Prognostic model to predict postoperative acute kidney injury in patients undergoing major gastrointestinal surgery based on a national prospective observational cohort study.

Background: Acute illness, existing co-morbidities and surgical stress response can all contribute to postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery. The aim of this study was prospectively to develop a pragmatic prognostic model to stratify patients according to risk of developing AKI after major gastrointestinal surgery. Methods: This prospective multicentre cohort study included consecutive adults undergoing elective or emergency gastrointestinal resection, liver resection or stoma reversal in 2-week blocks over a continuous 3-month period. The primary outcome was the rate of AKI within 7 days of surgery. Bootstrap stability was used to select clinically plausible risk factors into the model. Internal model validation was carried out by bootstrap validation. Results: A total of 4544 patients were included across 173 centres in the UK and Ireland. The overall rate of AKI was 14·2 per cent (646 of 4544) and the 30-day mortality rate was 1·8 per cent (84 of 4544). Stage 1 AKI was significantly associated with 30-day mortality (unadjusted odds ratio 7·61, 95 per cent c.i. 4·49 to 12·90; P < 0·001), with increasing odds of death with each AKI stage. Six variables were selected for inclusion in the prognostic model: age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker. Internal validation demonstrated good model discrimination (c-statistic 0·65). Discussion: Following major gastrointestinal surgery, AKI occurred in one in seven patients. This preoperative prognostic model identified patients at high risk of postoperative AKI. Validation in an independent data set is required to ensure generalizability

Comparison of 2018 AHA-ACC Multi-Society Cholesterol Guidelines with 2013 ACC-AHA Cholesterol Guidelines

The 2018 American Heart Association (AHA)–American College of Cardiology (ACC) Multi-Society Guideline on the Management of Blood Cholesterol provides an evidence-based update on the recommendations for lipid and lipoprotein management for the prevention of clinical atherosclerotic cardiovascular disease that were given in the 2013 ACC–AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. The 2018 Guideline also includes management recommendations for a variety of special populations, information on key laboratory issues impacting on lipid management, comments on the cost effectiveness of proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, and identifies strategies that impact on adherence and implementation of guideline-directed medical therapy. This chapter compares the recommendations given in the two guideline documents and provides a foundation for the reader to incorporate the most current evidence-based recommendations for the management of lipid disorders into daily practice