Acute kidney injury classification

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farima Kahe M.D. [2]

Overview

KDIGO guidelines are used for staging acute kidney injury (AKI). Prior to the 2012 KDIGO AKI guidelines, RIFLE and AKIN criteria were used interchangeably to stage patients with renal injury. Initially, the staging of AKI was a part of the proposed definition by the ADQI initiative and the RIFLE criteria. In 2007, AKIN proposed separated the two and created a new staging scheme modified from the RIFLE criteria.

Classification

Initially, the staging of AKI was a part of the proposed definition by the ADQI initiative and the RIFLE criteria. In 2007, AKIN proposed separated the 2 and created a new staging scheme modified from the RIFLE criteria. Prior to the 2012 KDIGO AKI guidelines, RIFLE and AKIN criteria were used interchangeably to stage patients with renal injury.[1][2] Although certain concerns about the differences between the 2 classification schemes, it was shown that the differences do not carry through to mortality and outcome measures.[3]

Modified RIFLE staging scheme for acute kidney injury according to the Acute Kidney Injury Network (AKIN)
Classification GFR criteria Urine output criteria
Stage 1 Increase in SCr ≥0.3 mg/dL or 1.5x to 2x increase from baseline <0.5 mL/kg/h for 6 hours
Stage 2 2x to 3x increase in SCr from baseline <0.5 mL/kg/h for 12 hours
Stage 3 >3x increase in SCr or SCr≥ 4.0 mg/dL with acute increase >0.5 md/dL <0.3 mL/kg/h for 24 hours or anuria for 12 hours

In 2012, the KDIGO AKI guidelines proposed a combined staging scheme that takes into account both criteria and clinical outcome. [4] The rationale behind AKI staging is the needed to determine overall outcome as higher stages of AKI carry a greater risk of all cause and cardiovascular mortality, renal replacement, as well as chronic kidney disease even after AKI resolution.[5][6][7][8]

2012 KDIGO AKI Guidelines - Proposed staging criteria for AKI modified from AKIN
Staging GFR criteria Urine output criteria
Stage 1 1.5 - 1.9 times baseline or ≥ 0.3 mg/dl increase <0.5 ml/kg/h for 6 - 12 hours
Stage 2 2.0 - 2.9 times baseline <0.5 ml/kg/h for ≥ 12 hours
Stage 3 3.0 times baseline
or increase in serum creatinine to 4.0 mg/dL
or initiation of renal replacement therapy
or decrease in eGFR to <35 ml/min per 1.73 m2 (in patients <18 years)
<0.3 mL/kg/h for 24 hours
or
anuria for 12 hours

The guidelines also advocated that in case of discordance between urine output and serum creatinine patients should be classified to the highest applicable AKI stage. Also, new emphasis on the differences seen in the pediatric population gave rise to revised definition of stage 3 AKI in patients less than 18 years of age.[4]

References

  1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P, Acute Dialysis Quality Initiative workgroup (2004). "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. 8 (4): R204–12. doi:10.1186/cc2872. PMC 522841. PMID 15312219.
  2. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG; et al. (2007). "Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury". Crit Care. 11 (2): R31. doi:10.1186/cc5713. PMC 2206446. PMID 17331245.
  3. Bagshaw SM, George C, Bellomo R, ANZICS Database Management Committe (2008). "A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients". Nephrol Dial Transplant. 23 (5): 1569–74. doi:10.1093/ndt/gfn009. PMID 18281319.
  4. 4.0 4.1 Kidney Disease Improving Global Outcomes Work Group (2012). "2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury". Kidey Int Supp. 2: 69–88. doi:10.1038/kisup.2011.34.
  5. Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C (2006). "An assessment of the RIFLE criteria for acute renal failure in hospitalized patients". Crit Care Med. 34 (7): 1913–7. doi:10.1097/01.CCM.0000224227.70642.4F. PMID 16715038.
  6. Bagshaw SM, George C, Dinu I, Bellomo R (2008). "A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients". Nephrol Dial Transplant. 23 (4): 1203–10. doi:10.1093/ndt/gfm744. PMID 17962378.
  7. Ricci Z, Cruz D, Ronco C (2008). "The RIFLE criteria and mortality in acute kidney injury: A systematic review". Kidney Int. 73 (5): 538–46. doi:10.1038/sj.ki.5002743. PMID 18160961.
  8. Ali T, Khan I, Simpson W, Prescott G, Townend J, Smith W; et al. (2007). "Incidence and outcomes in acute kidney injury: a comprehensive population-based study". J Am Soc Nephrol. 18 (4): 1292–8. doi:10.1681/ASN.2006070756. PMID 17314324.

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