Kinetic estimated glomerular filtration rate in critically ill patients: beyond the acute kidney injury severity classification system
|
|
- Aron Allison
- 6 years ago
- Views:
Transcription
1 de Oliveira Marques et al. Critical Care (2017) 21:280 DOI /s RESEARCH Kinetic estimated glomerular filtration rate in critically ill patients: beyond the acute kidney injury severity classification system Open Access Flávio de Oliveira Marques 1, Saulo Aires Oliveira 1, Priscila Ferreira de Lima e Souza 1, Wandervânia Gomes Nojoza 1, Maiara da Silva Sena 1, Taynara Muniz Ferreira 1, Bruno Gabriele Costa 2 and Alexandre Braga Libório 1,2,3* Abstract Background: Although significant advances have been achieved in acute kidney injury (AKI) research following its classification, potential pitfalls can be identified in clinical practice. The nonsteady-state (kinetic) estimated glomerular filtration rate (KeGFR) could add clinical and prognostic information in critically ill patients beyond the current AKI classification system. Methods: This was a retrospective analysis using data from the Multiparameter Intelligent Monitoring in Intensive Care II project. The KeGFR was calculated during the first 7 days of intensive care unit (ICU) stay in 13,284 patients and was correlated with outcomes. Results: In general, there was not a good agreement between AKI severity and the worst achieved KeGFR. The stepwise reductionintheworstachievedkegfr conferred an incremental risk of death, rising from 7.0% (KeGFR > 70 ml/min/1.73 m 2 ) to 27.8% (KeGFR < 30 ml/min/1.73 m 2 ). This stepwise increment in mortality remained in each AKI severity stage. For example, patients with AKI stage 3 who maintained KeGFR had a mortality rate of 16.5%, close to those patients with KeGFR < 30 ml/min/1.73 m 2 butnoaki;otherwise,mortalityincreased to 40% when both AKI stage 3 and KeGFR < 30 ml/min/1.73 m 2 were present. In relation to another outcome renal replacement therapy (RRT) patients with the worst achieved KeGFR < 30 ml/min/1.73 m 2 and KDIGO stage 1/2 had a rate of RRT of less than 10%. However, this rate was 44% when both AKI stage 3 and a worst KeGFR < 30 ml/min/1.73 m 2 were observed. This interaction between AKI and KeGFR was also present when looking at long-term survival. Conclusion: Both the AKI classification system and KeGFR are complementary to each other. Assessing both AKI stage and KeGFR can help to identify patients at different risk levels in clinical practice. Background Acute kidney injury (AKI) is now recognized as a major public health problem affecting millions of patients worldwide [1]. Critically ill patients are at high risk of developing AKI, with its incidence during intensive care unit (ICU) stay varying from 36% to 67% [2, 3]. During the last few years, acute-onset disturbance of kidney * Correspondence: alexandreliborio@yahoo.com.br 1 Medical Sciences Postgraduate Program, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil 2 Medical Sciences Postgraduate Program, Universidade de Fortaleza UNIFOR, Fortaleza, Ceará, Brazil Full list of author information is available at the end of the article function has been a subject of avid scientific discussion, which has led to the definition of acute kidney injury. AKI identification was based on changes in serum creatinine (SCr) compared with baseline levels before the disease onset and changes in diuresis. Scoring systems for AKI quantification have been developed at consensus conferences. These included the RIFLE [4] and AKIN [5] criteria for AKI. Most recently, the AKIN criteria were revised and clarified as the Kidney Disease Improving Global Outcomes (KDIGO) criteria for AKI [6]. Although significant advances have been achieved in AKI research following this classification, potential pitfalls can be identified in clinical practice. Intuitively, the shorter the amount of time during which a determined The Author(s) Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.
2 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 2 of 10 SCr change occurs, the greater the AKI severity. For example, going from a SCr of 1 to 1.5 mg/dl within 12 h signifies a worse glomerular filtration rate (GFR) fall than going from a SCr of 1 to 1.5 mg/dl within 48 h (see Additional file 1 for illustrative examples); however, if the same urinary output is maintained in both situations, AKI severity will be classified similarly. Also, even considering the difficulty in ascertaining a baseline SCr, the AKI score systems do not consider previous underlying chronic kidney disease (CKD) and its possible prognostic implications. To exemplify, a patient whose SCr varied from0.8to1.2mg/dlhasthesameakiseverityasanother patient whose variation was from 2 to 3 mg/dl, although the GFR is clearly more severely reduced in the second case. Finally, as suggested by Waikar and Bonventre [7] and demonstrated by our group [8], an SCr kinetic model can be superior to AKI classification systems in patients with previous CKD. Assessing the GFR is problematic when the SCr is changing quickly. In severe AKI and anuric patients, it is a consensus to consider that the GFR is < 10 ml/min/ 1.73 m 2. However, a less reduced GFR may also affect management and impact patient survival. Recently, the nonsteady-state (kinetic) estimated glomerular filtration rate (KeGFR) has been advocated in AKI and renal recovery assessment [9, 10]. The formula is derived from the initial SCr, the distribution volume, the creatinine production rate, and the quantitative difference between consecutive SCr over a given period. Taking these variables into account, KeGFR yields the measured creatinine clearance (CrCl) rate for that period between two SCr measurements. Thus, the KeGFR results in the same interpretation of a measured CrCl level, but without the need for collecting urine and measuring urinary creatinine levels. Using this approach, we can estimate the GFR in a determined time interval, regardless of whether Scr is slowly increasing as described in the abovementioned examples, where a patient whose SCr levels increased from 1 to 1.5 mg/dl in 12 h had a worse KeGFR in comparison with another whose SCr level also increased from 1 to 1.5 mg/dl in 48 h. In the present study, we hypothesized that a worse KeGFR could add clinical and prognostic information in critically ill patients beyond the current AKI classification system, mainly regarding the need for renal replacement therapy, hospital mortality, and 1-year survival. Methods Multiparameter Intelligent Monitoring in Intensive Care II database and data collection The Multiparameter Intelligent Monitoring in Intensive Care (MIMIC)-II project, maintained by the Massachusetts Institute of Technology Laboratory for Computational Physiology, contains data on patients hospitalized in an ICU at Beth Israel Deaconess Medical Center from 2001 to 2008 [11]. The database is freely available so that any researcher who accepts the data use agreement and has attended protecting human subjects training can apply for permission to access the data. This study was approved by the institutional review boards of Massachusetts Institute of Technology and Beth Israel Deaconess Medical Center and was granted a waiver of informed consent. We included all patients with an ICU length of stay (LOS) lasting more than 48 h with at least three SCr measurements taken. Patients with known end-stage renal disease (ESRD), previous renal transplantation, those who underwent renal replacement therapy (RRT) before ICU admission, and those with admission SCr > 4 mg/dl were excluded. Data collection All data were extracted from the MIMIC-II database (v2.6) and included demographic information (e.g., age, gender) and clinical information from the admission notes. The following admission data were collected: admission body weight, admission type (elective or emergency), care unit type (medical, coronary unit, surgery, or cardiac surgery), sepsis diagnosis as described by Angus et al. [12], admission SCr, and disease severity as assessed by the Simplified Acute Physiology Score (SAPS) II [13] and Sequential Organ Failure Assessment (SOFA) [14] scores. In the first 7 days of ICU stay, we also recorded daily SCr measurements, and the need for vasoactive drugs and mechanical ventilation. Estimated kinetic glomerular filtration rate The KeGFR was calculated during the first 7 days of ICU stay according the following equation: baselinescr X egfr KeGFR ¼ Mean SCr 24xΔSCr x 1 ΔTimeðhÞxMaxΔSCr=day where egfr = estimated glomerular filtration rate using baseline SCr, mean SCr = mean of two consecutive SCr measurements, ΔSCr = change in SCr, ΔTime(h) = interval in hours between two consecutive SCr measurements, and MaxΔSCr/Day = the maximal change (increase) in SCr that can occur per day if renal function is completely lost. The KeGFR was derived from the initial SCr, the distribution volume, the creatinine production rate, and the quantitative difference between consecutive SCr measurements over a given time. We included all SCr levels measured at least 6 h and no more than 48 h apart. KeGFR was calculated by taking each interval between two consecutive creatinine measurements. The volume
