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.

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    ABSTRACT: Acute kidney injury (AKI) is a common syndrome that is independently associated with increased mortality. A standardized definition is important to facilitate clinical care and research. The definition of AKI has evolved rapidly since 2004, with the introduction of the Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) classifications. RIFLE was modified for pediatric use (pRIFLE). They were developed using both evidence and consensus. Small rises in serum creatinine are independently associated with increased mortality, and hence are incorporated into the current definition of AKI. The recent definition from the international KDIGO guideline merged RIFLE and AKIN. Systematic review has found that these definitions do not differ significantly in their performance. Health-care staff caring for children or adults should use standard criteria for AKI, such as the pRIFLE or KDIGO definitions, respectively.These efforts to standardize AKI definition are a substantial advance, although areas of uncertainty remain. The new definitions have enabled the use of electronic alerts to warn clinicians of possible AKI. Novel biomarkers may further refine the definition of AKI, but their use will need to produce tangible improvements in outcomes and cost effectiveness. Further developments in AKI definitions should be informed by research into their practical application across health-care providers. This review will discuss the definition of AKI and its use in practice for clinicians and laboratory scientists.Kidney International advance online publication, 15 October 2014; doi:10.1038/ki.2014.328.
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    ABSTRACT: Serum creatinine is still the most important determinant in the assessment of perioperative renal function and in the prediction of adverse outcome in cardiac surgery. Many biomarkers have been studied to date; still, there is no surrogate for serum creatinine measurement in clinical practice because it is feasible and inexpensive. High levels of serum creatinine and its equivalents have been the most important preoperative risk factor for postoperative renal injury. Moreover, creatinine is the mainstay in predicting risk models and risk factor reduction has enhanced its importance in outcome pre-diction. The future perspective is the development of new definitions and novel tools for the early diagnosis of acute kidney injury largely based on serum creati-nine and a panel of novel biomarkers. Core tip: This manuscript aims to review the latest achievements in the diagnosis and treatment of acute kidney injury (AKI). Despite much progress in recent years, especially in the development of novel biomark-ers, serum creatinine still plays the major role. Creati-nine is not only the mainstay of definition, diagnosis and prediction of AKI, but also the most important pre-dictor of outcome after cardiac surgery, including mor-tality and morbidity as well as hospital length of stay. Najafi M. Serum creatinine role in predicting outcome after cardiac surgery beyond acute kidney injury. World J Cardiol
    world journal of cardiology. 09/2014; 6(9):1006-21.
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    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

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