Development of a clinical prediction rule for determining the risk of upper urinary tract deterioration in patients with spinal cord injury

Development of a clinical prediction rule for determining the risk of upper urinary tract deterioration in patients with spinal cord injury | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Development of a clinical prediction rule for determining the risk of upper urinary tract deterioration in patients with spinal cord injury Sintip Pattanakuhar, Patsaporn Jarupathirun, Phichayut Phinyo This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7129191/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To develop the clinical prediction rule (CPR) of upper urinary tract deterioration (UUTD) outcome at three years in patients with traumatic spinal cord injury (TSCI) Study design: Retrospective cohort study Setting: Department of Rehabilitation Medicine, Maharaj Nakorn Chiang Mai Hospital Subjects: TSCI patients with onset of injury in January 2008 - December 2020. Methods: After screening the medical records of 714 TSCI patients, clinical and urodynamic parameter data from 176 patients, collected at 3-18 months after SCI, were retrospectively analyzed. CPR was developed to predict UUTD at three years after SCI by conducting logistic regression analysis. The performance of the model was evaluated in terms of both discrimination and calibration using the AUROC and calibration plot, respectively. Results: The incidence of UUTD was 18.8% (33/176) with a mean duration of 3.72 years after the onset of injury. The developed CPR consists of three predictive factors, including neurological level, presence of detrusor overactivity, and having autonomic dysreflexia during urodynamic study to predict UUTD at three years after SCI. The developed CPR had acceptable discriminative and calibrating performance. Conclusions: Our developed CPR for prognosing UUTD at three years after SCI was established and proved that it has acceptable performance, in both the discrimination and the calibration aspects. However, a further external validation study is needed before applying this CPR in other clinical contexts. Health sciences/Neurology/Neurological disorders Health sciences/Medical research/Epidemiology Biological sciences/Neuroscience clinical prediction rule spinal cord injury upper urinary tract deterioration neurogenic lower urinary tract dysfunction vesicoureteral reflux hydronephrosis Figures Figure 1 Figure 2 Figure 3 Introduction Approximately 70–84% of patients with SCI suffered from neurogenic lower urinary tract dysfunction (NULTD), leading to the significant risk of upper urinary tract deterioration (UUTD) [ 1 ]. After a 45-year follow-up, 58% of patients with SCI exhibited a moderate degree of UUTD whereas 29% of them developed a severe degree of UUTD. Moreover, there are cumulative reports indicating UUTD in Thailand, estimated at approximately 25.16 cases per 1000 individuals per year, within an average period of 3.29 years post-spinal cord injury occurrence [ 2 ]. When it occurs, UUTD is difficult to cure. Therefore, early detection of UUTD and its risk factors is an important strategy for NLUTD management in patients with SCI. Several clinical parameters were predictive factors of UUTD, including retaining an indwelling urinary catheter (IDC) and age at the onset of SCI ≥ 60 years [ 3 – 5 ]. In addition to use as a diagnostic methods, urodynamic parameters could be used as a predictor for developing UUTD in patients with SCI, including high (≥ 40 cmH 2 O) maximal detrusor pressure (maxPdet) during filling phase [ 6 – 10 ], low (< 200 ml) cystometric capacity (CC) [ 10 ], low (< 20 ml/cmH2O) bladder compliance (BC) [ 3 , 11 , 12 ] and prolonged (≥ 0.33) duration of detrusor overactivity per filling cystometry ratio (DOratio) [ 13 ]. Using these predictive factors as a screening tool, clinicians, especially in limited-resource countries, could accurately identify and manage the patients who are at risk of developing UUTD. However, most of the studies reporting the predictive factors of UUTD proposed them as an odds ratio of a single factor or a difficult mathematical equation, causing difficulty for clinicians to apply them in real-life clinical situations. One way to obtain predictive risk is to create it as a clinical prediction rule (CPR) [ 14 ]. Unlike forcing clinicians to depend on a single predictive factor or to deal with a difficult equation, CPR uses a set of predictive factors to determine the probability of the outcome by using a simplified, ready-to-use scoring method [ 14 ]. Since there has been no study proposing a CPR for prognosing UUTD in patients with SCI, this study aims to develop a CPR for predicting UUTD in patients with SCI. Methods Study designs This study was a retrospective cohort study aiming to create a prognostic CPR for UUTD at 3 years since it is the average time to develop UUTD in our cohort [ 2 ]. The protocol for this analysis was approved by the local research ethics board, Faculty of Medicine, Chiang Mai University (Study code: REH-2565-09059). Informed consent was waived due to retrospective data collection. The Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement was used to guide model development and reporting [ 15 ]. Study populations The study focused on patients aged between 15 and 80 years old with TSCI between January 2008 and December 2020, visiting the Urodynamic unit at the Department of Rehabilitation Medicine, Maharaj Nakorn Chiang Mai Hospital. Inclusion criteria comprised of 1) having complete clinical and urodynamic data three to eighteen months after SCI onset 2) undergoing at least one upper urinary tract examination (ultrasound kidneys, voiding cystourethrography (VCUG), or estimated glomerular filtration rate (eGFR) 3 years after SCI onset. Exclusions criteria were defined as 1) patients with non-SCI-related abnormal lower urinary tract such as overactive bladder, autonomic peripheral neuropathy, or any gynecological-abdominal surgery 2) prior diagnosed UUTD or kidney conditions, and 3) incomplete or unreliable medical records (such as graph was unreliable due to artifact). Data collections Data of each patient were retrospectively reviewed from their medical records consisting of electronic medical records, urodynamic records, and radiologic reports. Collected data included: 1) general demographic data; 2) clinical data including history of urinary incontinence, bladder management methods, and prescribed medication including bladder and sphincter relaxant. 3) Urodynamic parameter derived from the urodynamic study at three to eighteen months after SCI. Predictive parameters The general demographic data was collected including sex (male vs female) [ 5 , 16 ], age at onset (years, and categorized as < 60 years vs ≥ 60 years) [ 4 ], neurological level (cervical, thoracic, lumbar, and sacral level) [ 5 ], completeness of SCI (ASIA A, B, C, D and E) [ 5 , 16 ], history of incontinence (yes vs no) [ 2 ], bladder management methods (indwelling, self-intermittent and intermittent catheterization by other, voluntary voiding, bladder reflex triggering and straining) [ 5 ], the presence of autonomic dysreflexia (AD) during urodynamic study (yes vs no [ 17 ]), and the use of bladder relaxant (yes vs no) [ 4 ]. Urodynamic parameters included type of detrusor function (detrusor overactivity - DO vs non-DO) [ 3 ], maximum detrusor pressure (maxPdet) in filling phase (high [≥ 40 cmH 2 O] vs low) [ 6 – 9 , 12 ], cystometric capacity (CC) (low [< 200 ml] vs normal) [ 10 ], bladder compliance (BC) (low [< 20 ml/cmH 2 O] vs normal) [ 3 , 11 , 12 ] and DOratio (prolonged [≥ 0.33] vs normal) [ 13 ], and urethral function at voiding cystometric phase (presence of DSD or non-relaxing sphincter vs absence) [ 3 ]. Outcome parameters The primary endpoint of this study was UUTD at 3 years after onset of injury determined by at least one of the followings: 1) any grade of vesicoureteral reflux assessed by VCUG [ 18 – 21 ]; 2) at least grade 1 of hydroureter or hydronephrosis classified by ultrasonography [ 18 , 21 ]; 3) creatinine clearance (eGFR) less than 60 ml/min/1.73m 2 estimated by CKD-EPI [ 20 , 21 ]. General statistical analysis All parameters were described using mean (SD), median (25th percentile, 50th percentile), and frequency (percentage), according to their type and distribution. A probability of less than 5% (p-value < 0.05) was considered statistically significant. All statistical analyses were conducted using Stata version 16 (StataCorp, Texas, USA). Complete case analysis was used to manage missing data. No imputation was performed. Development of CPR As this study used a predictive modelling strategy, parameter selection methods were applied to make the final model as parsimonious, i.e., containing minimal predictive parameters, as possible. First, data were analyzed with univariable logistic regression analysis (Fisher's exact test for categorical parameters and independent t-test for continuous variables) to eliminate all parameters that had a p-value > 0.2. After that, multivariable logistic regression analysis of all remaining parameters was performed. The area under the receiving operation curve (AuROC) of the regression model was calculated. The regression model was reduced by removing the least significant factor and the AuROC was calculated again. The AuROC of the initial model (containing all predictors) and the parsimonious model (containing only statistically significant factors) was compared using a chi-square test. If the AuROC was not significantly different, the model with fewer predictive factors was selected as the final model. After that, the regression coefficient of each predictive factor would be divided by the smallest one and the results would be rounded as an integer to simplify the coefficient. Then, a score from the developed CPR was calculated for all participants. Evaluation of CPR performance The measurement discrimination and calibration were used to demonstrate our clinical prediction score performance. To evaluate the model's ability to differentiate between groups (UUTD and non-UUTD) by using AuROC. The measurement of calibration demonstrated compatibility between the observed outcomes versus predicted probability plot. A cut-off level of the score was set after applying a diagnostic accuracy test as the level that produced the highest sensitivity and specificity when compared with the true diagnosis of UUTD. Internal validation According to the TRIPOD guideline, evaluating internal validation is a requirement for developing CPR. Internal validation was performed using a bootstrapping approach (200 iterations), optimism-corrected C-statistics were used to evaluate model discrimination, and the expected-to-observed ratio was used to assess model calibration [ 15 ]. Sample size calculation Sample size calculation for the development of CPR was proposed by Riley, et al. [ 22 ]. A sample size that had 10 outcome events per one predictive factor was used. To make our CPR not too complicated, we