3 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 3 of 10 of distribution for creatinine does not need to be equated with total body water, but can be expressed as a function of the creatinine production rate. The amount by which a known creatinine production rate can increase the creatinine concentration if all excretion has ceased (i.e., near-zero GFR) informs us about the volume of distribution. Since there is only creatinine addition and no subtraction, this situation describes the maximum increment of SCr in 1 day. To obtain it, we identified 94 patients with anuria and two SCr measurements apart with no RRT in this interval. The mean SCr incremental corrected for 24 h was 1.47 ± 0.44 mg/dl for men and 1.41 ± 0.49 mg/dl for women. We used these values instead of a fixed value of 1.7 mg/dl per day, as described by Chen [9].The other necessary variables for this formula included baseline SCr. Because the MIMIC-II does not provide any laboratory information prior to ICU admission, the lowest SCr available during ICU stay before RRT initiation was used as the baseline renal function and baseline CrCl was calculated using the CKD-EPI formula [15]. Any SCr measurement after RRT was not considered. After that, to exclude any influence from previous CKD or out-of-icu-acquired AKI, we performed a complete sensitivity analysis using only patients admitted to the ICU with an egfr > 70 ml/min/1.73 m 2. AKI definition AKI was defined according to the KDIGO criteria [6]. We classified patients based on the KDIGO maximum stage achieved within the first 7 days of ICU stay. Because we used RRT as an outcome, we did not apply it as a rule to patients that commenced RRT before achieving AKI stage 3. Urinary output was collected in fixed blocks of 6 h beginning at ICU admission. To be acceptable, the maximum gap between two actual values was 3 h. To stage a patient based on urine output (UO), a minimum of 6 h of data were required. Since Kellum et al. [16] have recently described that the risk of death over the index hospital stay and over the following year is greatest for patients that meet both UO and SCr criteria for AKI, and to exclude the fact that KeGFR is the only other approach to describe SCr increment, we performed a second sensitivity analysis with SCr-based KDIGO criteria only. Estimated GFR using steady-state SCr formula Although KeGFR theoretically provides better estimation of GFR than formulae that were developed to be used with steady-state SCr, we evaluated the capacity of the most recently proposed formula (CKD-EPI) [15] using the highest SCr during the first 7 days of ICU stay to predict the main outcomes. Outcomes Patient outcomes included the need for RRT during ICU stay, hospital mortality, and survival up to 1 year. Statistical analysis Patients were categorized in groups according to the worst achieved KeGFR. Variables were assessed for normality using the Kolmogorov-Smirnov test. Parametric variables were compared using a t test and nonparametric variables using the Mann-Whitney test. Categorical variables were compared using the chi-square test. We built a logistic regression model to assess the association between categorized KeGFR and hospital mortality according to each AKI KDIGO stage. We defined a priori that the following variables would be included in the logistic regression model for both outcomes: age, gender, SAPS II score, SOFA score, main comorbidities (hypertension, congestive heart failure, cardiac arrhythmias, chronic pulmonary obstructive disease, diabetes mellitus, lymphoma, metastatic cancer, liver disease, obesity), type of admission (clinical or surgical), vasoactive drugs, the need for mechanical ventilation, and baseline egfr. A Cox model was performed to access survival by AKI severity and lowest KeGFR after adjusting for comorbidities, baseline egfr, and age. Results Characteristics of study patients The MIMIC-II database contains the records of 32,425 patients, 24,175 of whom were adults aged > 15 years at the time of admission. Patients with an ICU LOS < 24 hours (n = 3549), those with less than two SCr measurements in a period of 48 h(n = 3951), and patients with ESRD/RRT before the ICU admission (n = 538) were excluded from the analysis. Additionally, patients at ICU admission with an SCr higher than 4 mg/dl (n = 1159) or an egfr lower than 30 ml/min/1.73 m 2 (n = 1694) were also excluded (Fig. 1). After all exclusions, 13,284 patients were eligible to be analyzed. Of the SCr levels used to calculate KeGFR, more than 85% had an interval between them of 20 to 28 h. Table 1 provides baseline characteristics of patients according to the worst KeGFR. Patients with a reduced KeGFR during the first 7 days of ICU stay were more prone to have more comorbidities (except arterial hypertension), more sepsis diagnosis, and were more severely ill. Main outcomes according to the worst KeGFR To explore the association between reduced KeGFR and observed outcomes, we first categorized the worst KeGFR achieved in the first 7 days. The cut-off values (30, 45, and 70 ml/min/1.73 m 2 ) were chosen to maintain the best discriminatory capacity for hospital mortality in comparison with the worst KeGFR as a continuous
4 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 4 of 10 Fig. 1 Patient distribution in the MIMIC-II database and exclusion criteria. egfr estimated glomerular filtration rate, ESRD end-stage renal disease, ICU intensivecareunit,los length of stay, MIMIC Multiparameter Intelligent Monitoring in Intensive Care, RRT renal replacement therapy, scr serum creatinine variable (Additional file 2: Figure S1). As shown in Table 1, a stepwise reduction in the worst achieved KeGFR conferred an incremental risk of death, rising from 7.0% (KeGFR > 70 ml/min/1.73 m 2 ) to 27.8% (KeGFR < 30 ml/ min/1.73 m 2 ). This association was also observed in the other evaluated outcomes (need for RRT, ICU LOS, and hospital LOS) (Table 1). Association between the worst achieved KeGFR and AKI stage The distribution of patients according to AKI stage and the worst KeGFR are shown in Table 2. There was not a good agreement between AKI severity and the worst achieved KeGFR. We identified many patients with AKI according to the KDIGO classification (stages 1 3) but who maintained a KeGFR above 70 ml/min/1.73 m 2. Although many of these patients achieved maximum KDIGO stage only by the UO criteria, 1008 patients had AKI according to the SCr-based KDIGO classification but no significant reduction in KeGFR (Additional file 3: Table S1). On the other hand, several patients achieved a KeGFR < 45 ml/min/1.73 m 2 but had no AKI or had KDIGO AKI stage 1 only. As shown in Table 3, which includes only patients with ICU admission egfr > 70 ml/min/1.73 m 2, this finding cannot be explained only by previous CKD. Impact of the worst achieved KeGFR on hospital mortality As previously stated, the hospital mortality rate increases according to the worst achieved KeGFR within the first 7 ICU days. This stepwise increment in mortality remained in each AKI severity stage (Table 2). Roughly, it is also possible to identify an increment in hospital death when using the KDIGO system within each worse KeGFR range. For example, patients with AKI stage 3 who maintained KeGFR had a mortality rate of 16.5%, close to those patients with KeGFR < 30 ml/min/1.73 m 2 but no AKI; otherwise, mortality increased to 40% when both AKI stage 3 and KeGFR < 30 ml/min/1.73 m 2 