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      Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients

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          Abstract

          Introduction

          Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI.

          Methods

          In 253 patients recruited from a prospective observational study of critically-ill patients with AKI, we calculated cumulative fluid balance and computed a fluid-adjusted sCr concentration reflecting the effect of volume of distribution during the development phase of AKI. The time to reach a relative 50% increase from the reference sCr using the crude and adjusted sCr was compared. We defined late recognition to estimate severity of AKI when this time interval to reach 50% relative increase between the crude and adjusted sCr exceeded 24 hours.

          Results

          The median cumulative fluid balance increased from 2.7 liters on day 2 to 6.5 liters on day 7. The difference between adjusted and crude sCr was significantly higher at each time point and progressively increased from a median difference of 0.09 mg/dL to 0.65 mg/dL after six days. Sixty-four (25%) patients met criteria for a late recognition to estimate severity progression of AKI. This group of patients had a lower urine output and a higher daily and cumulative fluid balance during the development phase of AKI. They were more likely to need dialysis but showed no difference in mortality compared to patients who did not meet the criteria for late recognition of severity progression.

          Conclusions

          In critically-ill patients, the dilution of sCr by fluid accumulation may lead to underestimation of the severity of AKI and increases the time required to identify a 50% relative increase in sCr. A simple formula to correct sCr for fluid balance can improve staging of AKI and provide a better parameter for earlier recognition of severity progression.

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

          Glenn Chertow, Elisabeth Burdick, Melissa M Honour … (2005)
          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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            Incidence and outcomes in acute kidney injury: a comprehensive population-based study.

            Tariq Ali, Izhar U.H. Khan, William Simpson … (2007)
            Epidemiological studies of acute kidney injury (AKI) and acute-on-chronic renal failure (ACRF) are surprisingly sparse and confounded by differences in definition. Reported incidences vary, with few studies being population-based. Given this and our aging population, the incidence of AKI may be much higher than currently thought. We tested the hypothesis that the incidence is higher by including all patients with AKI (in a geographical population base of 523,390) regardless of whether they required renal replacement therapy irrespective of the hospital setting in which they were treated. We also tested the hypothesis that the Risk, Injury, Failure, Loss, and End-Stage Kidney (RIFLE) classification predicts outcomes. We identified all patients with serum creatinine concentrations > or =150 micromol/L (male) or > or =130 micromol/L (female) over a 6-mo period in 2003. Clinical outcomes were obtained from each patient's case records. The incidences of AKI and ACRF were 1811 and 336 per million population, respectively. Median age was 76 yr for AKI and 80.5 yr for ACRF. Sepsis was a precipitating factor in 47% of patients. The RIFLE classification was useful for predicting full recovery of renal function (P < 0.001), renal replacement therapy requirement (P < 0.001), length of hospital stay [excluding those who died during admission (P < 0.001)], and in-hospital mortality (P = 0.035). RIFLE did not predict mortality at 90 d or 6 mo. Thus the incidence of AKI is much higher than previously thought, with implications for service planning and providing information to colleagues about methods to prevent deterioration of renal function. The RIFLE classification is useful for identifying patients at greatest risk of adverse short-term outcomes.
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              An assessment of the RIFLE criteria for acute renal failure in hospitalized patients.

              Shigehiko Uchino, Rinaldo Bellomo, Donna Goldsmith … (2006)
              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.
              Article 0 comments Cited 208 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): Crit Care
                Title: Critical Care
                Publisher: BioMed Central
                ISSN (Print): 1364-8535
                ISSN (Electronic): 1466-609X
                Publication date (Print): 2010
                Publication date (Electronic): 6 May 2010
                Volume: 14
                Issue: 3
                Page: R82
                Affiliations
                [1 ]Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego San Diego, 200 West Arbor Drive, MC 8342, San Diego, CA 92103, USA
                [2 ]Division of Nephrology, Department of Medicine, Stanford University School of Medicine, 780 Welch Road, Suite 106, Palo Alto, CA 94034, USA
                [3 ]Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, 908 Jefferson St, Seattle, WA 98104, USA
                [4 ]Division of Nephrology, Department of Medicine Vanderbilt University School of Medicine,638 Robinson Research Building, 2200 Pierce Avenue, Nashville, TN 37232-0146, USA
                [5 ]Division of Nephrology, Department of Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA
                Article
                Publisher ID: cc9004
                DOI: 10.1186/cc9004
                PMC ID: 2911707
                PubMed ID: 20459609
                SO-VID: 77f3f4d4-6fc7-4a66-a535-4afa7d597d0f
                Copyright © Copyright ©2010 Macedo et al.; licensee BioMed Central Ltd.
                License:

                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
                Date received : 7 January 2010
                Date revision received : 19 March 2010
                Date accepted : 6 May 2010
                Categories
                Subject: Research

                ScienceOpen disciplines: Emergency medicine & Trauma
                Data availability:
                ScienceOpen disciplines: Emergency medicine & Trauma

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