included 3–6 potential predictive factors, at least 30 outcome events were required. The prevalence of UUTD in our database was 18%, resulting in a sample size of at least 167. Results Characteristics of the cohort All 713 traumatic SCI patients underwent retrospective screening, with a total of 176 included in this study as shown in Fig. 1 . Demographic and clinical baseline characteristics are outlined in Table 1 . No significant differences were observed in age, gender, or history of UTI between the groups. Notably, 33 patients (18.8%) met the criteria of UUTD. Among these patients, 63.6% exhibited vesicourethral reflux, 18.2% had eGFR lower than 60 ml/min/1.73m 2 by CKD-EPI, and another 18.2% presented with hydronephrosis. The mean duration of UUTD was 3.72 years after the onset of injury. Most of the patients were male, constituting 81% of the included individuals, with an average injury age of 40.11 (SD 15.48) years which was consistent across both UUTD (81.8%) and non-UUTD (81.1%) groups. Regarding neurological levels, 55% were at the cervical, 40% at thoracic, 4% at lumbar, and 1% at sacral levels. Apparently, 50% of patients presented with complete cord injury. From the observed population, the primary method of bladder management was IDC (52%), followed by self-intermittent catheterization (28%) and intermittent catheterization by others (9%). As shown in Table 1 , an estimated 27% of the total population experienced a history of urinary incontinence which was concordant with the results in UUTD (30%) and non-UUTD (27%) groups. Remarkably, bladder relaxants were prescribed for 49% of the patients, while sphincter relaxants were given to only around 2%. Table 1 Baseline characteristics of the included participants Characteristics Total n (%) With UUTD n (%) Without UUTD n (%) p-value Clinical parameters No. of patients 176 (100) 33 (18.8) 143 (81.3) Male sex 143 (81.3) 27 (81.8) 116 (81.1) 0.604 Age at injury, years [Mean (SD)] 40.1 (15.5) 42.9 (15.8) 39.5 (15.4) 0.263 Age more than or equal to 60 years old 18 (10.0) 14 (9.8) 4 (12.5) 0.747 Neurological level Cervical 93 (55.1) 24 (72.7) 73 (51.0) 0.046* Thoracic 71 (40.3) 8 (24.2) 63 (44.1) Lumbosacral 8 (4.6) 1 (3.0) 7 (4.9) AIS A 88 (50.0) 13 (39.4) 75 (52.4) 0.101 B 29 (16.5) 4 (12.1) 25 (17.5) C 30 (17.0) 10 (30.3) 20 (14.0) D 29 (16.5) 6 (18.2) 23 (16.1) Bladder management method Indwelling catheterization 91 (51.7) 22 (66.7) 69 (48.3) 0.157 Clean intermittent self-catheterization 50 (28.4) 6 (18.2) 44 (30.8) Clean intermittent catheterization 15 (8.5) 3 (9.1) 12 (8.4) Voluntary voiding 15 (8.5) 1 (3.0) 14 (9.8) Bladder reflex triggering 3 (1.7) 1 (3.0) 2 (1.4) Straining 2 (1.1) 0 (0) 2 (1.4) History of urinary incontinence 48 (27.3) 10 (30.3) 38 (26.6) 0.829 History of UTI within 1 year before UDS, yes 80 (45.5) 15 (45.5) 65 (45.5) 1.000 Medication (bladder relaxant) 86 (48.9) 20 (60.6) 66 (46.2) 0.339 Urodynamic parameters Detrusor function in filling phase Normal 112 (63.6) 15 (45.5) 97 (67.8) 0.014* Detrusor overactivity 64 (36.4) 18 (54.5) 46 (32.2) Urethral function in voiding phase Normal or not applicable (no voiding phase) 72 (40.9) 15 (0) 57 (39.9) 0.552 Detrusor-sphincter dyssynergia or non-relaxing sphincter 104 (59.0) 18 (54.6) 86 (60.2) Maximal Pdet, in filling phase ≥ 40 cmH 2 O 57 (32.4) 8 (24.2) 49 (34.3) 0.212 < 40 cmH 2 O 119 (67.6) 25 (75.8) 94 (65.7) Cystometric capacity ≥ 200 mL 156 (88.6) 28 (84.8) 128 (89.5) 0.373 < 200 mL 20 (11.4) 5 (15.2) 15 (10.5) Bladder compliance ≥ 20 cmH 2 O 95 (54.0) 20 (60.6) 75 (52.4) 0.328 < 20 cmH 2 O 81 (46.0) 13 (39.4) 68 (47.6) Detrusor overactivity/ cystometry ratio < 0.33 106 (60.2) 23 (69.7) 83 (58.0) 0.166 ≥ 0.33 70 (39.8) 10 (30.3) 60 (42.0) Stop due to AD, No. of patients 74 (42.0) 20 (60.6) 54 (37.8) 0.017* No., number; UUTD, upper urinary tract deterioration; AIS, American Spinal Injury Association (ASIA) Impairment Scale; UDS, urodynamic study; UTI, urinary tract infection; Pdet, detrusor pressure; UUTD, upper urinary tract deterioration; mL, milliliter; cmH 2 O, centimeters of Water; No., number; AD, autonomic dysreflexia Significant level at p < 0.05 by Fisher exact test except age by independent t-test; bold, selected variables Table 1 also displays urodynamic parameters: 64% of the total population had detrusor overactivity (DO), with 68% among UUTD patients and 46% in non-UUTD patients. MaxPdet remained below 40 cmH 2 O in 66–76% across all groups, with a mean estimated pressure of 25–33 cmH 2 O. Cystometric capacity exceeded 200 mL in most cases, averaging 359.4 mL, 345.4 mL, and 362.6 mL in the total, UUTD, and non-UUTD groups, respectively. Low bladder compliance (< 20 mL/cmH 2 O) occurred in 46% of the total, 39% in UUTD, and 48% in non-UUTD patients. Additionally, DO/cystometry ratio < 0.33 was seen in 60%, 70%, and 58% of the total, UUTD, and non-UUTD groups. Substantially, the number of patients who had to stop the urodynamic study due to autonomic dysreflexia was noticeably larger in patients with the UUTD group (61%) than in the other group. Predictive variable selection Table 1 univariably compares clinical predictive factors between patients with UUTD and without UUTD. According to the previously set criteria for predictor selection of p < 0.2, there were three potential clinical predictors, including neurological level, AIS, and bladder management method. To simplify the score, the variables were recategorized from neurological level (polytomous answers) to cervical SCI (yes vs no), from AIS (polytomous answers) to AIS C (yes vs no), and bladder management method (polytomous answer) to retaining IDC (yes or no). Table 1 univariably compares urodynamic predictive factors between patients with UUTD and without UUTD. According to the previously set criteria for predictor selection of p < 0.2, there were three potential urodynamic predictors, including type of detrusor function (having DO or not), DOratio (less than vs more than or equal to 0.33), and having AD during urodynamic study (yes or no). Development of CPR Table 2 demonstrates the results of multivariable logistic regression analyses for predicting UUTD at 3 years after SCI. The initial model consists of all six predictors selected from the univariable analyses, including cervical SCI, AIS C, retaining IDC, having DO, DOratio, and AD. The AuROC of the initial model was 0.721 (95%CI: 0.610–0.832). The parsimonious model only consists of three statistically significant predictors, including AIS C, having DO, and AD. The AuROC of the parsimonious model was 0.718 (95%CI: 0.606–0.831). Therefore, the parsimonious model was selected as the final model. Table 2 Predictive factors of UUTD at three years after SCI in the initial and final model Predictive variables Initial model (AuROC = 0.721 [0.610–0.832]) Final model (AuROC = 0.718 [0.606–0.831]) Odds ratio 95% CI of Odds ratio p-value Odds ratio 95% CI of Odds ratio p-value Lower Upper Lower Upper AD during UDS 2.75 0.96 7.88 0.060 3.42 1.46 7.99 0.005* AIS C 3.31 1.21 9.04 0.019* 3.56 1.33 9.52 0.011* Presence of DO 3.47 1.20 10.07 0.022* 3.83 1.62 9.05 0.002* Cervical SCI 1.49 0.48 4.69 0.493 Prolonged DOratio 0.90 0.30 2.71 0.854 Retained IDC 1.029 0.34 3.10 0.959 AD, autonomic dysreflexia; UDS, urodynamic study; SCI, spinal cord injury; AuROC, area under the receiver operating curve; CI, confident interval; AIS, ASIA Impairment Scale; DO, detrusor overactivity; DOratio, duration of detrusor overactivity per filling cystometry ratio Significant level at p < 0.05, multivariable logistic regression analysis. A simple CPR was created by dividing the regression coefficient of each factor (3.42, 3.56, 3.83) by the smallest one (3.42), causing a multiplier of one for all predictors (Table 3 ). A score of the developed CPR was calculated in all patients, resulting in a mean (SD) score of 0.95 (0.73). The score of patients with UUTD was significantly higher than that of patients without UUTD (0.84 vs 1.5; p < 0.001, Mann-Whitney U test). Table 3 A simple prediction score for predicting UUTD at three years after spinal cord injury Predictors Range of test scores Weighted coefficient Minimum score Maximum score AD during UDS 0–1 1 0 1 AIS C 0–1 1 0 1 Presence of DO 0–1 1 0 1 Total 0 3 AD, autonomic dysreflexia; AIS, American Spinal Injury Association (ASIA) Impairment Scale; UDS, urodynamic study; DO, detrusor overactivity Performance of the developed CPR Discriminative ability of the developed CPR was evaluated using the AuROC of the CPR (Fig. 2 ). The developed CPR has an AuROC of 0.711 (95%CI: 0.603–0.819), indicating an acceptable discriminative ability [ 23 ]. The calibrating ability of the developed CPR was evaluated using a calibration plot (Fig. 3 ). The calibration plot demonstrates that the predicted probability of developing CPR and the observed probability are nearly, but not definitely approximate. The CPR underestimates the true risk of UUTD at scores 0 and 3 (0.05 vs 0.10 for score 0 and 0.71 vs 0.80 for score 3, respectively). Using a cut-off level of the score more than or equal to 2, the developed CPR has its sensitivity of 53.1% (95%CI: 34.7%-70.9%), specificity of 88.8% (95%CI: 82.5%-93.5%), positive predictive value (PPV) of 51.5% (95%CI: 33.5%-69.2%), negative predictive value (NPV) of 89.4% (95%CI: 83.2%-94.0%), and positive likelihood ratio (LR) of 4.75 (95%CI: 2.70–8.35). A cut-off level of the score more than or equal to 1 has its sensitivity of 84.4% (95%CI: 67.2%-94.7%), specificity of 28.0% (95%CI: 20.8%-36.1%), PPV of 20.8% (95%CI: 14.2%-28.8%), NPV of 88.9% (95%CI: 75.9%-96.3%), and positive LR of 1.17 (95%CI: 0.98–1.40). Internal validation of the CPR After applying the bootstrapping approach (200 iterations), optimism-corrected C-statistics were 0.709 (95%CI: 0.611–0.839), and the expected-to-observed ratio of the internal validation model was 0.976 (95%CI: 0.705–1.234), indicating an acceptable internal validation. Discussion The major findings of this study are: 1) a CPR for predicting has been developed, including two clinical parameters (having AD during UDS and being diagnosed with AIS C) and one urodynamic parameter (having DO in filling phase); 2) the developed CPR has good discriminative performance and acceptable calibrating performance; 3) a cut-off level of more than or equal to 2 optimizes clinical usefulness of the CPR. Predictive factors included and excluded in the CPR After conducting univariate analysis and multivariable logistic regression analysis, the regression model was established with three statistically significant predictors, including having AD during UDS, being diagnosed with AIS C, and having DO in the filling phase. Compared with patients with AIS A and B, patients with AIS D have early development of upper motor neuron lesion, including spasticity, potentially resulting in a risk of having early UUTD (citation). On the other hand, patients with AIS D have an opportunity to recover than others, resulting in a lower risk of developing UUTD. This might be an explanation why AIS C was positively associated with