were present. For illustrative purposes, we reduced the number of groups based on similar rates of hospital mortality (different colors in Tables 2 and 3 and Additional files 3 and 4: Tables S1 and S2). To rule out the fact that our findings are merely another way to explore the higher mortality rates in patients meeting both UO and scr criteria for AKI [16], we performed a sensitivity analysis using only SCr-based KDIGO criteria against reduced KeGFR (Additional file 3: Table S1). Overall, the results did not change. For further comparison, we evaluated the egfr using the CKD-EPI formula with the highest SCr. As shown in Additional file 5: Table S3, although there was an increment in mortality according to egfr, this remained true only in patients with no AKI. There was no stepwise increment in mortality in each AKI severity stage 1 through 3 according to egfr by CKD-EPI. To further explore the association of the worst achieved KeGFR and hospital mortality, we adjusted this association for potential confounders and evaluated the adjusted odds ratio in each AKI stage (Table 4). Again, egfr by CKD-EPI was independently associated with hospital mortality only in patients with no AKI (Additional file 6: Table S4). Worst KeGFR and need for RRT We also evaluated if the worst KeGFR was associated with a need for RRT beyond the KDIGO system during
5 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 5 of 10 Table 1 Baseline characteristics for patients according to worst KeGFR in the first 7 days of ICU stay Total patients (n = 13,284) Lowest KeGFR > 70 ml/min/ 1.73 m 2 (n = 7,089) Lowest KeGFR ml/min/ 1.73 m 2 (n = 3,420) Lowest KeGFR ml/min/ 1.73 m 2 (n = 1,112) Lowest KeGFR < 30 ml/min/ 1.73 m 2 (n = 1,663) Age (years), mean ± SD 63.3 ± ± ± ± ± 17.0 <0.001 p Male, n (%) 7067 (53.2) 3850 (54.3) 1772 (51.8) 596 (53.6) 849 (51.0) Hypertension, n (%) 4076 (30.7) 2349 (33.1) 1073 (31.4) 311 (28.0) 343 (20.6) <0.001 Uncomplicated diabetes, n (%) 2477 (18.6) 1294 (18.2) 676 (19.8) 238 (21.4) 269 (16.2) Complicated diabetes, n (%) 604 (4.5) 175 (2.5) 208 (6.1) 69 (6.2) 152 (9.1) <0.001 Obesity, n (%) 205 (1.5) 102 (1.4) 54 (1.6) 16 (1.4) 32 (1.9) Congestive heart failure, n (%) 2566 (19.3) 1051 (14.8) 762 (22.3) 289 (26.0) 464 (27.9) <0.001 COPD, n (%) 2054 (15.5) 1045 (14.7) 567 (16.6) 190 (17.1) 252 (15.1) Cardiac arrhythmia, n (%) 2414 (18.2) 1180 (16.6) 672 (19.6) 224 (20.1) 338 (20.3) <0.001 Liver disease, n (%) 727 (5.5) 334(4.7) 155(4.5) 82 (7.4) 156 (9.4) <0.001 Metastatic cancer, n (%) 620 (4.7) 333 (4.7) 167 (4.9) 39 (3.5) 81 (4.9) Surgical patients, n (%) 5275 (39.7) 2746 (38.7) 1512 (44.2) 471 (42.4) 546 (32.8) <0.001 Sepsis, n (%) 3964 (29.8) 1666 (23.5) 1084 (31.7) 415 (37.3) 799 (48.0) <0.001 SAPS II on ICU admission, median (IQR) 33 (24 41) 29 (22 38) 34 (27 43) 38 (30 47) 40 (31 49) <0.001 SOFA on ICU admission, median (IQR) 6 (3 9) 5 (3 8) 7 (3 9) 8 (4 11) 9 (5 12) <0.001 Baseline egfr* (ml/min), mean ± SD ± ± ± ± ± 34.7 <0.001 Vasopressors, n (%) 4793 (36.1) 2035 (28.7) 1377 (40.3) 539 (48.5) 842 (50.6) <0.001 Mechanical ventilation, n (%) 8484 (63.9) 4022 (56.7) 2359 (69.0) 837 (75.3) 1266 (76.1) <0.001 Lowest KeGFR during first 7 days of ICU stay (ml/ min), mean ± SD 66.4 ± ± ± ± ± 8.1 <0.001 ICU LOS (days), median (IQR) 3.3 ( ) 2.8 ( ) 3.7 ( ) 4.3 ( ) 5.3( ) <0.001 Hospital LOS (days), median (IQR) 9 (6 15) 8 (4 13) 9 (6 16) 11 (7 18) 12 (8 21) <0.001 ICU mortality, n (%) 1,023 (7.7) 275 (3.9) 253 (7.4) 134 (12.0) 361 (22.7) <0.001 Inhospital mortality, n (%) 1,562 (11.8) 499 (7.0) 420 (12.2) 180 (16.2) 463 (27.8) <0.001 *Using lowest serum creatinine during ICU stay COPD chronic obstructive pulmonary disease, egfr estimated glomerular filtration rate, ICU intensive care unit, IQR interquartile range, KeGFR kinetic estimated glomerular filtration rate, LOS length of stay, SAPS II Simplified Acute Physiology Score II, SD standard deviation, SOFA Sequential Organ Failure Assessment
6 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 6 of 10 Table 2 Outcomes for all patients according to maximum AKI severity and worst achieved KeGFR Colors denote similar outcome patterns AKI acute kidney injury, ICU intensive care unit, KDIGO Kidney Disease Improving Global Outcomes, KeGFR kinetic estimated glomerular filtration rate, RRT renal replacement therapy, SCr serum creatinine ICU stay. In Table 2, we can observe that in the group of patients with KDIGO stage 3 and a worst achieved KeGFR greater than 30 ml/min/1.73 m 2 or a worst achieved KeGFR < 30 ml/min/1.73 m 2 and KDIGO stage 1/2, the rate of RRT was no greater than 10%. However, this rate was almost 44% when both KDIGO stage 3 and a worst KeGFR < 30 ml/min/1.73 m 2 were observed. AKI, the worst achieved KeGFR, and long-term survival After adjusting for comorbidities, baseline egfr, and age, survival over 1 year after ICU admission followed a similar pattern to the hospital death shown in Table 2. In Fig. 2, there was separation among all, except one, of the five groups depicted in Table 3. Table 3 Outcomes for patients with baseline egfr > 70 ml/min/1.73 m 2 according to maximum AKI severity and worst achieved KeGFR Colors denote similar outcome patterns AKI acute kidney injury, egfr estimated glomerular filtration rate, ICU intensive care unit, KDIGO Kidney Disease Improving Global Outcomes, KeGFR kinetic estimated glomerular filtration rate, RRT renal replacement therapy, SCr serum creatinine
7 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 7 of 10 Table 4 Adjusted odds ratios for hospital death Odds ratio (95% confidence interval) KeGFR (ml/min/1.73 m 2 ) No AKI (n = 3922) AKI stage 1 (n = 3996) AKI stage 2 (n = 3826) AKI stage 3 (n = 1540) >70 Reference Reference Reference Reference ( ) 2.41 ( ) 0.86 ( ) 1.79 ( ) ( ) 2.47 ( ) 1.62 ( ) 2.28 ( ) < ( ) 5.43 ( ) 1.73 ( ) 4.39 ( ) Observe that the worst KeGFR is associated with hospital death even after dividing patients by maximum AKI stage Adjusted for age, gender, SAPS II score, SOFA score, main comorbidities (hypertension, congestive heart failure, cardiac arrhythmias, chronic pulmonary obstructive disease, diabetes mellitus, lymphoma, metastatic cancer, liver disease, obesity), type of admission (clinical or surgical), baseline estimated glomerular filtration rate, need for vasoactive drugs, and mechanical ventilation AKI acute kidney injury, KeGFR kinetic estimated glomerular filtration rate Sensitivity analysis Besides a separated analysis considering only patients with ICU admission egfr > 70 ml/min/1.73 m 2 and considering only scr-based KDIGO criteria, we performed another subgroup analysis with non-oliguric patients only (KDIGO stage 3 according to urine criterion were excluded) and the results are shown in Additional file 3: Table S1. In general, the main results were maintained regarding the need for RRT and hospital mortality. Discussion In this study, the performance of KeGFR in critically ill patients was evaluated for the first time. We found that the worst achieved KeGFR within the first 7 days of ICU stay was associated with several short- and long-term outcomes, such as the need for RRT, hospital mortality, and 1-year survival. Moreover, the worst KeGFR appears not to substitute for, but adds prognostic information to the current AKI classification. Fig. 2 Comorbidities, baseline egfr, and age-adjusted survival by AKI severity and worst KeGFR. Groups refer to combinations of maximum AKI stage and worst achieved KeGFR depicted in Table 4 and Additional file 4: Table S2. Group 1 (green), no AKI and KeGFR 30 ml/min/1.73 m 2 or AKI stage 1 and KeGFR 70 ml/min/1.73 m 2 ; group 2 (blue), AKI stage 1 and KeGFR between 30 and 70 ml/min/1.73 m 2 ; group 3 (yellow), AKI stage 2 and KeGFR > 45 ml/min/1.73 m 2 or AKI stage 3 and KeGFR 70 ml/min/1.73 m 2 or no AKI/AKI stage 1 and KeGFR < 30 ml/min/1.73 m 2 ; group 4 (brown), AKI stage 2 and KeGFR < 45 ml/min/1.73 m 2 or AKI stage 3 and KeGFR between 30 and 69 ml/min/1.73 m 2 ; group 5 (red), AKI stage 3 and KeGFR < 30 ml/min/1.73 m 2. The top panel shows age-adjusted 1-year survival for all patients (10 patients had missing age). Overall differences per groups were significant (p < 0.001). ICU intensive care unit
