aki definitions

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AKI Definitions Stuart L. Goldstein, MD Professor of Pediatrics University of Cincinnati College of Medicine Director, Center for Acute Care Nephrology Nephrology and Hypertension The Heart Institute Cincinnati Children’s Hospital Medical Center

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AKI Definitions. Stuart L. Goldstein, MD Professor of Pediatrics University of Cincinnati College of Medicine Director, Center for Acute Care Nephrology Nephrology and Hypertension The Heart Institute Cincinnati Children’s Hospital Medical Center. Outline. Review current AKI definitions - PowerPoint PPT Presentation

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Page 1: AKI Definitions

AKI Definitions

Stuart L. Goldstein, MD

Professor of PediatricsUniversity of Cincinnati College of MedicineDirector, Center for Acute Care Nephrology

Nephrology and HypertensionThe Heart Institute

Cincinnati Children’s Hospital Medical Center

Page 2: AKI Definitions

The Center for Acute Care Nephrology

Outline• Review current AKI definitions

– RIFLE– pRIFLE– AKIN– KDIGO

• Application of definitions across populations

• Effect of volume status on AKI epidemiology

• Set the stage for Devarajan, Chawla and Symons

Page 3: AKI Definitions

The Center for Acute Care Nephrology

AKI Definitions to 2002

• Over 30 definitions in published literature– Nearly all based on absolute/change in serum creatinine

concentration– Pediatric AKI definitions

• 100% rise in SCr• eCCL < 75 ml/min/1.73m2

• SCr twice normal for patient age

• All AKI was created equal – no dimensionality

Page 4: AKI Definitions

The Center for Acute Care Nephrology

Is All AKI Created Equal?

• Recent adult patient data demonstrate– Small SCr rises associated with mortality– AKI associated with mortality and length of

hospitalization• AKI is now recognized as risk factor for

poor outcome, independent of severity of illness

Page 5: AKI Definitions

The Center for Acute Care Nephrology

Page 6: AKI Definitions

The Center for Acute Care Nephrology

Page 7: AKI Definitions

The Center for Acute Care Nephrology

All AKI is NOT Created Equal

• Multidimensional classification system is needed to– Grade AKI severity– Follow changes in kidney function– Standardize AKI as a hard outcome measure

Page 8: AKI Definitions

The Center for Acute Care Nephrology

AKI RIFLE Criteria: ADQI II

Page 9: AKI Definitions

The Center for Acute Care Nephrology

Mortality increases with RIFLE strata

in every study

Page 10: AKI Definitions

The Center for Acute Care Nephrology

• eCCl determined by Schwartz formula

• Baseline eCCl from three months before PICU– 120 ml/min/1.73m2 if no

data available• pRIFLE differs from RIFLE

in– Oliguria duration– RIFLE-F limit eCCl

Page 11: AKI Definitions

The Center for Acute Care Nephrology

• Additional 11 studies in past year alone

• Total patients= 9,825• Nephrotoxic medications• Post CPB• Emergency center• Biomarker outcomes• Kidney transplant• Trauma

Page 12: AKI Definitions

The Center for Acute Care Nephrology

• pRIFLE AKI rates and distributions varied with populations studied

• Most studies show association between pRIFLE-I/F and mortality or LOS

• Criteria not uniformly applied across studies

• Outcomes associated with pRIFLE-I or –F• pRIFLE-I (100% SCr rise) used for risk

stratification comparison across populations in Renal Angina development

• We should use pRIFLE-R to direct “low hanging fruit” management change

Page 13: AKI Definitions

The Center for Acute Care Nephrology

AKIN Definition

RIFLE Stage RIFLE criteria AKIN Stage AKIN Criteria

R

≥150% increase in serum creatinine,

or >25% GFR decrease

I

≥150% or ≥0.3 mg/dL increase

in serum creatinine

I

≥200% increase in serum creatinine,

or >50% GFR decrease

II

>200% increase in serum

creatinine

F

≥300% increase in serum creatinine, or serum creatinine of ≥ 4.0 mg/dL in

setting of increase≥ 0.5 mg/dL, or >75% GFR decrease

III

>300% increase in serum

creatinine, or serum creatinine of ≥ 4.0 mg/dL in setting of

increase≥ 0.5 mg/dL

Page 14: AKI Definitions

The Center for Acute Care Nephrology

• Retrospective analysis of 490 infants (age <90 days)

• All underwent cardiac surgery requiring cardiopulmonary bypass

• Postoperative AKI (AKIN criteria) occurred in 225 patients (52.3%)

Page 15: AKI Definitions

The Center for Acute Care Nephrology

Page 16: AKI Definitions

The Center for Acute Care Nephrology

Page 17: AKI Definitions

The Center for Acute Care Nephrology

Page 18: AKI Definitions

The Center for Acute Care Nephrology

Page 19: AKI Definitions

The Center for Acute Care Nephrology

• 1000 patients in the ARDSnet study

• Liberal vs. conservative fluid strategy

• Patients in the liberal strategy group received:– More fluid boluses– Less diuretics

Page 20: AKI Definitions

The Center for Acute Care Nephrology

Page 21: AKI Definitions

The Center for Acute Care Nephrology

Page 22: AKI Definitions

The Center for Acute Care Nephrology

Summary

• Standardized AKI definitions demonstrate small rises in creatinine are independently associated with poor outcomes

• Standardized AKI severity strata demonstrate worsening AKI severity increases the rate of poor outcomes

• Fluid overload may mask creatinine based AKI detection, underestimating AKI rates

Page 23: AKI Definitions

The Center for Acute Care Nephrology

Conclusions: Setting the Table• Serum creatinine change is a late functional

biomarker of AKI– Devarajan to discuss novel AKI damage markers

• Identification of AKI risk in paramount to directing stage based AKI management and biomarker assessment– Chawla to discuss the Renal Angina prodrome

concept• When to initiate supportive and/or

therapeutic maneuvers depends upon a standard AKI definition– Symons to discuss present supportive options– Devarajan to discuss future therapeutic options

Page 24: AKI Definitions

The Center for Acute Care Nephrology

FUNCTIONAL CRITERIA* and/or DAMAGE CRITERIA

Biomarker Positivity (+)

RIFLE-R or AKIN-1

RIFLE-I or AKIN-2

RIFLE-F or AKIN-3

Biomarker Positivity (++)

Biomarker Positivity (+++)

FUNCTIONAL CRITERIA* and/or DAMAGE CRITERIA

Biomarker Positivity (+)

RIFLE-R or AKIN-1

RIFLE-I or AKIN-2

RIFLE-F or AKIN-3

Biomarker Positivity (++)

Biomarker Positivity (+++)

Page 25: AKI Definitions

The Center for Acute Care Nephrology