UUTD. Autonomic dysreflexia (AD) can be triggered by any noxious stimulus below the lesion level including during urological intervention such as a urodynamic study [ 24 ]. This finding is in accordance with prior studies suggesting that retaining IDC could be a potential risk of UUTD [ 4 , 5 , 12 ]. Furthermore, it is not surprising that our results confirm the association between the presence of DO and the occurrence of UUTD since DO is an established risk of VUR, hydronephrosis, and UUTD [ 3 ]. In contrast to earlier findings, this study has been unable to illustrate supporting evidence of a significant association between UUTD and other cystometric parameters (MaxPdet, BC, and CC) [ 6 – 10 ]. Notably, our results differ from previous studies that indicated no substantial relationship between injury completeness and UUTD [ 4 , 5 , 25 , 26 ]. This disagreement may arise from variation in data categorizations for statistical analysis across these studies. As opposed to Elmelund et al.'s results [ 25 ], the correlation between prolonged DOratio with UUTD was discovered with an odd ratio of 0.90 (95%CI: 0.30–2.71). A possible explanation for this discrepancy might be due to these patients benefiting from striking results leading to early UUTD prevention. This inconsistency might be due to the difference in cut-off level as well as the different predictive time point for UUTD in this study and the previous studies. Performance of the CPR: Discriminative ability The performance of CPR should be evaluated in both discrimination and calibration. The discrimination, i.e., the ability to differentiate between patients with and without UUTD, of the CPR could be evaluated using the AuROC. The AuROC of this CPR is 0.711 (95%CI: 0.603–0.819), indicating an acceptable discriminative ability [ 23 ]. This result means that if using this CPR on 100 patients with SCI, 71 patients could be correctly predicted. With this AuROC, this CPR should be an assistive (additionally used to suggest clinicians for further investigation of UUTD), not a directive (solely used to plan for management) CPR. This discriminative ability could be improved by applying more potential predictors other than those evaluated in this study, such as urinary interleukin-8 [ 27 ], in a larger cohort to ensure an adequate sample size and power of analysis. According to the internal validation, the C-statistics of 0.709 in the bootstrap model compared with 0.711 in the development model indicates an acceptably decreased discriminative ability of the CPR [ 15 ]. Performance of the CPR: Calibrating ability Calibrating ability is an ability of the CPR, evaluated by assessing the agreement between the predicted probabilities and the observed outcome frequencies in each total score [ 28 ]. Calibrating ability can be evaluated by various methods but observing and interpreting a calibration plot is one of the best methods to assess the calibrating ability of the CPR [ 28 ]. Although the predicted probability curve and the observed risk LOWESS curve are nearly approximate, they underestimate the UUTD events for patients with scores 0 and 3. Therefore, it should be considered if the applied patient has a score of 0 and 3 since the true observed probability may be higher than the predicted one (0.80 vs 0.71, respectively). According to the internal validation, the E:O ratio of 0.976 indicates an acceptably overestimated calibrating ability of the CPR [ 15 ]. Diagnostic indices of the CPR To make the CPR more clinically applicable, a cut-off level has been applied. A cut-off level of more than or equal to 1 has relatively higher sensitivity. However, a positive LR of the CPR is not statistically significant when using this cut-off level. Although a cut-off level of more than or equal to 2 has relatively lower sensitivity, its specificity is higher and its positive LR is statistically significant. Since the positive LR is one of the most clinically useful diagnostic indices [ 29 ], a cut-off level of more than or equal to 2 should be selected. With this cut-off level, the positive LR of the CPR is 4.75, indicating that when compared with the pre-test probability of UUTD of 0.18 (according to the prevalence), patients whose score of the CPR more than or equal to 2 have 4.75 times more likely to have UUTD, resulting in a post-test probability of 0.71. Strengths and limitations of the study To all our knowledge, this is the first CPR aiming to predict the incidence of UUTD in patients with SCI. The developed CPR has also been proven for its performance, in both discrimination, calibration, and diagnostic index aspects. This CPR was developed according to our database, which demonstrates the average time to diagnose UUTD of 3.72 years after SCI. This early prediction should be beneficial for clinicians to apply an early preventive evaluation and intervention program to the high-risk, i.e., the score more than or equal to 2, patients. This specific time point of prediction may also be a limitation since the time to UUTD development may be different in another context, causing a non-clinically important prediction at the 3-year time point. Since we used a retrospective study design, there would be a risk of missing data and we decided to manage it by applying complete case analysis. Therefore, we might miss data of some patients who did not attend the urodynamic examination in the 3–18 months period or who lost follow-up. Clinical and research implications Due to its acceptable discriminative and calibrating performance, the use of this CPR should be encouraged, at least in the developing facility. The CPR should be applied in all patients with SCI who have urodynamic results between 3–18 months after SCI. When the calculated score is more than or equal to 2, clinicians should apply an early preventive evaluation and intervention program, such as increasing the frequency of creatinine clearance and renal ultrasonographic evaluation to every 3–6 months, instead of 6–12 months. Bladder relaxant should be carefully adjusted and strictly administered to deliberately prevent UUTD. For research implications, an external validation study aiming to evaluate the performance of this developed CPR in other clinical contexts before generally applying it [ 30 ]. Conclusions Based on our database of 176 patients with SCI, a CPR for predicting UUTD at 3 years after SCI has been developed. This CPR had acceptable discriminative and calibrating performance. A cut-off of more than or equal to 2 has been proposed with a positive LR ratio of 4.75. A further external validation study is needed before applying this CPR in other clinical contexts. Declarations Acknowledgment Part of this study was presented at the International Spinal Cord Society (ISCoS) 63 rd Annual Scientific Meeting. Author Contributions P.J., P.P., and S.P. designed the study and contributed essential materials and reagents; P.J. and S.P. and. N.A. collected the data; P.J., P.P., and S.P. analysed the data; P.J. and S.P. wrote and revised the manuscript; P.P. and S.P. critically reviewed the manuscript. All authors reviewed the final manuscript before submission. Ethical consideration The study protocol was approved by the Institutional Ethics Committee of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Study ID: REH-2565-09059). Funding Not applicable Conflicts of Interest The authors declare that there are no conflicts of interest. Data Archiving The datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request. 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Çetinel B, Önal B, Can G, Talat Z, Erhan B, Gündüz B. Risk factors predicting upper urinary tract deterioration in patients with spinal cord injury: A retrospective study. Neurourol Urodyn. 2017;36(3):653–8. Weld KJ, Graney MJ, Dmochowski RR. Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients. J Urol. 2000;163(4):1228–33. Pannek J, Kennelly M, Kessler TM, Linsenmeyer T, Wyndaele JJ, Biering-Sørensen F. International spinal cord injury urodynamic basic data set (version 2.0). Spinal Cord Ser Cases. 2018;4:98. Elmelund M, Klarskov N, Bagi P, Oturai PS, Biering-Sørensen F. Renal deterioration after spinal cord injury is associated with length of detrusor contractions during cystometry-A study with a median of 41 years follow-up. Neurourol Urodyn. 2017;36(6):1607–15. Kennedy G, Gallego B. Clinical prediction rules: A systematic review of healthcare provider opinions and preferences. Int J Med Inform. 2019;123:1–10. Moons KG, Altman DG, Reitsma JB, Ioannidis JP, Macaskill P, Steyerberg EW, et al. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med. 2015;162(1):W1-73. Birkhäuser V, Anderson CE, Kozomara M, Bywater M, Gross O, Kiss S, et al. Urodynamics Are Essential to Predict the Risk for Upper Urinary Tract Damage after Acute Spinal Cord Injury. Biomedicines. 2023;11(6). Nosseir M, Hinkel A, Pannek J. Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury. Neurourol Urodyn. 2007;26(2):228–33. Weiss DJ, Fried GW, Chancellor MB, Herbison GJ, Ditunno JF, Jr., Staas WE, Jr. Spinal cord injury and bladder recovery. Arch Phys Med Rehabil. 1996;77(11):1133–5. Liao L, Zhang F, Chen G. New grading system for upper urinary tract dilation using magnetic resonance urography in patients with neurogenic bladder. BMC Urol. 2014;14:38. Sung BM, Oh DJ, Choi MH, Choi HM. Chronic kidney disease in neurogenic bladder. Nephrology (Carlton). 2018;23(3):231–6. Levey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604–12. Riley RD, Ensor J, Snell KIE, Harrell FE, Jr., Martin GP, Reitsma JB, et al. Calculating the sample size required for developing a clinical prediction model. Bmj. 2020;368:m441. Mandrekar JN. Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol. 2010;5(9):1315–6. Walter M, Knüpfer SC, Leitner L, Mehnert U, Schubert M, Curt A, Kessler TM. Autonomic dysreflexia and repeatability of cardiovascular changes during same session repeat urodynamic investigation in women with spinal cord injury. World J Urol. 2016;34(3):391–7. Elmelund M, Oturai PS, Toson B, Biering-Sørensen F. Forty-five-year follow-up on the renal function after spinal cord injury. Spinal Cord. 2016;54(6):445–51. Farrelly E, Lindbo L, Wijkström H, Seiger Å. The Stockholm Spinal Cord Uro Study: 2. Urinary tract infections in a regional prevalence group: frequency, symptoms and treatment strategies. Scand J Urol. 2020;54(2):155–61. Rahimkhani M, Mordadi A, Varmazyar S, Tavakoli A. Evaluation of urinary interleukin-8 levels in patients with spinal cord injury. Recent Pat Antiinfect Drug Discov. 