8 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 8 of 10 Although significant advances have been made in the diagnosis and prognosis of AKI since the development of the consensus classification system, several questions remained when evaluating patients in this setting. First, as stated in the introduction section, current AKI classifications are not able to discern prognosis between patients with pure AKI or acute-on-chronic kidney disease [8]. Another possible pitfall concerns the time patients take to fully develop AKI severity, as exemplified in the introduction section when one patient had an increment of 50% of baseline SCr within 12 h and another within 48 h, but both were classified as KDIGO stage 1. Theoretically, calculating KeGFR even when SCr changes acutely can avoid these gaps found in the AKI classification system. Our results demonstrate several important findings. First, we disclosed a disagreement between AKI severity and the worst achieved KeGFR. Several patients had AKI KDIGO stage 3, but maintained KeGFR greater than 70 ml/min/1.73 m 2. This can be explained by a slow increment of SCr over time. For example, one patient had a baseline SCr of 0.6 mg/dl and it increased only approximately 0.3 mg/dl each 48 h, going up to 1.8 mg/dl after 7 days. This patient was classified as AKI stage 3, but his KeGFR was never lower than 70 ml/min/ 1.73 m 2. On the other hand, other patients had severely reduced KeGFR but no or only a minor AKI stage. Clearly, some of these patients already had reduced egfr at baseline. However, when evaluating only those patients admitted with egfr above 70 ml/min/1.73 m 2 (Table 3) we can identify that most of these patients had no egrf reduction at baseline. In these cases, the increase in SCr was not so great, but occurred within a short time interval (for example, an increment of 0.3 mg/dl in two consecutive SCr measurements, obtained 8 h apart can reduce the KeGFR to less than 30 ml/min/1.73 m 2, but this patient will be classified as only AKI stage 1). Although the great majority of SCr measurements in the present study had an interval between them of 20 to 28 h, we maintained all measurements with an interval between 6 and 48 h, making it possible to evaluate the patients earlier, within the first 12 h after ICU admission, when SCr can already be increasing. At this time, it is possible there is not enough time for SCr to increase for the KDIGO system to achieve even AKI stage 1, although KeGFR can already be severely reduced. Secondly, and perhaps most importantly, both the AKI classification system and KeGFR seem to be complementary in predicting outcomes. For example, almost 45% of patients with AKI stage 3 and KeGFR < 30 ml/ min/1.73 m 2 needed RRT in comparison with less than 10% of patients with AKI stage 3 but less severe KeGFR reduction and less than 5% of those patients with KeGFR < 30 ml/min/1.73 m 2 but only AKI stage 1/2. In relation to hospital mortality, a stepwise reduction in the worst achieved KeGFR conferred an incremental risk of death to each AKI stage in both uni- and multivariate analyses. It is already known that AKI classification systems are not as good at predicting events in patients with previous CKD [7, 8]. Moreover, it has been recently suggested that different AKI patterns in relation to SCr trajectory (resolving/nonresolving) imply different prognoses [17]. Analyzing the KeGFR equation, it contains two important pieces of information not contemplated in the AKI classification systems: baseline egfr and the speed of SCr increase. In part, it is probable that KeGFR adds prognostic information because it can identify patients with previous CKD. However, our data suggest that to correctly quantify renal injury in critically ill patients we must take into consideration not only the SCr increment degree but also the speed at which this increment occurs, as suggested in the introductory section of this manuscript. Supported by the groups shown in Table 3, it is important to highlight that we do not propose substituting the AKI classification with KeGFR, but we think both must be used together the first to evaluate the magnitude of the acute injury and the latter to measure the effects of AKI on GFR. Because it is clear that oligoanuric patients had GFR close to zero and it is more difficult to ascertain egfr in these patients who maintain UO, we performed a sensitivity analysis excluding those patients with AKI KDIGO stage 3 according to the UO. Generally, the results were maintained, mainly when evaluating the need for RRT (almost 50% of patients with both AKI stage 3 according to the Scr criterion and a KeGFR < 30 ml/min/1.73 m 2 ). Finally, we also evaluated long-term mortality. Except for groups 1 and 2, there was a clear separation in survival lines according to the classification by AKI KDIGO stage/worst KeGFR. These results emphasize that AKI severity alone does not determine long-term outcome but that an interaction between baseline GFR and AKI severity and the speed of onset of AKI are important to assess both short- and long-term prognosis. Our study has several and important limitations. First, and most important, we did not have access to previous SCr measurements thus making it impossible to identify patients with actual previous CKD. To overcome this fact, we performed a sensitivity analysis including only patients with an egfr > 70 ml/min/1.73 m 2. We considered the lowest SCr available during ICU stay as the baseline, although this approach can inflate the AKI incidence, indicating that such a level is often lower than the most recent outpatient creatinine value [18]. Another limitation is that it is difficult to determine the actual maximal increase in SCr when egfr is near zero in critically ill patients and, consequently, the total body water volume as described in the methodology section.
9 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 9 of 10 Although it has been suggested to limit this increment to 1.7 mg/dl a day [9, 10], we analyzed a subset of patients with anuria and no RRT to determine the mean value of daily SCr increment (a real measure of maximal SCr increment) and used different means for men and women, although we acknowledge this can change according to obesity status, age, and other factors. While we have identified KeGFR as a prognostic tool in risk stratification regarding the need for RRT and survival, identifying patients at high risk and highlighting the importance of implementing measures that prevent/limits further renal damage [19], we recognize that, regarding the further practical use of KeGFR for drug dose correction, validation studies using standard GFR measurements (by measuring CrCl or using exogenous substances such as inulin, iohexol, and others) are warranted. Conclusion In conclusion, we suggest that both the AKI classification system and KeGFR are complementary to each other. Analyzing different prognoses according to the worst achieved KeGFR in each AKI stage, we suggest that patients with acute CKD, pure AKI, slow- or fastonset AKI, and all possible combinations thereof, have different prognoses and that assessing both AKI stage and KeGFR can help to identify patients at different risk levels in clinical practice. Additional files Additional file 1: Illustrative cases of differences between KDIGO stage and worst KeGFR. (DOCX 14 kb) Additional file 2: Figure S1. Discriminative ability of worst KeGFR as continuous or categorized variable in predicting hospital death. (DOCX 36 kb) Additional file 3: Table S1. Outcomes for patients according to maximum scr-based AKI severity and worst achieved egfr. (DOCX 16 kb) Additional file 4: Table S2. Outcomes for non-oliguric patients according to maximum scr-based AKI severity and worst achieved egfr. (DOCX 16 kb) Additional file 5: Table S3. Outcomes for patients according to maximum scr-based AKI severity and worst egfr estimated by CKD-EPI equation using maximum SCr. (DOCX 16 kb) Additional file 6: Table S4. Adjusted odds ratios for hospital death. Observe that worst egfr estimated by CKD-EPI equation using maximum SCr is associated with hospital death only in patients with no AKI. (DOCX 15 kb) Abbreviations AKI: Acute kidney injury; CKD: Chronic kidney disease; CrCl: Creatinine clearance; ESRD: End-stage renal disease; GFR: Glomerular filtration rate; ICU: Intensive care unit; KDIGO: Kidney Disease Improving Global Outcomes; KeGFR: Kinetic estimated glomerular filtration rate; LOS: Length of stay; MIMIC: Multiparameter Intelligent Monitoring in Intensive Care; RRT: Renal replacement therapy; SAPS: Simplified Acute Physiology Score; SCr: Serum creatinine; SOFA: Sequential Organ Failure Assessment; UO: Urine output Acknowledgements None. Funding Not applicable. Availability of data and materials The Multiparameter Intelligent Monitoring in Intensive Care (MIMIC)-II project is freely available, so that any researcher who accepts the data user agreement and has attended protecting human subjects training can apply for permission to access the data. Authors contributions ABL designed the study, carried out data extraction as well as data analysis, and wrote the manuscript. FdOM, SAO, PFdLeSS, WGN, MdSS, TMF, and BGC participated in data extraction and data analysis. FdOM participated in analyzing samples and data, including clinical aspects, and revised the manuscript. All authors read and approved the final manuscript. Ethics approval and consent to participate This study was approved by the institutional review boards of Massachusetts Institute of Technology and Beth Israel Deaconess Medical Center and was granted a waiver of informed consent. