Article

Challenges of defining acute kidney injury.

Department of Critical Care, Guy's & St Thomas' Foundation Hospital, London SE1 7EH, UK.
QJM: monthly journal of the Association of Physicians (Impact Factor: 2.36). 10/2010; 104(3):237-43. DOI: 10.1093/qjmed/hcq185
Source: PubMed

ABSTRACT Until recently, there was a lack of a uniform definition for acute kidney injury (AKI). The 'acute renal injury/acute renal failure syndrome/severe acute renal failure syndrome' criteria, the Risk - Injury - Failure - Loss of kidney function - End stage renal disease (RIFLE) criteria and the Acute Kidney Injury Network (AKIN) classification were the most recent proposals.
To compare the performance of the different AKI definitions. Design and
Application of the three most recent AKI definitions to 41 972 critically ill ICU patients and comparison of their performance.
Incidence and outcome of AKI varied depending on the criteria. The RIFLE and AKIN classification led to similar total incidences of AKI (35.9 vs. 35.4%) but different incidences and outcomes of the individual AKI stages. Multivariate analysis showed that the different stages of AKI were independently associated with mortality. The worst stage of AKI was associated with an increased odds ratio for mortality of 1.59-2.27. Non-surgical admission, maximum number of associated failed organ systems, emergency surgery and mechanical ventilation were consistently associated with the highest risk of hospital mortality. The proposed AKI definitions differ in the cut-off values of serum creatinine, the suggested time frame, the approach towards patients with missing baseline values and the method of classifying patients on renal replacement therapy. All classifications can miss patients with definite AKI.
The three most recent definitions of AKI confirmed a correlation between severity of AKI and outcome but have limitations and the potential to miss patients with definite AKI. These limitations need to be considered when using the criteria in clinical practice.

0 Bookmarks
 · 
90 Views
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose:To assess the hemodynamic effect of iodinated contrast media (CM) on glomerular filtration rate (GFR) by using dynamic three-dimensional magnetic resonance (MR) renography in a rabbit model.Materials and Methods:This study was approved by the university animal care and use committee. Twelve healthy male New Zealand rabbits (body mass range, 2.5-3.0 kg) were included. Two of them were sacrificed before MR examination to obtain renal histologic samples as controls. The other ten rabbits completed 4-minute dynamic contrast material-enhanced MR imaging 24 hours before and 20 minutes after intravenous injection of iopamidol (370 mg of iodine per milliliter) at a dose of 6 mL per kilogram of body weight. Blood volume (VB), GFR, and tubule volume (VE) of the renal cortex were determined with a two-compartment kinetic model. Maximum upslope (Km), peak concentration (Pc), and initial 60-second area under the curve (IAUC) of the whole kidney renogram curve were measured with semiquantitative analysis. The self-control data were compared by using the Student paired t test.Results:Iopamidol significantly decreased cortical VB (mean, 42.53% ± 10.16 [standard deviation] before CM administration vs 27.23% ± 16.13 after CM administration; P < .01), VE (mean, 22.40% ± 11.69 before CM administration vs 11.51% ± 6.58 after CM administration; P < .01), and GFR (mean, 31.92 mL/100 g per minute ± 12.52 before CM administration vs 21.48 mL/100 g per minute ± 10.02 after CM administration; P < .01). Results of whole-kidney renogram analysis showed a decrease in Km, Pc, and IAUC caused by iopamidol administration.Conclusion:High-dose iopamidol resulted in a marked decrease in renal function, which could be detected at dynamic three-dimensional MR renography.© RSNA, 2013Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13122495/-/DC1.
    Radiology 10/2013; · 6.34 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Although acute kidney injury (AKI) is well studied in the acute care setting, investigation of AKI in the nursing home (NH) setting is virtually nonexistent. The goal of this study was to determine the incidence of drug-associated AKI using the RIFLE (Risk, Injury, Failure, Loss of kidney function, or End-Stage kidney disease) criteria in NH residents. We conducted a retrospective study between February 9, 2012, and February 8, 2013, for all residents at 4 UPMC NHs located in southwest Pennsylvania. The TheraDoc™ Clinical Surveillance Software System, which monitors laboratory and medication data and fires alerts when patients have a sufficient increase in serum creatinine, was used for automated case detection. An increase in serum creatinine in the presence of an active medication order identified to potentially cause AKI triggered an alert, and drug-associated AKI was staged according to the RIFLE criteria. Data were analyzed by frequency and distribution of alert type by risk, injury, and failure. Of the 249 residents who had a drug-associated AKI alert fire, 170 (68.3%) were women, and the mean age was 74.2 years. Using the total number of alerts (n = 668), the rate of drug-associated AKI was 0.35 events per 100 resident-months. Based on the RIFLE criteria, there were 191, 70, and 44 residents who were classified as AKI risk, injury, and failure, respectively. The most common medication classes included in the AKI alerts were diuretics, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEIs/ARBs), and antibiotics. Drug-associated AKI was a common cause of potential adverse drug events. The vast majority of cases were related to the use of diuretics, ACEIs/ARBs, and antibiotics. Future studies are needed to better understand patient, provider, and facility risk factors, as well as strategies to enhance the detection and management of drug-associated AKI in the NH.
    Journal of the American Medical Directors Association 05/2014; · 5.30 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: The effects of preoperative (pre-op) renin-angiotensin system (RAS) inhibitors on outcomes in patients undergoing cardiac surgery remain uncertain. The aim of this study was to evaluate whether the use of pre-op RAS inhibitors affected major outcomes of cardiac surgery. DESIGN: A retrospective cohort study. SETTING: A university teaching hospital. PARTICIPANTS: Patients undergoing cardiac surgery between January 1, 2001 and December 31, 2011. INTERVENTIONS: One thousand two hundred thirty-nine patients who received pre-op RAS inhibitors were compared with those who did not (control group, n = 1,083). MEASUREMENTS AND MAIN RESULTS: Acute kidney injury (AKI) was defined using Acute Kidney Injury Network classification. Patients in the RAS inhibitors group presented with higher comorbidities. Pre-op RAS inhibitors therapy was associated with the reduction in the incidence of AKI (27.2% v 34.0%, p<0.001), septicemia (1.9% v 3.5%, p = 0.019), and operative mortality (2.99% v 4.62%, p = 0.039). After adjusted propensity scores and multivariate logistic regression, the pre-op RAS inhibitors were found to have protective effects against AKI (odds ratio [OR]: 0.764, 95% confidence interval [CI]: 0.670-0.873, p<0.001), septicemia (OR: 0.515, 95% CI: 0.348-0.761, p>0.001), and operative mortality (OR: 0.539, 95% CI: 0.348-0.758, p<0.001). CONCLUSION: The results suggested that pre-op RAS inhibitor therapy was associated with significant reductions in the risk of AKI, operative mortality, and septicemia.
    Journal of cardiothoracic and vascular anesthesia 05/2013; · 1.06 Impact Factor

Full-text (2 Sources)

View
27 Downloads
Available from
May 30, 2014