2014;9(2):144–9. D'Arrigo G, Gori M, Pitino A, Torino C, Roumeliotis S, Tripepi G. Statistical methods to assess the prognostic value of risk prediction rules in clinical research. Aging Clin Exp Res. 2021;33(2):279–83. Deeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. Bmj. 2004;329(7458):168–9. Rajchagool B, Wongyikul P, Lumkul L, Phinyo P, Pattanakuhar S. Performance of the Dutch clinical prediction rule for the ambulation outcome after spinal cord injury in a middle-income country clinical setting: an external validation study in the Thai retrospective cohort. Spinal Cord. 2023;61(11):608–14. Additional Declarations There is no duality of interest Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7129191","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":499554763,"identity":"16fdd562-3f52-4d40-9888-9603a4c0b074","order_by":0,"name":"Sintip Pattanakuhar","email":"data:image/png;base64,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","orcid":"","institution":"","correspondingAuthor":true,"prefix":"","firstName":"Sintip","middleName":"","lastName":"Pattanakuhar","suffix":""},{"id":499554764,"identity":"294f9c56-18b0-46e6-9abf-7a4224c67c41","order_by":1,"name":"Patsaporn Jarupathirun","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Patsaporn","middleName":"","lastName":"Jarupathirun","suffix":""},{"id":499554765,"identity":"dec8f5b5-c2ab-4e4f-ba04-3fe2aa1ed744","order_by":2,"name":"Phichayut Phinyo","email":"","orcid":"","institution":"","correspondingAuthor":false,"prefix":"","firstName":"Phichayut","middleName":"","lastName":"Phinyo","suffix":""}],"badges":[],"createdAt":"2025-07-15 10:05:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7129191/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7129191/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89560254,"identity":"1964e073-2d9a-4aee-8b6d-7a7a6a9bee7b","added_by":"auto","created_at":"2025-08-21 10:18:31","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":247462,"visible":true,"origin":"","legend":"\u003cp\u003eA study flow showing included and excluded participants\u003cstrong\u003e\u003cbr\u003e\n \u003c/strong\u003e\u003cem\u003eUUTD, upper urinary tract deterioration; SCI, spinal cord injury\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1CPRUUTD.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7129191/v1/9aadab0c9ee48da4ceba199d.jpg"},{"id":89562825,"identity":"8885f36a-6b4e-4f07-8888-0292902fd749","added_by":"auto","created_at":"2025-08-21 10:26:31","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1121458,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAn area under the receiver operating curve (AuROC) of the developed CPR for predicting UUTD at three years after SCI\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAUC, area under the curve\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2CPRUUTD.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7129191/v1/f3cbd75b22297b3bc7844a67.jpg"},{"id":89565392,"identity":"f95a9e42-4f61-4c49-9808-742901918abb","added_by":"auto","created_at":"2025-08-21 10:42:31","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1029676,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA calibration curve of the developed CPR for predicting UUTD at three years after SCI. \u003c/strong\u003eBlack line, Locally Weighted Scatterplot Smoothing (LOWESS) line of the observed risk of each score; Gray line, probability of the predicted risk of each score\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eUUTD, upper urinary tract deterioration; CPR, clinical prediction rule; SCI, spinal cord injury\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3CPRUUTD.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7129191/v1/79528d67ab7840278ef6fb28.jpg"},{"id":92406353,"identity":"696dbd3c-0166-4a01-bf73-2afda1ab10bf","added_by":"auto","created_at":"2025-09-29 11:18:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3328546,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7129191/v1/57d12e10-11e8-4cc7-b9c9-28a2dc31010b.pdf"}],"financialInterests":"There is no duality of interest","formattedTitle":"Development of a clinical prediction rule for determining the risk of upper urinary tract deterioration in patients with spinal cord injury","fulltext":[{"header":"Introduction","content":"\u003cp\u003eApproximately 70–84% of patients with SCI suffered from neurogenic lower urinary tract dysfunction (NULTD), leading to the significant risk of upper urinary tract deterioration (UUTD) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. After a 45-year follow-up, 58% of patients with SCI exhibited a moderate degree of UUTD whereas 29% of them developed a severe degree of UUTD. Moreover, there are cumulative reports indicating UUTD in Thailand, estimated at approximately 25.16 cases per 1000 individuals per year, within an average period of 3.29 years post-spinal cord injury occurrence [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. When it occurs, UUTD is difficult to cure. Therefore, early detection of UUTD and its risk factors is an important strategy for NLUTD management in patients with SCI.\u003c/p\u003e\u003cp\u003eSeveral clinical parameters were predictive factors of UUTD, including retaining an indwelling urinary catheter (IDC) and age at the onset of SCI ≥ 60 years [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition to use as a diagnostic methods, urodynamic parameters could be used as a predictor for developing UUTD in patients with SCI, including high (≥ 40 cmH\u003csub\u003e2\u003c/sub\u003eO) maximal detrusor pressure (maxPdet) during filling phase [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], low (\u0026lt; 200 ml) cystometric capacity (CC) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], low (\u0026lt; 20 ml/cmH2O) bladder compliance (BC) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and prolonged (≥ 0.33) duration of detrusor overactivity per filling cystometry ratio (DOratio) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Using these predictive factors as a screening tool, clinicians, especially in limited-resource countries, could accurately identify and manage the patients who are at risk of developing UUTD.\u003c/p\u003e\u003cp\u003eHowever, most of the studies reporting the predictive factors of UUTD proposed them as an odds ratio of a single factor or a difficult mathematical equation, causing difficulty for clinicians to apply them in real-life clinical situations. One way to obtain predictive risk is to create it as a clinical prediction rule (CPR) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Unlike forcing clinicians to depend on a single predictive factor or to deal with a difficult equation, CPR uses a set of predictive factors to determine the probability of the outcome by using a simplified, ready-to-use scoring method [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Since there has been no study proposing a CPR for prognosing UUTD in patients with SCI, this study aims to develop a CPR for predicting UUTD in patients with SCI.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy designs\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThis study was a retrospective cohort study aiming to create a prognostic CPR for UUTD at 3 years since it is the average time to develop UUTD in our cohort [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The protocol for this analysis was approved by the local research ethics board, Faculty of Medicine, Chiang Mai University (Study code: REH-2565-09059). Informed consent was waived due to retrospective data collection. The Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement was used to guide model development and reporting [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eStudy populations\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe study focused on patients aged between 15 and 80 years old with TSCI between January 2008 and December 2020, visiting the Urodynamic unit at the Department of Rehabilitation Medicine, Maharaj Nakorn Chiang Mai Hospital. Inclusion criteria comprised of 1) having complete clinical and urodynamic data three to eighteen months after SCI onset 2) undergoing at least one upper urinary tract examination (ultrasound kidneys, voiding cystourethrography (VCUG), or estimated glomerular filtration rate (eGFR) 3 years after SCI onset. Exclusions criteria were defined as 1) patients with non-SCI-related abnormal lower urinary tract such as overactive bladder, autonomic peripheral neuropathy, or any gynecological-abdominal surgery 2) prior diagnosed UUTD or kidney conditions, and 3) incomplete or unreliable medical records (such as graph was unreliable due to artifact).\u003c/p\u003e\u003cp\u003e\u003cem\u003eData collections\u003c/em\u003e\u003c/p\u003e\u003cp\u003eData of each patient were retrospectively reviewed from their medical records consisting of electronic medical records, urodynamic records, and radiologic reports. Collected data included: 1) general demographic data; 2) clinical data including history of urinary incontinence, bladder management methods, and prescribed medication including bladder and sphincter relaxant.\u003c/p\u003e\u003cp\u003e3) Urodynamic parameter derived from the urodynamic study at three to eighteen months after SCI.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePredictive parameters\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe general demographic data was collected including sex (male vs female) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], age at onset (years, and categorized as \u0026lt; 60 years vs ≥ 60 years) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], neurological level (cervical, thoracic, lumbar, and sacral level) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], completeness of SCI (ASIA A, B, C, D and E) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], history of incontinence (yes vs no) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], bladder management methods (indwelling, self-intermittent and intermittent catheterization by other, voluntary voiding, bladder reflex triggering and straining) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the presence of autonomic dysreflexia (AD) during urodynamic study (yes vs no [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]), and the use of bladder relaxant (yes vs no) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Urodynamic parameters included type of detrusor function (detrusor overactivity - DO vs non-DO) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], maximum detrusor pressure (maxPdet) in filling phase (high [≥ 40 cmH\u003csub\u003e2\u003c/sub\u003eO] vs low) [\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e–\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], cystometric capacity (CC) (low [\u0026lt; 200 ml] vs normal) [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], bladder compliance (BC) (low [\u0026lt; 20 ml/cmH\u003csub\u003e2\u003c/sub\u003eO] vs normal) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and DOratio (prolonged [≥ 0.33] vs normal) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], and urethral function at voiding cystometric phase (presence of DSD or non-relaxing sphincter vs absence) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eOutcome parameters\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe primary endpoint of this study was UUTD at 3 years after onset of injury determined by at least one of the followings: 1) any grade of vesicoureteral reflux assessed by VCUG [\u003cspan additionalcitationids=\"CR19 CR20\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e–\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; 2) at least grade 1 of hydroureter or hydronephrosis classified by ultrasonography [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]; 3) creatinine clearance (eGFR) less than 60 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e estimated by CKD-EPI [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eGeneral statistical analysis\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll parameters were described using mean (SD), median (25th percentile, 50th percentile), and frequency (percentage), according to their type and distribution. A probability of less than 5% (p-value \u0026lt; 0.05) was considered statistically significant. All statistical analyses were conducted using Stata version 16 (StataCorp, Texas, USA). Complete case analysis was used to manage missing data. No imputation was performed.