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Background  Acute kidney injury (AKI) has been associated with increased mortality in  ST ‐segment elevation myocardial infarction. We compared the mortality predictive accuracy of the 3  AKI  definitions used most widely for patients with  ST ‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.    Methods and Results  We included 3771 patients with  ST ‐segment elevation myocardial infarction treated with primary percutaneous coronary intervention at 2 Italian hospitals.  AKI  incidence was evaluated according to creatinine increases of ≥25% ( AKI ‐25), ≥0.3 mg/dL ( AKI ‐0.3), and ≥0.5 mg/dL ( AKI ‐0.5). The primary end point was in‐hospital mortality. Overall, 557 (15%), 522 (14%), and 270 (7%) patients developed  AKI ‐25,  AKI ‐0.3, and  AKI ‐0.5, respectively ( P <0.01). All  AKI  definitions independently predicted in‐hospital mortality (adjusted odds ratio 4.9 [95%  CI  3.1–7.8], 5.4 [95%  CI  3.3–8.6], and 8.3 [95%  CI  5.1–13.3], respectively;  P <0.01 for all). At receiver operating characteristic analysis, the addition of each  AKI  definition to combined clinical predictors of mortality (age, sex, left ventricular ejection fraction, admission creatinine, creatine kinase‐ MB  peak) found at stepwise analysis significantly improved mortality prognostication (area under the curve increased from 0.89 for clinical predictor combination alone to 0.92 for  AKI ‐25, 0.92 for  AKI ‐0.3, and 0.93 for  AKI ‐0.5;  P <0.01 for all). At reclassification analysis,  AKI ‐0.5 added to clinical predictors, provided the highest score in mortality (net reclassification improvement +10% versus  AKI ‐0.3 [ P =0.01] and +8% versus  AKI ‐25 [ P =0.05]).    Conclusions  Each  AKI  definition significantly improved the mortality prediction beyond major clinical variables.  AKI ‐0.5 showed a mortality discrimination advantage, suggesting it should be the preferred definition in studies addressing  ST ‐segment elevation myocardial infarction and focusing on short‐term mortality.

journal of the american heart association

Acute Kidney Injury Definition and In‐Hospital Mortality in Patients Undergoing Primary Percutaneous Coronary Intervention for  ST ‐Segment Elevation Myocardial Infarction