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. Publisher s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Author details 1 Medical Sciences Postgraduate Program, Department of Clinical Medicine, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil. 2 Medical Sciences Postgraduate Program, Universidade de Fortaleza UNIFOR, Fortaleza, Ceará, Brazil. 3 Instituto Dr. José Frota, Avenida Abolição, 4043 Ap 1203, Fortaleza, Ceará CEP , Brazil. Received: 16 August 2017 Accepted: 26 October 2017 References 1. Bagshaw SM, George C, Bellomo R, ANZICS Database Management Committee. A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrol Dial Transplant. 2008;23: Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81: Hoste EAJ, Clermont G, Kersten A, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care. 2006;10:R Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup. Acute renal failure definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;8:R Molitoris BA, Levin A, Warnock DG, et al. Improving outcomes of acute kidney injury: report of an initiative. Nat Clin Pract Nephrol. 2007;3: Kellum JA, Lameire N, KDIGO AKI Guideline Work Group. Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1). Crit Care. 2013;17: Waikar SS, Bonventre JV. Creatinine kinetics and the definition of acute kidney injury. J Am Soc Nephrol. 2009;20: Libório AB, Macedo E, de Queiroz REB, et al. Kidney Disease Improving Global Outcomes or creatinine kinetics criteria in acute kidney injury: a proof of concept study. Nephrol Dial Transplant. 2013;28: Chen S. Retooling the creatinine clearance equation to estimate kinetic GFR when the plasma creatinine is changing acutely. J Am Soc Nephrol. 2013;24: Dewitte A, Joannès-Boyau O, Sidobre C, et al. Kinetic egfr and novel AKI biomarkers to predict renal recovery. Clin J Am Soc Nephrol. 2015;10:
10 de Oliveira Marques et al. Critical Care (2017) 21:280 Page 10 of Saeed M, Villarroel M, Reisner AT, et al. Multiparameter Intelligent Monitoring in Intensive Care II: a public-access intensive care unit database. Crit Care Med. 2011;39: Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29: Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;270: Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on sepsis-related problems of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26: Levey AS, Stevens LA, Schmid CH, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150: Kellum JA, Sileanu FE, Murugan R, Lucko N, Shaw AD, Clermont G. Classifying AKI by urine output versus serum creatinine level. J Am Soc Nephrol. 2015;26: Bhatraju PK, Mukherjee P, Robinson-Cohen C, et al. Acute kidney injury subphenotypes based on creatinine trajectory identifies patients at increased risk of death. Crit Care. 2016;20: Siew ED, Matheny ME, Ikizler TA, et al. Commonly used surrogates for baseline renal function affect the classification and prognosis of acute kidney injury. Kidney Int. 2010;77: Joannidis M, Druml W, Forni LG, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017: expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med. 2017;43: Submit your next manuscript to BioMed Central and we will help you at every step: We accept pre-submission inquiries Our selector tool helps you to find the most relevant journal We provide round the clock customer support Convenient online submission Thorough peer review Inclusion in PubMed and all major indexing services Maximum visibility for your research Submit your manuscript at
Increased serum bicarbonate in critically ill patients: a retrospective analysis
Intensive Care Med (2015) 41:479 486 DOI 10.1007/s00134-015-3649-9 ORIGINAL Alexandre Braga Libório Danilo Teixeira Noritomi Tacyano Tavares Leite Candice Torres de Melo Bezerra Evandro Rodrigues de Faria
AKI-6 Epidemiology of Acute Kidney Injury
FACULTY OF MEDICINE AND HEALTH SCIENCES Academic Year 2011-2012 AKI-6 Epidemiology of Acute Kidney Injury Anne NOBELS Promotor: Prof. Dr. E. Hoste Co-promotor: Prof. Dr. J. Kellum (Pittsburg) Dissertation
Las dos caras de la cretinina sérica The two sides of serum creatinine
Las dos caras de la cretinina sérica The two sides of serum creatinine ASOCIACION COSTARRICENSE DE MEDICINA INTERNA San José, Costa Rica June 2017 Kianoush B. Kashani, MD, MSc, FASN, FCCP 2013 MFMER 3322132-1
DEFINITION, CLASSIFICATION AND DIAGNOSIS OF ACUTE KIDNEY INJURY
DEFINITION, CLASSIFICATION AND DIAGNOSIS OF ACUTE KIDNEY INJURY JOSÉ ANTÓNIO LOPES, MD, PhD Faculty of Medicine, University of Lisbon Department of Nephrology and Renal Transplantation Centro Hospitalar
Empirical relationships among oliguria, creatinine, mortality, and renal replacement therapy in the critically ill
Empirical relationships among oliguria, creatinine, mortality, and renal replacement therapy in the critically ill The MIT Faculty has made this article openly available. Please share how this access benefits
AKI: definitions, detection & pitfalls. Jon Murray
AKI: definitions, detection & pitfalls Jon Murray Previous conventional definition Acute renal failure (ARF) An abrupt and sustained decline in renal excretory function due to a reduction in glomerular
Actual versus ideal body weight for acute kidney injury diagnosis and classification in critically Ill patients
Thongprayoon et al. BMC Nephrology 2014, 15:176 RESEARCH ARTICLE Open Access Actual versus ideal body weight for acute kidney injury diagnosis and classification in critically Ill patients Charat Thongprayoon
ENDPOINTS FOR AKI STUDIES
ENDPOINTS FOR AKI STUDIES Raymond Vanholder, University Hospital, Ghent, Belgium SUMMARY! AKI as an endpoint! Endpoints for studies in AKI 2 AKI AS AN ENDPOINT BEFORE RIFLE THE LIST OF DEFINITIONS WAS
JMSCR Vol 04 Issue 12 Page December 2016
www.jmscr.igmpublication.org Impact Factor 5.244 Index Copernicus Value: 83.27 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: https://dx.doi.org/10.18535/jmscr/v4i12.19 Clinical Profile of Acute Kidney Injury:
Severity and Outcome of Acute Kidney Injury According to Rifle Criteria in the Intensive Care Unit
BANTAO Journal 2010; 8 (1): 35-39 BJ BANTAO Journal Original Article Severity and Outcome of Acute Kidney Injury According to Rifle Criteria in the Intensive Care Unit Albana Gjyzari 1, Elizana Petrela
International Journal of Medical and Health Sciences
International Journal of Medical and Health Sciences Journal Home Page: http://www.ijmhs.net ISSN:2277-4505 Original article Incidences and clinical outcomes of acute kidney injury in PICU: A prospective
Perioperative fluid balance affects staging of acute kidney injury in postsurgical patients: a retrospective case-control study
Horiguchi et al. Journal of Intensive Care 214, 2:26 RESEARCH Perioperative fluid balance affects staging of acute kidney injury in postsurgical patients: a retrospective case-control study Yu Horiguchi
Outcome of critically ill patients with acute kidney injury using the akin criteria
Outcome of critically ill patients with acute kidney injury using the akin criteria The MIT Faculty has made this article openly available. Please share how this access benefits you. Your story matters.