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDevelopment of CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAs this study used a predictive modelling strategy, parameter selection methods were applied to make the final model as parsimonious, i.e., containing minimal predictive parameters, as possible. First, data were analyzed with univariable logistic regression analysis (Fisher's exact test for categorical parameters and independent t-test for continuous variables) to eliminate all parameters that had a p-value \u0026gt; 0.2. After that, multivariable logistic regression analysis of all remaining parameters was performed. The area under the receiving operation curve (AuROC) of the regression model was calculated. The regression model was reduced by removing the least significant factor and the AuROC was calculated again. The AuROC of the initial model (containing all predictors) and the parsimonious model (containing only statistically significant factors) was compared using a chi-square test. If the AuROC was not significantly different, the model with fewer predictive factors was selected as the final model. After that, the regression coefficient of each predictive factor would be divided by the smallest one and the results would be rounded as an integer to simplify the coefficient. Then, a score from the developed CPR was calculated for all participants.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEvaluation of CPR performance\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe measurement discrimination and calibration were used to demonstrate our clinical prediction score performance. To evaluate the model's ability to differentiate between groups (UUTD and non-UUTD) by using AuROC. The measurement of calibration demonstrated compatibility between the observed outcomes versus predicted probability plot. A cut-off level of the score was set after applying a diagnostic accuracy test as the level that produced the highest sensitivity and specificity when compared with the true diagnosis of UUTD.\u003c/p\u003e\u003cp\u003e\u003cem\u003eInternal validation\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAccording to the TRIPOD guideline, evaluating internal validation is a requirement for developing CPR. Internal validation was performed using a bootstrapping approach (200 iterations), optimism-corrected C-statistics were used to evaluate model discrimination, and the expected-to-observed ratio was used to assess model calibration [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eSample size calculation\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSample size calculation for the development of CPR was proposed by Riley, et al. [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. A sample size that had 10 outcome events per one predictive factor was used. To make our CPR not too complicated, we included 3–6 potential predictive factors, at least 30 outcome events were required. The prevalence of UUTD in our database was 18%, resulting in a sample size of at least 167.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eCharacteristics of the cohort\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll 713 traumatic SCI patients underwent retrospective screening, with a total of 176 included in this study as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Demographic and clinical baseline characteristics are outlined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. No significant differences were observed in age, gender, or history of UTI between the groups. Notably, 33 patients (18.8%) met the criteria of UUTD. Among these patients, 63.6% exhibited vesicourethral reflux, 18.2% had eGFR lower than 60 ml/min/1.73m\u003csup\u003e2\u003c/sup\u003e by CKD-EPI, and another 18.2% presented with hydronephrosis. The mean duration of UUTD was 3.72 years after the onset of injury. Most of the patients were male, constituting 81% of the included individuals, with an average injury age of 40.11 (SD 15.48) years which was consistent across both UUTD (81.8%) and non-UUTD (81.1%) groups. Regarding neurological levels, 55% were at the cervical, 40% at thoracic, 4% at lumbar, and 1% at sacral levels. Apparently, 50% of patients presented with complete cord injury. From the observed population, the primary method of bladder management was IDC (52%), followed by self-intermittent catheterization (28%) and intermittent catheterization by others (9%). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, an estimated 27% of the total population experienced a history of urinary incontinence which was concordant with the results in UUTD (30%) and non-UUTD (27%) groups. Remarkably, bladder relaxants were prescribed for 49% of the patients, while sphincter relaxants were given to only around 2%.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline characteristics of the included participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWith UUTD\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWithout UUTD\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eClinical parameters\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e176 (100)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e143 (81.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale sex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e143 (81.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (81.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e116 (81.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.604\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at injury, years\u003c/p\u003e\u003cp\u003e[Mean (SD)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e40.1 (15.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e42.9 (15.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.5 (15.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.263\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge more than or equal to \u003c/p\u003e\u003cp\u003e60 years old\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18 (10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (12.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.747\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eNeurological level\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e93 (55.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (72.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e73 (51.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e0.046*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThoracic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e71 (40.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e63 (44.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLumbosacral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (4.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (4.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eAIS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88 (50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (39.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (52.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e0.101\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (12.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (17.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 (17.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (14.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (16.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (16.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eBladder management method\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndwelling catheterization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (51.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69 (48.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u003cb\u003e0.157\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClean intermittent self-catheterization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50 (28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44 (30.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClean intermittent catheterization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (9.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (8.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVoluntary voiding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (8.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (9.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBladder reflex triggering\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStraining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2 (1.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of urinary incontinence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48 (27.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.829\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of UTI within 1 year before UDS, yes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e65 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedication (bladder relaxant)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e86 (48.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66 (46.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.339\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eUrodynamic parameters\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDetrusor function in filling phase\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e112 (63.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e97 (67.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.014*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDetrusor overactivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64 (36.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46 (32.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eUrethral function in voiding phase\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNormal or not applicable (no voiding phase)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e72 (40.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e57 (39.