title: An integrated biochemical prediction model of all-cause mortality in patients undergoing lower extremity bypass surgery for advanced peripheral artery disease.
abstract: BACKGROUND
  Patients with advanced peripheral artery disease (PAD) have a high prevalence of cardiovascular (CV) risk factors and shortened life expectancy. However, CV risk factors poorly predict midterm (<5 years) mortality in this population. This study tested the hypothesis that baseline biochemical parameters would add clinically meaningful predictive information in patients undergoing lower extremity bypass operations.
  
  
  METHODS
  This was a prospective cohort study of patients with clinically advanced PAD undergoing lower extremity bypass surgery. The Cox proportional hazard model was used to assess the main outcome of all-cause mortality. A clinical model was constructed with known CV risk factors, and the incremental value of the addition of clinical chemistry, lipid assessment, and a panel of 11 inflammatory parameters was investigated using the C statistic, the integrated discrimination improvement index, and Akaike information criterion.
  
  
  RESULTS
  The study monitored 225 patients for a median of 893 days (interquartile range, 539-1315 days). In this study, 50 patients (22.22%) died during the follow-up period. By life-table analysis (expressed as percent surviving ± standard error), survival at 1, 2, 3, 4, and 5 years, respectively, was 90.5% ± 1.9%, 83.4% ± 2.5%, 77.5% ± 3.1%, 71.0% ± 3.8%, and 65.3% ± 6.5%. Compared with survivors, decedents were older, diabetic, had extant coronary artery disease, and were more likely to present with critical limb ischemia as their indication for bypass surgery (P < .05). After adjustment for the above, clinical chemistry and inflammatory parameters significant (hazard ratio [95% confidence interval]) for all-cause mortality were albumin (0.43 [0.26-0.71]; P = .001), estimated glomerular filtration rate (0.98 [0.97-0.99]; P = .023), high-sensitivity C-reactive protein (hsCRP; 3.21 [1.21-8.55]; P = .019), and soluble vascular cell adhesion molecule (1.74 [1.04-2.91]; P = .034). Of the inflammatory molecules investigated, hsCRP proved most robust and representative of the integrated inflammatory response. Albumin, eGFR, and hsCRP improved the C statistic and integrated discrimination improvement index beyond that of the clinical model and produced a final C statistic of 0.82.
  
  
  CONCLUSIONS
  A risk prediction model including traditional risk factors and parameters of inflammation, renal function, and nutrition had excellent discriminatory ability in predicting all-cause mortality in patients with clinically advanced PAD undergoing bypass surgery.
authors.affiliation: Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, Calif 94148, USA. christopher.owens@ucsfmedctr.org
authors.forename: Christopher D
authors.initials: CD
authors.lastname: Owens
authors.forename: Ji Min
authors.initials: JM
authors.lastname: Kim
authors.forename: Nathanael D
authors.initials: ND
authors.lastname: Hevelone
authors.forename: Warren J
authors.initials: WJ
authors.lastname: Gasper
authors.forename: Michael
authors.initials: M
authors.lastname: Belkin
authors.forename: Mark A
authors.initials: MA
authors.lastname: Creager
authors.forename: Michael S
authors.initials: MS
authors.lastname: Conte
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D002423:Cause of Death; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D018836:Inflammation Mediators / Q000097:blood; D015993:Life Tables; D008055:Lipids / Q000097:blood; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D058729:Peripheral Arterial Disease / Q000097:blood / Q000401:mortality* / Q000503:physiopathology / Q000601:surgery*; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality*
chemical_list: D015415:Biomarkers; D018836:Inflammation Mediators; D008055:Lipids