Defining urine output criterion for acute kidney injury in critically ill patients
Nephrol Dial Transplant (2011) 26: 509 515 doi: 10.1093/ndt/gfq332 Advance Access publication 17 June 2010 Original Articles Defining urine output criterion for acute kidney injury in critically ill patients
Optimal Use of Iodinated Contrast Media In Oncology Patients. Focus on CI-AKI & cancer patient management
Optimal Use of Iodinated Contrast Media In Oncology Patients Focus on CI-AKI & cancer patient management Dr. Saritha Nair Manager-Medical Affairs-India & South Asia GE Healthcare Context Cancer patients
Commonly used surrogates for baseline renal function affect the classification and prognosis of acute kidney injury
http://www.kidney-international.org & 2010 International Society of Nephrology Commonly used surrogates for baseline renal function affect the classification and prognosis of acute kidney injury Edward
Paul R. Bowlin, M.D. University of Colorado Denver. May 12 th, 2008
Paul R. Bowlin, M.D. University of Colorado Denver May 12 th, 2008 Presentation Overview Background / Definitions History Indications for initiation of therapy Outcomes Studies Conclusions Questions Background
Incidence, timing and outcome of AKI in critically ill patients varies with the definition used and the addition of urine output criteria
Koeze et al. BMC Nephrology (2017) 18:70 DOI 10.1186/s12882-017-0487-8 RESEARCH ARTICLE Open Access Incidence, timing and outcome of AKI in critically ill patients varies with the definition used and the
Acute kidney injury patterns and outcomes in low-risk versus high-risk critically ill patients admitted to the medical intensive care unit
Original article Acute kidney injury patterns and outcomes in low-risk versus high-risk critically ill patients admitted to the medical intensive care unit Cyriacus U Anaele MD, Gabriela Suarez MD, Sofia
Marlies Ostermann, MD, MRCP (UK); René W. S. Chang, BSc, MS, FRCS
Continuing Medical Education Article Acute kidney injury in the intensive care unit according to RIFLE* Marlies Ostermann, MD, MRCP (UK); René W. S. Chang, BSc, MS, FRCS LEARNING OBJECTIVES On completion
Hospital-acquired Acute Kidney Injury: An Analysis of Nadir-to-Peak Serum Creatinine Increments Stratified by Baseline Estimated GFR
Article Hospital-acquired Acute Kidney Injury: An Analysis of Nadir-to-Peak Serum Creatinine Increments Stratified by Baseline Estimated GFR Jose Calvo Broce,* Lori Lyn Price, Orfeas Liangos, Katrin Uhlig,*
Une promenade dans l'épidémiologie de l'insuffisance rénale aiguë en quatre étapes
Une promenade dans l'épidémiologie de l'insuffisance rénale aiguë en quatre étapes Fernando Liaño Hospital Universitario Ramón y Cajal Madrid, España Genéve, 14-12-2012 Une promenade dans l'épidémiologie
Measure Abbreviation: AKI 01 (QCDR Measure ID: ASPIRE19)
Measure Abbreviation: AKI 01 (QCDR Measure ID: ASPIRE19) Data Collection Method: This measure is calculated based on data extracted from the electronic medical record combined with administrative data
Duration of acute kidney injury and mortality in critically ill patients: a retrospective observational study
Han et al. BMC Nephrology 2013, 14:133 RESEARCH ARTICLE Open Access Duration of acute kidney injury and mortality in critically ill patients: a retrospective observational study Seung Seok Han 1, Sejoong
Acute Kidney Injury. Amandeep Khurana, MD Southwest Kidney Institute
Acute Kidney Injury Amandeep Khurana, MD Southwest Kidney Institute 66 yr white male w/ DM, HTN, CAD admitted to an OSH w/ E Coli UTI on 7/24/16, developed E Coli bacteremia and Shock (on vaso + levo)
Rationale for renal replacement therapy in ICU: indications, approaches and outcomes. Richard Beale
Rationale for renal replacement therapy in ICU: indications, approaches and outcomes Richard Beale RIFLE classification (ADQI group) 2004 Outcome AKIN classification Definition: Abrupt (within 48 hrs)
Original Article. Defining reduced urine output in neonatal ICU: importance for mortality and acute kidney injury classification
Nephrol Dial Transplant (2013) 28: 901 909 doi: 10.1093/ndt/gfs604 Advance Access publication 24 January 2013 Original Article Defining reduced urine output in neonatal ICU: importance for mortality and
Prognostic robustness of serum creatinine based AKI definitions in patients with sepsis: a prospective cohort study
Vanmassenhove et al. BMC Nephrology (2015)16:12 DOI 10.1186/s12882-015-0107-4 RESEARCH ARTICLE Open Access Prognostic robustness of serum creatinine based AKI definitions in patients with sepsis: a prospective
Ascertainment and Epidemiology of Acute Kidney Injury Varies with Definition Interpretation
Original Articles Ascertainment and Epidemiology of Acute Kidney Injury Varies with Definition Interpretation Michael Zappitelli,* Chirag R. Parikh, Ayse Akcan-Arikan,* Kimberley K. Washburn,* Brady S.
USRDS UNITED STATES RENAL DATA SYSTEM
USRDS UNITED STATES RENAL DATA SYSTEM Chapter 2: Identification and Care of Patients With CKD Over half of patients from the Medicare 5 percent sample have either a diagnosis of chronic kidney disease
The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review
Clin Kidney J (2013) 6: 8 14 doi: 10.1093/ckj/sfs160 In Depth Review The RIFLE and AKIN classifications for acute kidney injury: a critical and comprehensive review José António Lopes and Sofia Jorge Department
The Duration of Postoperative Acute Kidney Injury Predicts In-Hospital Mortality in Surgical Patients
Original Article Elmer Press The Duration of Postoperative Acute Kidney Injury Predicts In-Hospital Mortality in Surgical Patients Hung-Chieh Wu a, Yu-Wei Chen b, c, d, Wei-Jie Wang a, e, Jui-Tsung Ting
The Association between Renin-Angiotensin System Blockade, Premorbid Blood Pressure Control, and Acute Kidney Injury in Critically Ill Patients
ICU AKI RAS A The Association between Renin-Angiotensin System Blockade, Premorbid Blood Pressure Control, and Acute Kidney Injury in Critically Ill Patients Acute Kidney Injury: AKI KDIGO ICU A 30 60%
Use of Multiple Imputation Method to Improve Estimation of Missing Baseline Serum Creatinine in Acute Kidney Injury Research
Article Use of Multiple Imputation Method to Improve Estimation of Missing Baseline Serum Creatinine in Acute Kidney Injury Research Edward D. Siew,* Josh F. Peterson, Svetlana K. Eden Karel G. Moons,
Chapter 2: Identification and Care of Patients With CKD
Chapter 2: Identification and Care of Patients With CKD Over half of patients in the Medicare 5% sample (aged 65 and older) had at least one of three diagnosed chronic conditions chronic kidney disease
Chapter 5: Acute Kidney Injury
Chapter 5: Acute Kidney Injury In 2015, 4.3% of Medicare fee-for-service beneficiaries experienced a hospitalization complicated by Acute Kidney Injury (AKI); this appears to have plateaued since 2011
Shuma Hirashio 1,2, Shigehiro Doi 1 and Takao Masaki 1*
Hirashio et al. Renal Replacement Therapy (2018) 4:24 https://doi.org/10.1186/s41100-018-0164-9 CASE REPORT Open Access Magnetic resonance imaging is effective for evaluating the therapeutic effect of
Estimating Baseline Kidney Function in Hospitalized Patients with Impaired Kidney Function
Article Estimating Baseline Kidney Function in Hospitalized Patients with Impaired Kidney Function Edward D. Siew,* T. Alp Ikizler,* Michael E. Matheny, Yaping Shi, Jonathan S. Schildcrout, Ioana Danciu,
Transient versus Persistent Acute Kidney Injury and the Diagnostic Performance of Fractional Excretion of Urea in Critically Ill Patients
Original Paper Received: June 27, 2013 Accepted: November 29, 2013 Published online: January 11, 2014 Transient versus Persistent Acute Kidney Injury and the Diagnostic Performance of Fractional Excretion
Lucia Cea Soriano 1, Saga Johansson 2, Bergur Stefansson 2 and Luis A García Rodríguez 1*
Cea Soriano et al. Cardiovascular Diabetology (2015) 14:38 DOI 10.1186/s12933-015-0204-5 CARDIO VASCULAR DIABETOLOGY ORIGINAL INVESTIGATION Open Access Cardiovascular events and all-cause mortality in
Original Article. Correspondence and offprint requests to: Matthew T. James;
Nephrol Dial Transplant (2016) 31: 2049 2056 doi: 10.1093/ndt/gfw374 Original Article Prognostic implications of adding urine output to serum creatinine measurements for staging of acute kidney injury
Supplementary Online Content
Supplementary Online Content Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney
Chapter 2: Identification and Care of Patients With Chronic Kidney Disease
Chapter 2: Identification and Care of Patients With Chronic Kidney Disease Introduction The examination of care in patients with chronic kidney disease (CKD) is a significant challenge, as most large datasets
Chapter 1: CKD in the General Population
Chapter 1: CKD in the General Population Overall prevalence of CKD (Stages 1-5) in the U.S. adult general population was 14.8% in 2011-2014. CKD Stage 3 is the most prevalent (NHANES: Figure 1.2 and Table
Chapter 2: Identification and Care of Patients with CKD
Chapter 2: Identification and Care of Patients with CKD Over half of patients in the Medicare 5% sample (aged 65 and older) had at least one of three diagnosed chronic conditions chronic kidney disease
Acute Kidney Injury (AKI) How Wise is Early Dialysis in Critically Ill Patients? Modalities of Dialysis
Acute Kidney Injury (AKI) How Wise is Early Dialysis in Critically Ill Patients? A common condition in ICU patients Associated with high mortality and morbidity Renal Replacement Therapy (RRT) is the cornerstone
Cystatin C: A New Approach to Improve Medication Dosing
Cystatin C: A New Approach to Improve Medication Dosing Erin Frazee Barreto, PharmD, MSc, FCCM Assistant Professor of Pharmacy and Medicine Kern Scholar, Center for the Science of Health Care Delivery
Grading of acute kidney injury(2013)
Acute kidney disease represents a spectrum of disease associated with a sudden onset of renal parenchymal injury most typically characterized by generalized failure of the kidneys to meet the excretory,
Ahmad Kaddourah, M.D., Rajit K. Basu, M.D., Sean M. Bagshaw, M.D., and Stuart L. Goldstein, M.D., for the AWARE Investigators* abstract
The new england journal of medicine established in 1812 January 5, 2017 vol. 376 no. 1 Epidemiology of Acute Kidney Injury in Critically Ill Children and Young Adults Ahmad Kaddourah, M.D., Rajit K. Basu,
Predictors of renal recovery in patients with severe acute kidney injury on renal replacement therapy
Predictors of renal recovery in patients with severe acute kidney injury on renal replacement therapy Protocol version 10 02/02/2018 1 BACKGROUND The incidence of acute kidney injury (AKI) is increasing
Incidence and etiology of acute kidney injury in children admitted to PICU using prifle criteria
International Journal of Contemporary Pediatrics Maqbool J et al. Int J Contemp Pediatr. 2018 May;5(3):917-921 http://www.ijpediatrics.com pissn 2349-3283 eissn 2349-3291 Original Research Article DOI:
SUPPLEMENTARY INFORMATION
Supplementary information S1 Studies of the effect of AKI duration on outcomes Study Study group (n) Criteria for AKI Definition of RR Outcomes Uchino et al. All patients admitted to (2010) 1 a university-affiliated
Chapter 2: Identification and Care of Patients With CKD
Chapter 2: Identification and Care of Patients With Over half of patients from the Medicare 5% sample (restricted to age 65 and older) have a diagnosis of chronic kidney disease (), cardiovascular disease,
University of Groningen. Acute kidney injury after cardiac surgery Loef, Berthus Gerard
University of Groningen Acute kidney injury after cardiac surgery Loef, Berthus Gerard IMPORTANT NOTE: You are advised to consult the publisher's version (publisher's PDF) if you wish to cite from it.