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.552\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDetrusor-sphincter dyssynergia or non-relaxing sphincter\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e104 (59.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (54.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86 (60.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eMaximal Pdet, in filling phase\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;40 cmH\u003csub\u003e2\u003c/sub\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57 (32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (24.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e49 (34.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.212\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;40 cmH\u003csub\u003e2\u003c/sub\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119 (67.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25 (75.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e94 (65.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eCystometric capacity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;200 mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e156 (88.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (84.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e128 (89.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.373\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;200 mL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20 (11.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15 (10.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eBladder compliance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20 cmH\u003csub\u003e2\u003c/sub\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e95 (54.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (52.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.328\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;20 cmH\u003csub\u003e2\u003c/sub\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81 (46.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (39.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68 (47.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003eDetrusor overactivity/ cystometry ratio\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e106 (60.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (69.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e83 (58.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e0.166\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;0.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70 (39.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (30.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e60 (42.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStop due to AD, No. of patients\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74 (42.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (60.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54 (37.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.017*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNo., number; UUTD, upper urinary tract deterioration; AIS, American Spinal Injury Association (ASIA) Impairment Scale; UDS, urodynamic study; UTI, urinary tract infection; Pdet, detrusor pressure; UUTD, upper urinary tract deterioration; mL, milliliter; cmH\u003c/em\u003e\u003csub\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sub\u003e\u003cem\u003eO, centimeters of Water; No., number; AD, autonomic dysreflexia\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eSignificant level at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 by Fisher exact test except age by independent t-test; bold, selected variables\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e also displays urodynamic parameters: 64% of the total population had detrusor overactivity (DO), with 68% among UUTD patients and 46% in non-UUTD patients. MaxPdet remained below 40 cmH\u003csub\u003e2\u003c/sub\u003eO in 66\u0026ndash;76% across all groups, with a mean estimated pressure of 25\u0026ndash;33 cmH\u003csub\u003e2\u003c/sub\u003eO. Cystometric capacity exceeded 200 mL in most cases, averaging 359.4 mL, 345.4 mL, and 362.6 mL in the total, UUTD, and non-UUTD groups, respectively. Low bladder compliance (\u0026lt;\u0026thinsp;20 mL/cmH\u003csub\u003e2\u003c/sub\u003eO) occurred in 46% of the total, 39% in UUTD, and 48% in non-UUTD patients. Additionally, DO/cystometry ratio\u0026thinsp;\u0026lt;\u0026thinsp;0.33 was seen in 60%, 70%, and 58% of the total, UUTD, and non-UUTD groups. Substantially, the number of patients who had to stop the urodynamic study due to autonomic dysreflexia was noticeably larger in patients with the UUTD group (61%) than in the other group.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePredictive variable selection\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e univariably compares clinical predictive factors between patients with UUTD and without UUTD. According to the previously set criteria for predictor selection of p\u0026thinsp;\u0026lt;\u0026thinsp;0.2, there were three potential clinical predictors, including neurological level, AIS, and bladder management method. To simplify the score, the variables were recategorized from neurological level (polytomous answers) to cervical SCI (yes vs no), from AIS (polytomous answers) to AIS C (yes vs no), and bladder management method (polytomous answer) to retaining IDC (yes or no).\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e univariably compares urodynamic predictive factors between patients with UUTD and without UUTD. According to the previously set criteria for predictor selection of p\u0026thinsp;\u0026lt;\u0026thinsp;0.2, there were three potential urodynamic predictors, including type of detrusor function (having DO or not), DOratio (less than vs more than or equal to 0.33), and having AD during urodynamic study (yes or no).\u003c/p\u003e\u003cp\u003e\u003cem\u003eDevelopment of CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e demonstrates the results of multivariable logistic regression analyses for predicting UUTD at 3 years after SCI. The initial model consists of all six predictors selected from the univariable analyses, including cervical SCI, AIS C, retaining IDC, having DO, DOratio, and AD. The AuROC of the initial model was 0.721 (95%CI: 0.610\u0026ndash;0.832). The parsimonious model only consists of three statistically significant predictors, including AIS C, having DO, and AD. The AuROC of the parsimonious model was 0.718 (95%CI: 0.606\u0026ndash;0.831). Therefore, the parsimonious model was selected as the final model.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePredictive factors of UUTD at three years after SCI in the initial and final model\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003ePredictive variables\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eInitial model \u003c/p\u003e\u003cp\u003e(AuROC\u0026thinsp;=\u0026thinsp;0.721 [0.610\u0026ndash;0.832])\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\u003e\u003cp\u003eFinal model \u003c/p\u003e\u003cp\u003e(AuROC\u0026thinsp;=\u0026thinsp;0.718 [0.606\u0026ndash;0.831])\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e95% CI of Odds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOdds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e95% CI of Odds ratio\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUpper\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eLower\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eUpper\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAD during UDS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.060\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e7.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.005*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIS C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.019*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e9.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.011*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresence of DO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.022*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e1.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e9.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e0.002*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervical SCI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.493\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProlonged DOratio\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.854\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRetained IDC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1.029\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e0.959\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eAD, autonomic dysreflexia; UDS, urodynamic study; SCI, spinal cord injury; AuROC, area under the receiver operating curve; CI, confident interval; AIS, ASIA Impairment Scale; DO, detrusor overactivity; DOratio, duration of detrusor overactivity per filling cystometry ratio\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eSignificant level at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, multivariable logistic regression analysis.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA simple CPR was created by dividing the regression coefficient of each factor (3.42, 3.56, 3.83) by the smallest one (3.42), causing a multiplier of one for all predictors (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A score of the developed CPR was calculated in all patients, resulting in a mean (SD) score of 0.95 (0.73). The score of patients with UUTD was significantly higher than that of patients without UUTD (0.84 vs 1.5; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Mann-Whitney U test).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eA simple prediction score for predicting UUTD at three years after spinal cord injury\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePredictors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRange of test scores\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeighted coefficient\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMinimum score\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMaximum score\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAD during UDS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAIS C\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePresence of DO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026ndash;1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eAD, autonomic dysreflexia; AIS, American Spinal Injury Association (ASIA) Impairment Scale; UDS, urodynamic study; DO, detrusor overactivity\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerformance of the developed CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDiscriminative ability of the developed CPR was evaluated using the AuROC of the CPR (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The developed CPR has an AuROC of 0.711 (95%CI: 0.603\u0026ndash;0.819), indicating an acceptable discriminative ability [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The calibrating ability of the developed CPR was evaluated using a calibration plot (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). The calibration plot demonstrates that the predicted probability of developing CPR and the observed probability are nearly, but not definitely approximate. The CPR underestimates the true risk of UUTD at scores 0 and 3 (0.05 vs 0.10 for score 0 and 0.71 vs 0.80 for score 3, respectively).