI exposure and outcomes including length of intensive care unit stay, duration of mechanical ventilation, length of hospital stay and 30-day mortality was assessed. In addition, we determined areas under the receiver operating characteristic curve and cutoff value of CysC at different timepoints to predict AKI. Results 507 (20.8%) patients developed SCr-AKI, with 337 (13.8%) in stage 1, 77(3.2%) in stage 2 and 93 (3.8%) in stage 3 respectively. Of the 1925 patients without SCr-AKI, 256 (14.3%) met the definition of sub-AKI. Of the 507 patients with SCr-AKI, 281 (55.4%) patients were defined as AKI substage A, while others (226, 44.6%) were defined as AKI substage B. After adjusting for BSA, neonates, STAT mortality score≥4, previous sternotomy and CPB time>120min, the postoperative LOIS, LOHS and DMV were prolonged with increasing hospitalization expense (P<0.05) in patients with SCr-AKI and/or CysC-AKI. Meanwhile, only the hospitalization expense was increased in patients with SCr-AKI(P<0.05) after the same adjustment. The AUC was 0.691, 0.720 and 0.817 respectively in ROC curves of preoperative, relative variation of or postoperative serum CysC. Delong’ test showed that postoperative serum CysC might have better diagnostic performance characteristic than preoperative or relative variation of CysC (P<0.001), with a cutoff point at 1.29 mg/dL (Specificity, 0.77; Sensitivity, 0.71) Conclusions Our analysis indicates defining AKI with both CysC and SCr might more significantly affecting clinical outcome associations in pediatric patients undergoing cardiac surgery. Moreover, the serum CysC cutoff of 1.29mg/dL postoperatively is a valuable threshold for AKI risk assessment to define AKI subtypes.

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