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. 2025 Jul 22:12:1555478.
doi: 10.3389/fmed.2025.1555478. eCollection 2025.

Acute kidney injury after myocardial infarction: prognostic implications via dual robust methods

Pan Guo #  1 , Fang Tao #  2 , Lili Du #  3 , Hongmei Yang  1 , Wenguang Wang  1 , Chunpeng Ma  1 , Xile Bi  1 , Lin Ren  1 , Hongtao Yin  1 , Lixiang Ma  1
Affiliations

Acute kidney injury after myocardial infarction: prognostic implications via dual robust methods

Pan Guo et al. Front Med (Lausanne). .

Abstract

Background: Acute kidney injury (AKI) following acute myocardial infarction (AMI) notably affects patient outcomes. The impact of KDIGO AKI staging on post-discharge short- and long-term outcomes, particularly early-stage AKI, is not well understood. This study evaluates the prognostic implications of various KDIGO stages in AMI patients.

Methods: Utilizing the Medical Information Mart for Intensive Care IV (version 3.0) database, this retrospective cohort study included adult patients primarily diagnosed with AMI. Statistical analyses, including doubly robust estimation, propensity score matching, logistic regression, and Cox regression, were performed. The study compared Non-AKI (KDIGO stage 0) with Mild-AKI (maximum KDIGO stage 1 during hospitalization), and Normal-or-mild AKI (KDIGO stages 0-1) with Moderate-to-severe AKI (KDIGO stages 2-3).

Results: Among 5,715 patients analyzed, 4,306 (75.36%) developed AKI. Doubly robust analysis revealed no significant differences in outcomes between Non-AKI and Mild-AKI groups (28-day mortality: OR 0.97, 95% CI 0.68-1.38; 180-day mortality: HR 0.94, 95% CI 0.76-1.18; 1-year mortality: HR 0.98, 95% CI 0.81-1.20). However, Moderate-to-severe AKI was significantly associated with worse outcomes compared to Normal-or-mild AKI (28-day mortality: OR 1.67, 95% CI 1.36-2.05; 180-day mortality: HR 1.06, 95% CI 1.02-1.10; 1-year mortality: HR 1.22, 95% CI 1.07-1.38; all p < 0.001). Subgroup analyses revealed that patients under 65 years with Mild-AKI showed higher risks of 180-day and 1-year mortality compared to Non-AKI, while Moderate-to-severe AKI consistently demonstrated worse outcomes across all subgroups (age, SOFA score, heart failure status, and renal disease status). These findings were robust across multiple sensitivity analyses.

Conclusions: Patients with Mild-AKI can be considered as having "subclinical AKI," with prognoses similar to Non-AKI patients. In contrast, Moderate-to-severe AKI significantly worsens prognosis compared to Normal-or-mild AKI.

Keywords: acute kidney injury; doubly robust analysis; myocardial infarction; prognosis; propensity score matching.

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Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Figures

Flowchart detailing the selection process from the MIMIC-IV databases (2008-2022) with 546,028 records. Exclusions include non-ICU hospitalizations, non-acute myocardial infarction diagnoses, patients under 18, non-first hospital admissions, and ICU stays under one day. Final records included are 5,715.
Figure 1
Flow chart of inclusion and exclusion criteria for the target study population of patients with acute myocardial infarction who developed acute kidney injury.
Four graphical panels display data comparisons across different covariates. Panel A and B are bar charts showing the distribution of various factors such as ”Loss of consciousness,“ ”SOFA Score,“ and ”Vasopressors,“ with their frequency of occurrence. Panel C and D are line plots comparing standardized mean differences (SMD) across covariates ”Before matching,“ ”After matching,“ and ”IPTW“ methods. Covariates include ”WBC,“ ”Vasopressors,“ and ”SOFA Score,“ among others. The charts highlight differences in data distributions and adjustments through different statistical methods.
Figure 2
The relative influence factors evaluate the discriminative power of the 39 covariates within the propensity score model in predicting acute kidney injury (AKI) outcomes (the higher the value in the bar graph, the more important the variable). (A) For Non-AKI and Mild-AKI; (B) For Normal-or-mild-AKI and Moderate-to-severe-AKI; Change in standardized mean difference (SMD) of cohorts before and after propensity score matching: the red curve represents pre-matching, the green curve represents post-matching, and the blue curve represents inverse probability of treatment weighting (IPTW) adjustment. The smaller the curve fluctuation, the better the data quality. (C) For Non-AKI and Mild-AKI; (D) For Normal-or-mild-AKI and Moderate-to-severe-AKI.
Six survival probability graphs compare different groups over time. Panels A, B, and C show Non-AKI versus Mild AKI, with p-values of 0.082, 0.032, and 0.005, respectively. Panels D, E, and F compare Normal or Mild AKI and Moderate to Severe AKI, all with p-values less than 0.001. Each chart includes a cumulative events table, illustrating how survival probabilities change over time for each group.
Figure 3
Unadjusted Kaplan-Meier survival curves for 28-day mortality (A, D), 180-day mortality (B, E), and 1-year mortality (C, F). (A–C) represent comparisons between Non-AKI and Mild-AKI groups, while (D–F) represent comparisons between Normal-or-mild-AKI and Moderate-to-severe-AKI groups. The shaded areas in the graphs indicate the 95% confidence interval.
Forest plots in six panels labeled A to F, showing hazard ratios and confidence intervals for variables including age, SOFA score, IF, IHE, renal disease, and IND across different groups. Each panel compares a specific group with reference data, presenting count, percent, hazard ratios, and p-values to indicate statistical significance.
Figure 4
Forest plot of subgroup analysis for 28-day mortality (A, D), 180-day mortality (B, E), and 1-year mortality (C, F). (A–C) represent comparisons between Non-AKI and Mild-AKI groups, while (D–F) represent comparisons between Normal-or-mild-AKI and Moderate-to-severe-AKI groups. The dashed lines in the plots indicate the null effect line, and any result intersecting the null effect line suggests no significant difference.
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