\u003c/p\u003e\u003cp\u003eUsing a cut-off level of the score more than or equal to 2, the developed CPR has its sensitivity of 53.1% (95%CI: 34.7%-70.9%), specificity of 88.8% (95%CI: 82.5%-93.5%), positive predictive value (PPV) of 51.5% (95%CI: 33.5%-69.2%), negative predictive value (NPV) of 89.4% (95%CI: 83.2%-94.0%), and positive likelihood ratio (LR) of 4.75 (95%CI: 2.70\u0026ndash;8.35). A cut-off level of the score more than or equal to 1 has its sensitivity of 84.4% (95%CI: 67.2%-94.7%), specificity of 28.0% (95%CI: 20.8%-36.1%), PPV of 20.8% (95%CI: 14.2%-28.8%), NPV of 88.9% (95%CI: 75.9%-96.3%), and positive LR of 1.17 (95%CI: 0.98\u0026ndash;1.40).\u003c/p\u003e\u003cp\u003e\u003cem\u003eInternal validation of the CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAfter applying the bootstrapping approach (200 iterations), optimism-corrected C-statistics were 0.709 (95%CI: 0.611\u0026ndash;0.839), and the expected-to-observed ratio of the internal validation model was 0.976 (95%CI: 0.705\u0026ndash;1.234), indicating an acceptable internal validation.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe major findings of this study are: 1) a CPR for predicting has been developed, including two clinical parameters (having AD during UDS and being diagnosed with AIS C) and one urodynamic parameter (having DO in filling phase); 2) the developed CPR has good discriminative performance and acceptable calibrating performance; 3) a cut-off level of more than or equal to 2 optimizes clinical usefulness of the CPR.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePredictive factors included and excluded in the CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAfter conducting univariate analysis and multivariable logistic regression analysis, the regression model was established with three statistically significant predictors, including having AD during UDS, being diagnosed with AIS C, and having DO in the filling phase. Compared with patients with AIS A and B, patients with AIS D have early development of upper motor neuron lesion, including spasticity, potentially resulting in a risk of having early UUTD (citation). On the other hand, patients with AIS D have an opportunity to recover than others, resulting in a lower risk of developing UUTD. This might be an explanation why AIS C was positively associated with UUTD. Autonomic dysreflexia (AD) can be triggered by any noxious stimulus below the lesion level including during urological intervention such as a urodynamic study [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This finding is in accordance with prior studies suggesting that retaining IDC could be a potential risk of UUTD [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Furthermore, it is not surprising that our results confirm the association between the presence of DO and the occurrence of UUTD since DO is an established risk of VUR, hydronephrosis, and UUTD [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn contrast to earlier findings, this study has been unable to illustrate supporting evidence of a significant association between UUTD and other cystometric parameters (MaxPdet, BC, and CC) [\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Notably, our results differ from previous studies that indicated no substantial relationship between injury completeness and UUTD [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. This disagreement may arise from variation in data categorizations for statistical analysis across these studies. As opposed to Elmelund et al.'s results [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], the correlation between prolonged DOratio with UUTD was discovered with an odd ratio of 0.90 (95%CI: 0.30\u0026ndash;2.71). A possible explanation for this discrepancy might be due to these patients benefiting from striking results leading to early UUTD prevention. This inconsistency might be due to the difference in cut-off level as well as the different predictive time point for UUTD in this study and the previous studies.\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerformance of the CPR: Discriminative ability\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe performance of CPR should be evaluated in both discrimination and calibration. The discrimination, i.e., the ability to differentiate between patients with and without UUTD, of the CPR could be evaluated using the AuROC. The AuROC of this CPR is 0.711 (95%CI: 0.603\u0026ndash;0.819), indicating an acceptable discriminative ability [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This result means that if using this CPR on 100 patients with SCI, 71 patients could be correctly predicted. With this AuROC, this CPR should be an assistive (additionally used to suggest clinicians for further investigation of UUTD), not a directive (solely used to plan for management) CPR. This discriminative ability could be improved by applying more potential predictors other than those evaluated in this study, such as urinary interleukin-8 [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], in a larger cohort to ensure an adequate sample size and power of analysis. According to the internal validation, the C-statistics of 0.709 in the bootstrap model compared with 0.711 in the development model indicates an acceptably decreased discriminative ability of the CPR [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003ePerformance of the CPR: Calibrating ability\u003c/em\u003e\u003c/p\u003e\u003cp\u003eCalibrating ability is an ability of the CPR, evaluated by assessing the agreement between the predicted probabilities and the observed outcome frequencies in each total score [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Calibrating ability can be evaluated by various methods but observing and interpreting a calibration plot is one of the best methods to assess the calibrating ability of the CPR [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Although the predicted probability curve and the observed risk LOWESS curve are nearly approximate, they underestimate the UUTD events for patients with scores 0 and 3. Therefore, it should be considered if the applied patient has a score of 0 and 3 since the true observed probability may be higher than the predicted one (0.80 vs 0.71, respectively). According to the internal validation, the E:O ratio of 0.976 indicates an acceptably overestimated calibrating ability of the CPR [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cem\u003eDiagnostic indices of the CPR\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo make the CPR more clinically applicable, a cut-off level has been applied. A cut-off level of more than or equal to 1 has relatively higher sensitivity. However, a positive LR of the CPR is not statistically significant when using this cut-off level. Although a cut-off level of more than or equal to 2 has relatively lower sensitivity, its specificity is higher and its positive LR is statistically significant. Since the positive LR is one of the most clinically useful diagnostic indices [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e], a cut-off level of more than or equal to 2 should be selected. With this cut-off level, the positive LR of the CPR is 4.75, indicating that when compared with the pre-test probability of UUTD of 0.18 (according to the prevalence), patients whose score of the CPR more than or equal to 2 have 4.75 times more likely to have UUTD, resulting in a post-test probability of 0.71.\u003c/p\u003e\u003cp\u003e\u003cem\u003eStrengths and limitations of the study\u003c/em\u003e\u003c/p\u003e\u003cp\u003eTo all our knowledge, this is the first CPR aiming to predict the incidence of UUTD in patients with SCI. The developed CPR has also been proven for its performance, in both discrimination, calibration, and diagnostic index aspects. This CPR was developed according to our database, which demonstrates the average time to diagnose UUTD of 3.72 years after SCI. This early prediction should be beneficial for clinicians to apply an early preventive evaluation and intervention program to the high-risk, i.e., the score more than or equal to 2, patients. This specific time point of prediction may also be a limitation since the time to UUTD development may be different in another context, causing a non-clinically important prediction at the 3-year time point. Since we used a retrospective study design, there would be a risk of missing data and we decided to manage it by applying complete case analysis. Therefore, we might miss data of some patients who did not attend the urodynamic examination in the 3\u0026ndash;18 months period or who lost follow-up.\u003c/p\u003e\u003cp\u003e\u003cem\u003eClinical and research implications\u003c/em\u003e\u003c/p\u003e\u003cp\u003eDue to its acceptable discriminative and calibrating performance, the use of this CPR should be encouraged, at least in the developing facility. The CPR should be applied in all patients with SCI who have urodynamic results between 3\u0026ndash;18 months after SCI. When the calculated score is more than or equal to 2, clinicians should apply an early preventive evaluation and intervention program, such as increasing the frequency of creatinine clearance and renal ultrasonographic evaluation to every 3\u0026ndash;6 months, instead of 6\u0026ndash;12 months. Bladder relaxant should be carefully adjusted and strictly administered to deliberately prevent UUTD. For research implications, an external validation study aiming to evaluate the performance of this developed CPR in other clinical contexts before generally applying it [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eBased on our database of 176 patients with SCI, a CPR for predicting UUTD at 3 years after SCI has been developed. This CPR had acceptable discriminative and calibrating performance. A cut-off of more than or equal to 2 has been proposed with a positive LR ratio of 4.75. A further external validation study is needed before applying this CPR in other clinical contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePart of this study was presented at the International Spinal Cord Society (ISCoS) 63\u003csup\u003erd\u003c/sup\u003e Annual Scientific Meeting.