Predicting the risk of acute kidney injury in primary care: derivation and validation of STRATIFY-AKI

Koshiaris, Constantinos; Archer, Lucinda; Lay-Flurrie, Sarah; Snell, Kym I E; Riley, Richard D; Stevens, Richard; Banerjee, Amitava; Usher‐Smith, Juliet A.; Clegg, Andrew; Payne, Rupert; Ogden, Margaret; Hobbs, FD Richard; McManus, Richard J; Sheppard, James P

doi:10.3399/bjgp.2022.0389

Cited by 4 publications

(4 citation statements)

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“…This approach is common place in the context of anticoagulation for patients with atrial fibrillation [ 31 ], where prediction models are used to estimate an individual’s risk of stroke (and likelihood of benefiting from treatment) [ 32 ] and weigh this against their risk of a serious bleed (which may be exacerbated by treatment) [ 33 ]. Such models are now being developed in the context of antihypertensive treatment prescription [ 34 , 35 ], and these are needed to facilitate personalised treatment decisions based on an individual’s risk and personal preferences. It is likely to be some time before these are available in routine clinical practice, so in the meantime, the results from our study offer an important insight as to when one might want to consider intervening to prevent an individual from suffering adverse events from antihypertensive treatment.…”

Section: Discussionmentioning

confidence: 99%

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

et al. 2023

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Background Antihypertensives are effective at reducing the risk of cardiovascular disease, but limited data exist quantifying their association with serious adverse events, particularly in older people with frailty. This study aimed to examine this association using nationally representative electronic health record data. Methods and findings This was a retrospective cohort study utilising linked data from 1,256 general practices across England held within the Clinical Practice Research Datalink between 1998 and 2018. Included patients were aged 40+ years, with a systolic blood pressure reading between 130 and 179 mm Hg, and not previously prescribed antihypertensive treatment. The main exposure was defined as a first prescription of antihypertensive treatment. The primary outcome was hospitalisation or death within 10 years from falls. Secondary outcomes were hypotension, syncope, fractures, acute kidney injury, electrolyte abnormalities, and primary care attendance with gout. The association between treatment and these serious adverse events was examined by Cox regression adjusted for propensity score. This propensity score was generated from a multivariable logistic regression model with patient characteristics, medical history and medication prescriptions as covariates, and new antihypertensive treatment as the outcome. Subgroup analyses were undertaken by age and frailty. Of 3,834,056 patients followed for a median of 7.1 years, 484,187 (12.6%) were prescribed new antihypertensive treatment in the 12 months before the index date (baseline). Antihypertensives were associated with an increased risk of hospitalisation or death from falls (adjusted hazard ratio [aHR] 1.23, 95% confidence interval (CI) 1.21 to 1.26), hypotension (aHR 1.32, 95% CI 1.29 to 1.35), syncope (aHR 1.20, 95% CI 1.17 to 1.22), acute kidney injury (aHR 1.44, 95% CI 1.41 to 1.47), electrolyte abnormalities (aHR 1.45, 95% CI 1.43 to 1.48), and primary care attendance with gout (aHR 1.35, 95% CI 1.32 to 1.37). The absolute risk of serious adverse events with treatment was very low, with 6 fall events per 10,000 patients treated per year. In older patients (80 to 89 years) and those with severe frailty, this absolute risk was increased, with 61 and 84 fall events per 10,000 patients treated per year (respectively). Findings were consistent in sensitivity analyses using different approaches to address confounding and taking into account the competing risk of death. A strength of this analysis is that it provides evidence regarding the association between antihypertensive treatment and serious adverse events, in a population of patients more representative than those enrolled in previous randomised controlled trials. Although treatment effect estimates fell within the 95% CIs of those from such trials, these analyses were observational in nature and so bias from unmeasured confounding cannot be ruled out. Conclusions Antihypertensive treatment was associated with serious adverse events. Overall, the absolute risk of this harm was low, with the exception of older patients and those with moderate to severe frailty, where the risks were similar to the likelihood of benefit from treatment. In these populations, physicians may want to consider alternative approaches to management of blood pressure and refrain from prescribing new treatment.

