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      New Criterion to Evaluate Acute-on-Chronic Kidney Injury Based on the Creatinine Reference Change

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          Background: The lack of consensus criteria of acute on chronic kidney injury (ACKI) affects the judgment for its clinical prognosis. Methods: In this study, we analyzed the data from 711,615 hospitalized adults who had at least 2 serum creatinine (SCr) tests within 30 days. We estimated the reference change value (RCV) of SCr given initial SCr level in adults without known risks of acute kidney injury other than chronic kidney disease (CKD). We proposed a criterion for ACKI based on the RCV of SCr (cROCK), which defined ACKI as a ≥25% increase in SCr in 7 days. We validated cROCK by its association with the risks of in-hospital mortality, death after discharge, and CKD progression in a large cohort of patients with CKD stage 3. Results: In 21,661 patients with CKD stage 3, a total of 3,145 (14.5%), 1,512 (7.0%), and 221 (1.0%) ACKI events were detected by both cROCK and Kidney Disease Improving Global Outcomes (KDIGO), cROCK only, and KDIGO only, respectively. cROCK detected 40% more ACKI events than KDIGO. Compared with patients without ACKI by both definitions, those with cROCK- but not KDIGO-defined ACKI had a significantly increased risk of in-hospital mortality (hazard ratio [HR] 5.53; 95% CI 3.75–8.16), death after discharge (HR 1.51; 95% CI 1.21–1.83), and CKD progression (OR 5.65; 95% CI 3.05–10.48). Conclusions: RCV-based criterion (cROCK) for ACKI is clinically valid in that it has a substantially improved sensitivity in identifying patients with high risk of adverse outcomes.

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          Author and article information

          Am J Nephrol
          American Journal of Nephrology
          S. Karger AG
          June 2020
          29 April 2020
          : 51
          : 6
          : 453-462
          aNational Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
          bThe First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
          cSichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
          dGuangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
          eGuizhou Provincial People’s Hospital, Guizhou University, Guiyang, China
          fGuilin Medical University Affiliated Hospital, Guilin, China
          gTongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
          hKidney Disease Center, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
          iCenter for Nephrology and Urology Shenzhen University, The First Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China
          jThe Second Affiliated Hospital of Dalian Medical University, Dalian, China
          kHuashan Hospital, Fudan University, Shanghai, China
          lInstitute of Nephrology, Zhong Da Hospital, Nanjing, China
          mSun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
          nThe Second Affiliated Hospital, Zhejiang University, Hangzhou, China
          oChildren’s Hospital of Nanjing Medical University, Nanjing, China
          pThe Children Hospital of Zhejiang University, Hangzhou, China
          qAnhui Institute of Pediatric Research, Anhui Provincial Children’s Hospital, Hefei, China
          rGuangzhou Women and Children’s Medical Center, Guangzhou Medical University, Guangzhou, China
          sChildren’s Hospital of Fudan University, Shanghai, China
          tChengdu Women and Children’s Central Hospital, Chengdu, China
          uShanghai Children’s Medical Center, Shanghai Jiaotong University, Shanghai, China
          vJinan Children’s Hospital, Jinan, China
          wPediatric Medical Research Center, Gansu Province Child’s Hospital, Lanzhou University Second Hospital, Lanzhou, China
          xWest China Second University Hospital, Sichuan University, Chengdu, China
          yChildren’s Hospital of Chongqing Medical University, Chongqing, China
          zNational Center for Chronic and Noncommunicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
          Author notes
          *Dr. Fan Fan Hou or Dr. Xin Xu, Renal Division, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Ave, Guangzhou 510515 (China), E-Mail or
          506664 Am J Nephrol 2020;51:453–462
          © 2020 S. Karger AG, Basel

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          Page count
          Figures: 4, Tables: 3, Pages: 10
          Patient-Oriented, Translational Research: Research Article


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