Low mean perfusion pressure is a risk factor for progression of acute kidney injury in critically ill patients A retrospective analysis
Ostermann et al. BMC Nephrology (2017) 18:151 DOI 10.1186/s12882-017-0568-8 RESEARCH ARTICLE Open Access Low mean perfusion pressure is a risk factor for progression of acute kidney injury in critically
THE PROGNOSIS OF PATIENTS WITH CHRONIC KIDNEY DISEASE AND DIABETES MELLITUS
214 ILEX PUBLISHING HOUSE, Bucharest, Roumania http://www.jrdiabet.ro Rom J Diabetes Nutr Metab Dis. 21(3):23-212 doi: 1.2478/rjdnmd-214-25 THE PROGNOSIS OF PATIENTS WITH CHRONIC KIDNEY DISEASE AND DIABETES
Zhao Y Y et al. Ann Intern Med 2012;156:
Zhao Y Y et al. Ann Intern Med 2012;156:560-569 Introduction Fibrates are commonly prescribed to treat dyslipidemia An increase in serum creatinine level after use has been observed in randomized, placebocontrolled
The Risk Study. A prospective, multi-centre, evaluation of an AKI risk prediction tool for emergency hospital admissions
The Risk Study A prospective, multi-centre, evaluation of an AKI risk prediction tool for emergency hospital admissions Disclosures Research Funding Commercial Trials Honorarium/Travel Astute Medical SBRI/D4D
Narender Goel et al. Middletown Medical PC, Montefiore Medical Center & Albert Einstein College of Medicine, New York
Narender Goel et al. Middletown Medical PC, Montefiore Medical Center & Albert Einstein College of Medicine, New York 4th International Conference on Nephrology & Therapeutics September 14, 2015 Baltimore,
AKI in Hospitalized Children: Comparing the prifle, AKIN, and KDIGO Definitions
CJASN epress. Published on February 3, 2015 as doi: 10.2215/CJN.01900214 Article AKI in Hospitalized Children: Comparing the prifle, AKIN, and KDIGO Definitions Scott M. Sutherland,* John J. Byrnes, Manish
Initiation Strategies for Renal Replacement Therapy in ICU
Initiation Strategies for Renal Replacement Therapy in ICU The Artificial Kidney Initiation in Kidney Injury trial AKIKI Stéphane Gaudry Réanimation médico-chirurgicale Hôpital Louis Mourier, Colombes
Original Article Characteristics and predictors of acute kidney injury among patients attending ICU: a prospective study
Int J Clin Exp Med 2017;10(9):13331-13340 www.ijcem.com /ISSN:1940-5901/IJCEM0021367 Original Article Characteristics and predictors of acute kidney injury among patients attending ICU: a prospective study
NEPHROCHECK. Know earlier. Intervene sooner. Avoid the danger and damage of Acute Kidney Injury.
Know earlier. Intervene sooner. Avoid the danger and damage of Acute Kidney Injury. 42% of critically ill patients with Sepsis develop AKI 1 2 SEPSIS AND ACUTE KIDNEY INJURY (AKI) ARE OFTEN CO-MORBIDITIES.
ACB National Audit: Acute Kidney Injury. Jamie West Peterborough City Hospital June 2016
ACB National Audit: Acute Kidney Injury Jamie West Peterborough City Hospital June 2016 Acute Kidney Injury (AKI) Pre-renal: Dehydration Haemorrhage Fluid loss Sepsis Acute cardiac failure Intrinsic: Glomerular
Neutrophil Gelatinase-Associated Lipocalin as a Biomarker of Acute Kidney Injury in Patients with Morbid Obesity Who Underwent Bariatric Surgery
Published online: October 31, 213 1664 5529/13/31 11$38./ This is an Open Access article licensed under the terms of the Creative Commons Attribution- NonCommercial 3. Unported license (CC BY-NC) (www.karger.com/oa-license),
Acute renal failure Definition and detection
Acute renal failure Definition and detection Pierre Delanaye, MD, PhD Nephrology, Dialysis, Transplantation CHU Sart Tilman University of Liège BELGIUM Definition Acute Renal Failure Acute Kidney Injury
Augmented Renal Clearance: Let s Get the Discussion Flowing
Augmented Renal Clearance: Let s Get the Discussion Flowing Terry Makhoul, PharmD PGY-2 Emergency Medicine Pharmacy Resident University of Rochester Medical Center Strong Memorial Hospital Disclosures
Accepted Manuscript. Epidemiology of Cardiac Surgery Associated Acute Kidney Injury. Eric AJ. Hoste, Wim Vandenberghe
Accepted Manuscript Epidemiology of Cardiac Surgery Associated Acute Kidney Injury Eric AJ. Hoste, Wim Vandenberghe PII: S1521-6896(17)30079-4 DOI: 10.1016/j.bpa.2017.11.001 Reference: YBEAN 968 To appear
Duration of acute kidney injury in critically ill patients
https://doi.org/10.1186/s13613-018-0374-x RESEARCH Open Access Duration of acute kidney injury in critically ill patients Christine K. Federspiel 1,2, Theis S. Itenov 2, Kala Mehta 3, Raymond K. Hsu 4,
A THESIS SUBMITTED TO THE FACULTY OF THE GRADUATE SCHOOL OF THE UNIVERSITY OF MINNESOTA BY FARSAD AFSHINNIA
An Optimized Classification System of Acute Kidney Injury for Predicting the Short term Mortality after Open Heart Surgery; Comparison of Current Classification Systems A THESIS SUBMITTED TO THE FACULTY
Research Article A Simple Method to Detect Recovery of Glomerular Filtration Rate following Acute Kidney Injury
BioMed Research International, Article ID 542069, 8 pages http://dx.doi.org/10.1155/2014/542069 Research Article A Simple Method to Detect Recovery of Glomerular Filtration Rate following Acute Kidney
WORSENING OF RENAL FUNCTION AFTER RAS INHIBITION IN DECOMPENSATED HEART FAILURE: CLINICAL IMPLICATIONS
WORSENING OF RENAL FUNCTION AFTER RAS INHIBITION IN DECOMPENSATED HEART FAILURE: CLINICAL IMPLICATIONS George Bakris, MD, FASH, FAHA, FASN Professor of Medicine Director, Comprehensive Hypertension Center
Introduction. Soe Ko, 1 Sudharsan Venkatesan, 1 Kushma Nand, 1,2 Vicki Levidiotis, 2,3 Craig Nelson 2,3 and Edward Janus 1,3.
