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      Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

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          Abstract

          Introduction

          Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI.

          Methods

          Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results.

          Results

          The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed.

          Conclusion

          We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

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          Most cited references33

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          Acute kidney injury, mortality, length of stay, and costs in hospitalized patients.

          The marginal effects of acute kidney injury on in-hospital mortality, length of stay (LOS), and costs have not been well described. A consecutive sample of 19,982 adults who were admitted to an urban academic medical center, including 9210 who had two or more serum creatinine (SCr) determinations, was evaluated. The presence and degree of acute kidney injury were assessed using absolute and relative increases from baseline to peak SCr concentration during hospitalization. Large increases in SCr concentration were relatively rare (e.g., >or=2.0 mg/dl in 105 [1%] patients), whereas more modest increases in SCr were common (e.g., >or=0.5 mg/dl in 1237 [13%] patients). Modest changes in SCr were significantly associated with mortality, LOS, and costs, even after adjustment for age, gender, admission International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis, severity of illness (diagnosis-related group weight), and chronic kidney disease. For example, an increase in SCr >or=0.5 mg/dl was associated with a 6.5-fold (95% confidence interval 5.0 to 8.5) increase in the odds of death, a 3.5-d increase in LOS, and nearly 7500 dollars in excess hospital costs. Acute kidney injury is associated with significantly increased mortality, LOS, and costs across a broad spectrum of conditions. Moreover, outcomes are related directly to the severity of acute kidney injury, whether characterized by nominal or percentage changes in serum creatinine.
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            Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study.

            Acute renal failure increases risk of death after cardiac surgery. However, it is not known whether more subtle changes in renal function might have an impact on outcome. Thus, the association between small serum creatinine changes after surgery and mortality, independent of other established perioperative risk indicators, was analyzed. In a prospective cohort study in 4118 patients who underwent cardiac and thoracic aortic surgery, the effect of changes in serum creatinine within 48 h postoperatively on 30-d mortality was analyzed. Cox regression was used to correct for various established demographic preoperative risk indicators, intraoperative parameters, and postoperative complications. In the 2441 patients in whom serum creatinine decreased, early mortality was 2.6% in contrast to 8.9% in patients with increased postoperative serum creatinine values. Patients with large decreases (DeltaCrea or =0.5 mg/dl. For all groups, increases in mortality remained significant in multivariate analyses, including postoperative renal replacement therapy. After cardiac and thoracic aortic surgery, 30-d mortality was lowest in patients with a slight postoperative decrease in serum creatinine. Any even minimal increase or profound decrease of serum creatinine was associated with a substantial decrease in survival.
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              An assessment of the RIFLE criteria for acute renal failure in hospitalized patients.

              The Acute Dialysis Quality Initiative (ADQI) Group published a consensus definition (the RIFLE criteria) for acute renal failure. We sought to assess the ability of the RIFLE criteria to predict mortality in hospital patients. Retrospective single-center study. University-affiliated hospital. All patients admitted to the study hospital between January 2000 and December 2002. Patients were excluded if they were younger than 15 yrs old, were on chronic dialysis, or had kidney transplant or if their length of hospital stay was <24 hrs. None. We included 20,126 patients. Mean age was 64 yrs, 14.7% of patients required intensive care unit admission, and hospital mortality was 8.0%. According to the RIFLE criteria, 9.1% of all patients were in the Risk category for acute renal failure, 5.2% were in the Injury category, and 3.7% were in the Failure category. There was an almost linear increase in hospital mortality from Normal to Failure (Normal, 4.4%; Risk, 15.1%; Injury, 29.2%; and Failure, 41.1%). Multivariate logistic regression analysis showed that all RIFLE criteria were significantly predictive factors for hospital mortality, with an almost linear increase in odds ratios from Risk to Failure (odds ratios, Risk 2.5, Injury 5.4, Failure 10.1). The RIFLE criteria for acute renal failure classified close to 20% of our study patients as having some degrees of acute impairment in renal function and were useful in predicting their hospital mortality.
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                Author and article information

                Journal
                Crit Care
                Critical Care
                BioMed Central
                1364-8535
                1466-609X
                2007
                1 March 2007
                : 11
                : 2
                : R31
                Affiliations
                [1 ]Department of Medicine, University of California San Diego Medical Center 8342, 200 W. Arbor Drive, San Diego, CA 92103, USA
                [2 ]Department of Critical Care Medicine, University of Pittsburgh, 3550 Terrace Street, 608 Scaife Hall, Pittsburgh, PA 15261, USA
                [3 ]Division of Nephrology, UAMS College of Medicine, 4301 West Markham, Slot 501, Little Rock, AR 72205, USA
                [4 ]Department of Medicine, Indiana University, Indianapolis, IN, USA
                [5 ]Department of Nephrology Dialysis & Transplantation, San Bortolo Hospital, Vicenza, Italy
                [6 ]Department of Medicine, University of Alabama, 1900 University Blvd, Birmingham, AL, USA
                [7 ]Department of Medicine, University of British Columbia, St Pauls Hospital, 1160 Burrard St, Vancouver BC, V6Z1Y8, Canada
                Article
                cc5713
                10.1186/cc5713
                2206446
                17331245
                4b64f4f2-a9a3-4c2c-ae67-7985d8e3e34c
                Copyright © 2007 Mehta et al.; licensee BioMed Central Ltd.

                This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 8 December 2006
                : 28 December 2006
                : 9 February 2007
                : 1 March 2007
                Categories
                Research

                Emergency medicine & Trauma
                Emergency medicine & Trauma

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