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eP.J., P.P., and S.P. designed the study and contributed essential materials and reagents; P.J. and S.P. and. N.A. collected the data; P.J., P.P., and S.P. analysed the data; P.J. and S.P. wrote and revised the manuscript; P.P. and S.P. critically reviewed the manuscript. All authors reviewed the final manuscript before submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan dir=\"RTL\"\u003eEthical consideration\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Institutional Ethics Committee of the Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand (Study ID: REH-2565-09059).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eData Archiving\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan lang=\"\"\u003eDeclaration of generative AI in scientific writing\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan lang=\"\"\u003e \u003c/span\u003e\u003c/strong\u003e\u003cspan lang=\"\"\u003eNo generative AI was used during the development of this manuscript.\u003c/span\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMiller CA, Kennelly MJ. Pulse article: survey of neurogenic bladder management in spinal cord injury patients around the world. Spinal Cord Ser Cases. 2021;7(1):16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKammuang-Lue P, Pattanakuhar S, Sermsuk M, Angkurawaranon C. Duration of detrusor overactivity as an independent predictive factor of upper urinary tract deterioration in patients with traumatic spinal cord injury: results of a retrospective cohort study. Spinal Cord. 2024;62(6):328\u0026ndash;335.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMusco S, Padilla-Fern\u0026aacute;ndez B, Del Popolo G, Bonifazi M, Blok BFM, Groen J, et al. Value of urodynamic findings in predicting upper urinary tract damage in neuro-urological patients: A systematic review. Neurourol Urodyn. 2018;37(5):1522\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSirasaporn P, Saengsuwan J. Incidence and predictive factors for developing vesicoureteric reflux in individuals with suprasarcral spinal cord injury: a historical cohort study. Spinal Cord. 2021;59(7):753\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Z, Liao L. Risk factors predicting upper urinary tract deterioration in patients with spinal cord injury: a prospective study. Spinal Cord. 2014;52(6):468\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcGuire EJ, Woodside JR, Borden TA, Weiss RM. Prognostic value of urodynamic testing in myelodysplastic patients. J Urol. 1981;126(2):205\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGerridzen RG, Thijssen AM, Dehoux E. Risk factors for upper tract deterioration in chronic spinal cord injury patients. J Urol. 1992;147(2):416\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShin JC, Lee Y, Yang H, Kim DH. Clinical significance of urodynamic study parameters in maintenance of renal function in spinal cord injury patients. Ann Rehabil Med. 2014;38(3):353\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShingleton WB, Bodner DR. The development of urologic complications in relationship to bladder pressure in spinal cord injured patients. J Am Paraplegia Soc. 1993;16(1):14\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u0026Ccedil;etinel B, \u0026Ouml;nal B, Can G, Talat Z, Erhan B, G\u0026uuml;nd\u0026uuml;z B. Risk factors predicting upper urinary tract deterioration in patients with spinal cord injury: A retrospective study. Neurourol Urodyn. 2017;36(3):653\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeld KJ, Graney MJ, Dmochowski RR. Differences in bladder compliance with time and associations of bladder management with compliance in spinal cord injured patients. J Urol. 2000;163(4):1228\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePannek J, Kennelly M, Kessler TM, Linsenmeyer T, Wyndaele JJ, Biering-S\u0026oslash;rensen F. International spinal cord injury urodynamic basic data set (version 2.0). Spinal Cord Ser Cases. 2018;4:98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElmelund M, Klarskov N, Bagi P, Oturai PS, Biering-S\u0026oslash;rensen F. Renal deterioration after spinal cord injury is associated with length of detrusor contractions during cystometry-A study with a median of 41 years follow-up. Neurourol Urodyn. 2017;36(6):1607\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKennedy G, Gallego B. Clinical prediction rules: A systematic review of healthcare provider opinions and preferences. Int J Med Inform. 2019;123:1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoons KG, Altman DG, Reitsma JB, Ioannidis JP, Macaskill P, Steyerberg EW, et al. Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med. 2015;162(1):W1-73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBirkh\u0026auml;user V, Anderson CE, Kozomara M, Bywater M, Gross O, Kiss S, et al. Urodynamics Are Essential to Predict the Risk for Upper Urinary Tract Damage after Acute Spinal Cord Injury. Biomedicines. 2023;11(6).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNosseir M, Hinkel A, Pannek J. Clinical usefulness of urodynamic assessment for maintenance of bladder function in patients with spinal cord injury. Neurourol Urodyn. 2007;26(2):228\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWeiss DJ, Fried GW, Chancellor MB, Herbison GJ, Ditunno JF, Jr., Staas WE, Jr. Spinal cord injury and bladder recovery. Arch Phys Med Rehabil. 1996;77(11):1133\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiao L, Zhang F, Chen G. New grading system for upper urinary tract dilation using magnetic resonance urography in patients with neurogenic bladder. BMC Urol. 2014;14:38.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSung BM, Oh DJ, Choi MH, Choi HM. Chronic kidney disease in neurogenic bladder. Nephrology (Carlton). 2018;23(3):231\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLevey AS, Stevens LA, Schmid CH, Zhang YL, Castro AF, 3rd, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150(9):604\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRiley RD, Ensor J, Snell KIE, Harrell FE, Jr., Martin GP, Reitsma JB, et al. Calculating the sample size required for developing a clinical prediction model. Bmj. 2020;368:m441.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMandrekar JN. Receiver operating characteristic curve in diagnostic test assessment. J Thorac Oncol. 2010;5(9):1315\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWalter M, Kn\u0026uuml;pfer SC, Leitner L, Mehnert U, Schubert M, Curt A, Kessler TM. Autonomic dysreflexia and repeatability of cardiovascular changes during same session repeat urodynamic investigation in women with spinal cord injury. World J Urol. 2016;34(3):391\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eElmelund M, Oturai PS, Toson B, Biering-S\u0026oslash;rensen F. Forty-five-year follow-up on the renal function after spinal cord injury. Spinal Cord. 2016;54(6):445\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFarrelly E, Lindbo L, Wijkstr\u0026ouml;m H, Seiger \u0026Aring;. The Stockholm Spinal Cord Uro Study: 2. Urinary tract infections in a regional prevalence group: frequency, symptoms and treatment strategies. Scand J Urol. 2020;54(2):155\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRahimkhani M, Mordadi A, Varmazyar S, Tavakoli A. Evaluation of urinary interleukin-8 levels in patients with spinal cord injury. Recent Pat Antiinfect Drug Discov. 2014;9(2):144\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD'Arrigo G, Gori M, Pitino A, Torino C, Roumeliotis S, Tripepi G. Statistical methods to assess the prognostic value of risk prediction rules in clinical research. Aging Clin Exp Res. 2021;33(2):279\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeeks JJ, Altman DG. Diagnostic tests 4: likelihood ratios. Bmj. 2004;329(7458):168\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRajchagool B, Wongyikul P, Lumkul L, Phinyo P, Pattanakuhar S. Performance of the Dutch clinical prediction rule for the ambulation outcome after spinal cord injury in a middle-income country clinical setting: an external validation study in the Thai retrospective cohort. Spinal Cord. 2023;61(11):608\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"clinical prediction rule, spinal cord injury, upper urinary tract deterioration, neurogenic lower urinary tract dysfunction, vesicoureteral reflux, hydronephrosis","lastPublishedDoi":"10.21203/rs.3.rs-7129191/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7129191/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo develop the clinical prediction rule (CPR) of upper urinary tract deterioration (UUTD) outcome at three years in patients with traumatic spinal cord injury (TSCI)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design: \u003c/strong\u003eRetrospective cohort study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting: \u003c/strong\u003eDepartment of Rehabilitation Medicine, Maharaj Nakorn Chiang Mai Hospital\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSubjects:\u003c/strong\u003eTSCI patients with onset of injury in January 2008 - December 2020.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eAfter screening the medical records of 714 TSCI patients, clinical and urodynamic parameter data from 176 patients, collected at 3-18 months after SCI, were retrospectively analyzed. CPR was developed to predict UUTD at three years after SCI by conducting logistic regression analysis. The performance of the model was evaluated in terms of both discrimination and calibration using the AUROC and calibration plot, respectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe incidence of UUTD was 18.8% (33/176) with a mean duration of 3.72 years after the onset of injury. The developed CPR consists of three predictive factors, including neurological level, presence of detrusor overactivity, and having autonomic dysreflexia during urodynamic study to predict UUTD at three years after SCI. The developed CPR had acceptable discriminative and calibrating performance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Our developed CPR for prognosing UUTD at three years after SCI was established and proved that it has acceptable performance, in both the discrimination and the calibration aspects. However, a further external validation study is needed before applying this CPR in other clinical contexts.\u003c/p\u003e","manuscriptTitle":"Development of a clinical prediction rule for determining the risk of upper urinary tract deterioration in patients with spinal cord injury","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-21 10:18:26","doi":"10.21203/rs.3.rs-7129191/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3b397cd4-d9e7-4a8b-aa76-74a954ee8942","owner":[],"postedDate":"August 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":53065485,"name":"Health sciences/Neurology/Neurological disorders"},{"id":53065486,"name":"Health sciences/Medical research/Epidemiology"},{"id":53065487,"name":"Biological sciences/Neuroscience"}],"tags":[],"updatedAt":"2025-09-29T11:10:42+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-21 10:18:26","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7129191","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7129191","identity":"rs-7129191","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}