doi:10.1111/imj.13729 International statistical classification of diseases and related health problems coding underestimates the incidence and prevalence of acute kidney injury and chronic kidney disease
Critical care resources are often provided to the too well and as well as. to the too sick. The former include the patients admitted to an ICU
Literature Review Critical care resources are often provided to the too well and as well as to the too sick. The former include the patients admitted to an ICU following major elective surgery for overnight
Chronic Renal Failure Followed by Acute Renal Failure
Chronic Renal Failure Followed by Acute Renal Failure Dr Emre Karakoç Çukurova Üniversity Department of Medical ICU Terminology Acute Kidney Injury Chronic Kidney Disease Acute Kidney Disease Acute kidney
Adding Insult to Injury. Marlies Ostermann Consultant in Nephrology & Critical Care Guy s & St Thomas Hospital, London
Acute Kidney Injury Adding Insult to Injury Marlies Ostermann Consultant in Nephrology & Critical Care Guy s & St Thomas Hospital, London Content 1. Brief review of AKI and its impact 2. Comments on the
Takashi Yagisawa 1,2*, Makiko Mieno 1,3, Norio Yoshimura 1,4, Kenji Yuzawa 1,5 and Shiro Takahara 1,6
Yagisawa et al. Renal Replacement Therapy (2016) 2:68 DOI 10.1186/s41100-016-0080-9 POSITION STATEMENT Current status of kidney transplantation in Japan in 2015: the data of the Kidney Transplant Registry
Choice of Reference Serum Creatinine in Defining Acute Kidney Injury
Clinical Practice: Review Received: June 5, 2015 Accepted: August 2, 2015 Published online: September 2, 2015 Choice of Reference Serum Creatinine in Defining Acute Kidney Injury Edward D. Siew a c, g
High urinary excretion of kidney injury molecule-1 predicts adverse outcomes in acute kidney injury: a case control study
Xie et al. Critical Care (2016) 20:286 DOI 10.1186/s13054-016-1455-6 RESEARCH High urinary excretion of kidney injury molecule-1 predicts adverse outcomes in acute kidney injury: a case control study Yuanyuan
Jun Suzuki 1, Tetsu Ohnuma 2, Hidenori Sanayama 3, Kiyonori Ito 4, Takayuki Fujiwara 5, Hodaka Yamada 6, Alan Kawarai Lefor 7 and Masamitsu Sanui 2*
Suzuki et al. Renal Replacement Therapy (2017) 3:30 DOI 10.1186/s41100-017-0111-1 RESEARCH Open Access The optimal timing of continuous renal replacement therapy according to the modified RIFLE classification
CME/SAM. Enhanced Creatinine and Estimated Glomerular Filtration Rate Reporting to Facilitate Detection of Acute Kidney Injury
Enhanced Creatinine and Estimated Glomerular Filtration Rate Reporting to Facilitate Detection of Acute Kidney Injury Jason M. Baron, MD, 1,2 Xingxing S. Cheng, MD, 2,3 Hasan Bazari, MD, 2,3,4 Ishir Bhan,
The outcome of Acute Kidney Injury in patients with severe Malaria
Open Access Journal of Clinical Nephrology Research Article The outcome of Acute Kidney Injury in patients with severe Malaria João Alberto Brandão 1 and João Egidio Romão Jr. 2 * 1 Clínica Multiperfil,
Acute Kidney Injury for the General Surgeon
Acute Kidney Injury for the General Surgeon UCSF Postgraduate Course in General Surgery Maui, HI March 20, 2011 Epidemiology & Definition Pathophysiology Clinical Studies Management Summary Hobart W. Harris,
Original Article Incidence and outcomes of acute kidney injury among patients attending intensive care unit in China
Int J Clin Exp Med 2017;10(2):3517-3525 www.ijcem.com /ISSN:1940-5901/IJCEM0031692 Original Article Incidence and outcomes of acute kidney injury among patients attending intensive care unit in China Hong-Shuang
NIH Public Access Author Manuscript Kidney Int. Author manuscript; available in PMC 2013 October 02.
NIH Public Access Author Manuscript Published in final edited form as: Kidney Int. 2012 March ; 81(5): 442 448. doi:10.1038/ki.2011.379. Chronic Kidney Disease after Acute Kidney Injury: A Systematic Review
Several investigations have demonstrated that acute
Association Between Progression and Improvement of Acute Kidney Injury and Mortality in Critically Ill Children* L. Nelson Sanchez-Pinto, MD 1 ; Stuart L. Goldstein, MD 2 ; James B. Schneider, MD 3 ; Robinder
Acute Kidney Injury Is Associated with Increased Hospital Mortality after Stroke
Acute Kidney Injury Is Associated with Increased Hospital Mortality after Stroke Minesh Khatri, MD,* Jonathan Himmelfarb, MD, Derk Adams, BS, Kyra Becker, MD, W. T. Longstreth, MD, and David L. Tirschwell,
Body weight definitions for evaluating a urinary diagnosis of acute kidney injury in patients with sepsis
Katayama et al. BMC Nephrology (2018) 19:101 https://doi.org/10.1186/s12882-018-0895-4 RESEARCH ARTICLE Body weight definitions for evaluating a urinary diagnosis of acute kidney injury in patients with
Prevalence of anemia and cardiovascular diseases in chronic kidney disease patients: a single tertiary care centre study
International Journal of Advances in Medicine Sathyan S et al. Int J Adv Med. 2017 Feb;4(1):247-251 http://www.ijmedicine.com pissn 2349-3925 eissn 2349-3933 Original Research Article DOI: http://dx.doi.org/10.18203/2349-3933.ijam20170120
Sebastião Rodrigues Ferreira-Filho, Camila Caetano Cardoso, Luiz Augusto Vieira de Castro, Ricardo Mendes Oliveira, and Renata Rodrigues Sá
SAGE-Hindawi Access to Research International Nephrology Volume 211, Article ID 626178, 4 pages doi:1.461/211/626178 Research Article Comparison of Measured Creatinine Clearance and Clearances Estimated
Guillaume Manoeuvrier 1, Kalyane Bach-Ngohou 2, Eric Batard 3,4, Damien Masson 2 and David Trewick 3,4*
Manoeuvrier et al. BMC Nephrology (2017) 18:173 DOI 10.1186/s12882-017-0591-9 RESEARCH ARTICLE Open Access Diagnostic performance of serum blood urea nitrogen to creatinine ratio for distinguishing prerenal
ALLHAT RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR)
1 RENAL DISEASE OUTCOMES IN HYPERTENSIVE PATIENTS STRATIFIED INTO 4 GROUPS BY BASELINE GLOMERULAR FILTRATION RATE (GFR) 6 / 5 / 1006-1 2 Introduction Hypertension is the second most common cause of end-stage
Duration of anuria predicts recovery of renal function after acute kidney injury requiring continuous renal replacement therapy
ORIGINAL ARTICLE Korean J Intern Med 2016;31:930-937 Duration of anuria predicts recovery of renal function after acute kidney injury requiring continuous renal replacement therapy Hee-Yeon Jung *, Jong-Hak
Evidence-based practice in nephrology : Meta-analysis
Evidence-based practice in nephrology : Meta-analysis Paweena Susantitaphong, MD,Ph.D 1-3 1 Associate Professor, Division of Nephrology, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn
Preoperative Serum Bicarbonate Levels Predict Acute Kidney Iinjry after Cardiac Surgery
International Journal of ChemTech Research CODEN (USA): IJCRGG, ISSN: 0974-4290, ISSN(Online):2455-9555 Vol.11 No.06, pp 203-208, 2018 Preoperative Serum Bicarbonate Levels Predict Acute Kidney Iinjry
How and why to measure renal function in patients with liver disease?
ow and why to measure renal function in patients with liver disease? P. Angeli, Dept. of Medicine, Unit of Internal Medicine and epatology (), University of Padova (Italy) pangeli@unipd.it 10th Paris epatology
Ruolo della clinica e del laboratorio nella diagnosi di IRA
Ruolo della clinica e del laboratorio nella diagnosi di IRA Antonio Granata Ospedale San Giovanni di Dio - Agrigento Scuola Nazionale Specialistica di Ecografia Nefrologica SIUMB Centro di Riferimento
NIH Public Access Author Manuscript Comput Cardiol (2010). Author manuscript; available in PMC 2014 March 25.
NIH Public Access Author Manuscript Published in final edited form as: Comput Cardiol (2010). 2012 ; 39: 245 248. Predicting In-Hospital Mortality of ICU Patients: The PhysioNet/ Computing in Cardiology
Acute kidney injury definition, causes and pathophysiology. Financial Disclosure. Some History Trivia. Key Points. What is AKI
Acute kidney injury definition, causes and pathophysiology Financial Disclosure Current support: Center for Sepsis and Critical Illness Award P50 GM-111152 from the National Institute of General Medical
Torsion bottle, a very simple, reliable, and cheap tool for a basic scoliosis screening
Romano and Mastrantonio Scoliosis and Spinal Disorders (2018) 13:4 DOI 10.1186/s13013-018-0150-6 RESEARCH Open Access Torsion bottle, a very simple, reliable, and cheap tool for a basic scoliosis screening