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Section: Discussionmentioning

confidence: 99%

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

et al. 2023

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“…The model has been externally validated, showing excellent discrimination and good calibration in most patients, except those at very high risk [ 38 •]. Similarly, the STRATIFY-AKI tool uses commonly available information within an individual’s electronic health record to estimate the risk of hospitalisation or death from acute kidney injury within the next 1, 5, or 10 years [ 39 ]. Upon external validation, this model also showed excellent discrimination and reasonable calibration across the vast majority of patients attending primary care, potentially eligible for blood pressure lowering treatment [ 39 ].…”

Section: Measuring the Risk Of Adverse Eventsmentioning

confidence: 99%

“…It is therefore important that deprescribing decisions are made in collaboration between the primary care clinician, geriatrician, cardiologist and pharmacist, using as much information about an individual’s health status and underlying risk as possible. Here, the STRATIFY tools [ 38 •, 39 ] described above may be useful in providing insights as to which patients are most likely to be at non-cardiovascular-related harm.…”

Section: Understanding the Potential Benefits And Harms Of Treatmentmentioning

confidence: 99%

Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review

Sheppard,

Benetos,

Bogaerts

et al. 2024

Curr Hypertens Rep

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Purpose of Review To summarise the evidence regarding which patients might benefit from deprescribing antihypertensive medications. Recent Findings Older patients with frailty, multi-morbidity and subsequent polypharmacy are at higher risk of adverse events from antihypertensive treatment, and therefore may benefit from antihypertensive deprescribing. It is possible to examine an individual’s risk of these adverse events, and use this to identify those people where the benefits of treatment may be outweighed by the harms. While such patients might be considered for deprescribing, the long-term effects of this treatment strategy remain unclear. Summary Evidence now exists to support identification of those who are at risk of adverse events from antihypertensive treatment. These patients could be targeted for deprescribing interventions, although the long-term benefits and harms of this approach are unclear. Perspectives Randomised controlled trials are still needed to examine the long-term effects of deprescribing in high-risk patients with frailty and multi-morbidity.

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“…6 Additionally, as individuals at the highest risk of CVD may be those most likely to experience SAEs, alternative hypertension management strategies to the intensive protocol and SBP goals of SPRINT may need to be considered in SPRINT‐eligible US adults. 7 , 8 …”

mentioning

confidence: 99%

Effectiveness of Hypertension Management Strategies in SPRINT‐Eligible US Adults: A Simulation Study

Zhang,

Bryant,

Moran

et al. 2024

JAHA

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Background Despite reducing cardiovascular disease (CVD) events and death in SPRINT (Systolic Blood Pressure Intervention Trial), intensive systolic blood pressure goals have not been adopted in the United States. This study aimed to simulate the potential long‐term impact of 4 hypertension management strategies in SPRINT‐eligible US adults. Methods and Results The validated Blood Pressure Control–Cardiovascular Disease Policy Model, a discrete event simulation of hypertension care processes (ie, visit frequency, blood pressure [BP] measurement accuracy, medication intensification, and medication adherence) and CVD outcomes, was populated with 25 000 SPRINT‐eligible US adults. Four hypertension management strategies were simulated: (1) usual care targeting BP <140/90 mm Hg (Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care), (2) intensive care per the SPRINT protocol targeting BP <120/90 mm Hg (SPRINT intensive), (3) usual care targeting guideline‐recommended BP <130/80 mm Hg (American College of Cardiology/American Heart Association usual care), and (4) team‐based care added to usual care and targeting BP <130/80 mm Hg. Relative to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, among the 18.1 million SPRINT‐eligible US adults, an estimated 138 100 total CVD events could be prevented per year with SPRINT intensive, 33 900 with American College of Cardiology/American Heart Association usual care, and 89 100 with team‐based care. Compared with the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure usual care, SPRINT intensive care was projected to increase treatment‐related serious adverse events by 77 600 per year, American College of Cardiology/American Heart Association usual care by 33 300, and team‐based care by 27 200. Conclusions As BP control has declined in recent years, health systems must prioritize hypertension management and invest in effective strategies. Adding team‐based care to usual care may be a pragmatic way to manage risk in this high‐CVD‐risk population.

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Predicting the risk of acute kidney injury in primary care: derivation and validation of STRATIFY-AKI

Cited by 4 publications

References 30 publications

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

The association between antihypertensive treatment and serious adverse events by age and frailty: A cohort study

Strategies for Identifying Patients for Deprescribing of Blood Pressure Medications in Routine Practice: An Evidence Review

Effectiveness of Hypertension Management Strategies in SPRINT‐Eligible US Adults: A Simulation Study

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