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Classification Systems for Acute Kidney Injury
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Acute kidney injury (AKI), formerly
called acute renal failure (ARF), is commonly defined as an abrupt decline in
renal function, clinically manifesting as a reversible acute increase in nitrogen
waste products—measured by blood urea nitrogen (BUN) and serum creatinine
levels—over the course of hours to weeks. The vague nature of this definition
has historically made it difficult to compare between scholarly works and to
generalize findings on epidemiologic studies of AKI to patient populations.
Several classification systems have been developed to streamline research and
clinical practice with respect to AKI.
Acute
Kidney Injury Network:-
In September 2004, the Acute Kidney Injury Network (AKIN)
was formed. AKIN advised that the term acute kidney injury (AKI) be used to
represent the full spectrum of renal injury, from mild to severe, with the
latter having increased likelihood for unfavorable outcomes (eg, loss of
function and end-stage renal disease [ESRD]).
A
report by the AKIN proposed the following criteria for AKI
·
Abrupt (within 48 h) reduction in kidney function currently
defined as an absolute increase in serum creatinine of 0.3 mg/dL or more (≥26.4
μmol/L) or
·
A percentage increase in serum creatinine of 50% or more
(1.5-fold from baseline) or
·
A reduction in urine output (documented oliguria of < 0.5
mL/kg/h for >6 h)
The
AKIN criteria differ from the RIFLE criteria in several ways. The RIFLE
criteria are defined as changes within 7 days, while the AKIN criteria suggest
using 48 hours. The AKIN classification includes less severe injury in the
criteria and AKIN also avoids using the glomerular filtration rate as a marker
in AKI, as there is no dependable way to measure glomerular filtration rate and
estimated glomerular filtration rate are unreliable in AKI.
AKIN
notes that the diagnostic criteria proposed only after volume status has been
optimized and urinary tract obstructions must be excluded when using oliguria
as diagnostic criteria.
Fujii
and colleagues assessed the three systems discriminative ability based on serum
creatinine for the prediction of hospital mortaliy and found the AKIN
classification system to be inferior to the RIFLE and KDIGO systems.
KDIGO
Clinical Practice Guidelines:-
In 2012 the Kidney Disease Improving Global Outcomes
(KDIGO) released their clinical practice guidelines for acute kidney injury
(AKI), which build off of the RIFLE criteria and the AKIN criteria.
KDIGO
defines AKI as any of the following:
·
Increase in serum creatinine by 0.3mg/dL or more within 48 hours or
·
Increase in serum creatinine to 1.5 times baseline or more
within the last 7 days or
·
Urine output less than 0.5 mL/kg/h for 6 hours
The
KDIGO has also recommended a staging system for the severity of the AKI.
The
KDIGO consensus classification has yet to be validated.
Comparison
of AKI Incidence:-
In a cohort of 14,795 hospitalized children,
7712 children were diagnosed with AKI according to at least one of the
three definitions. A total of 5406 (70%) children were diagnosed by all
three definitions. Differences in the definitions resulted in the following
variances
·
1720 were diagnosed by RIFLE alone
·
427 were diagnosed by RIFLE and KDIGO but not AKIN
·
153 were diagnosed by KDIBO and AKIN but not by RIFLE
·
6 were diagnosed by KDIGO alone
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