Classifying AKI by Urine Output versus Serum Creatinine Level

John A Kellum, Florentina E Sileanu, Raghavan Murugan, Nicole Lucko, Andrew D Shaw, Gilles Clermont, John A Kellum, Florentina E Sileanu, Raghavan Murugan, Nicole Lucko, Andrew D Shaw, Gilles Clermont

Abstract

Severity of AKI is determined by the magnitude of increase in serum creatinine level or decrease in urine output. However, patients manifesting both oliguria and azotemia and those in which these impairments are persistent are more likely to have worse disease. Thus, we investigated the relationship of AKI severity and duration across creatinine and urine output domains with the risk for RRT and likelihood of renal recovery and survival using a large, academic medical center database of critically ill patients. We analyzed electronic records from 32,045 patients treated between 2000 and 2008, of which 23,866 (74.5%) developed AKI. We classified patients by levels of serum creatinine and/or urine output according to Kidney Disease Improving Global Outcomes staging criteria for AKI. In-hospital mortality and RRT rates increased from 4.3% and 0%, respectively, for no AKI to 51.1% and 55.3%, respectively, when serum creatinine level and urine output both indicated stage 3 AKI. Both short- and long-term outcomes were worse when patients had any stage of AKI defined by both criteria. Duration of AKI was also a significant predictor of long-term outcomes irrespective of severity. We conclude that short- and long-term risk of death or RRT is greatest when patients meet both the serum creatinine level and urine output criteria for AKI and when these abnormalities persist.

Keywords: ARF; dialysis; mortality.

Copyright © 2015 by the American Society of Nephrology.

Figures

Figure 1.
Figure 1.
Age-adjusted survival and RRT rates by AKI severity. Groups refer to combinations of UO and creatinine criteria depicted in Table 3 and Supplemental Table 5. Group 1 (green), no AKI by either criterion; group 2 (blue), stages 1–2 by UO criteria but no AKI by SC or stage 1 by SC and no AKI by UO; group 3 (yellow), stages 1–2 by UO plus stage 1 by SC or stages 2–3 by SC alone; group 4 (orange), stages 1–2 by UO plus stage 2 by SC or stage 3 by UO alone; group 5 (red), stage 3 by UO plus stages 1–2 by SC or stage 3 by SC plus stages 1–2 by UO; and group 6 (dark red), stage 3 by both criteria. The top panel shows age-adjusted 1-year survival for all patients (10 patients had missing age). The bottom panel shows age-adjusted 1-year dialysis rates for patients that entered the USRDS before 1 year. Patients who died before 1 year are excluded. Overall differences by groups are significant for both sets (P<0.001).
Figure 2.
Figure 2.
Age-adjusted 1-year risk for death or RRT for AKI staging based solely on UO or creatinine criteria. Shown are death or RRT rates over 1 year (includes in-hospital events) for patients with AKI staging based solely on UO (no AKI by SC; 7 patients had missing age) (top) and those with AKI based solely on SC (no AKI by UO; 8 patients had missing age) (bottom). Overall differences by stage are significant for both sets (P<0.001).
Figure 3.
Figure 3.
Relationship between duration of AKI and death or dialysis at 1 year after ICU admission. (A) Duration of AKI by SC criteria (in all patients with or without AKI by UO) and likelihood of death or dialysis at 1 year. Likelihood of death or dialysis is significantly different by stage and also by time (P<0.001 and P=0.02, respectively) and the interaction between time and stage is significant (P<0.001). (B) Duration of AKI by SC criteria and likelihood of death or dialysis at 1 year (excludes death or RRT during the index hospitalization). Likelihood of death or dialysis is significantly different by stage and also by time (P=0.01 and P<0.001, respectively). (C) Duration of AKI by UO criteria (in all patients with or without AKI by SC) and likelihood of death or dialysis at 1 year. Likelihood of death or dialysis is significantly different by stage and also by time (analysis limited to only patients with stages 2–3) (P<0.001). (D) Duration of AKI by UO criteria and likelihood of death or dialysis at 1 year (excludes death or RRT during the index hospitalization). Likelihood of death or dialysis is significantly different by stage and also by time (analysis limited to only patients with stages 2–3) (P<0.001).
Figure 4.
Figure 4.
The source population included all patients cared for in an ICU over the 8-year study period. The study population included 32,045 patients (70.2% of the source population) after excluding missing data (mainly urine output) and ESRD.

References

    1. Palevsky PM, Molitoris BA, Okusa MD, Levin A, Waikar SS, Wald R, Chertow GM, Murray PT, Parikh CR, Shaw AD, Go AS, Faubel SG, Kellum JA, Chinchilli VM, Liu KD, Cheung AK, Weisbord SD, Chawla LS, Kaufman JS, Devarajan P, Toto RM, Hsu CY, Greene T, Mehta RL, Stokes JB, Thompson AM, Thompson BT, Westenfelder CS, Tumlin JA, Warnock DG, Shah SV, Xie Y, Duggan EG, Kimmel PL, Star RA: Design of clinical trials in acute kidney injury: Report from an NIDDK workshop on trial methodology. Clin J Am Soc Nephrol 7: 844–850, 2012
    1. Okusa MD, Molitoris BA, Palevsky PM, Chinchilli VM, Liu KD, Cheung AK, Weisbord SD, Faubel S, Kellum JA, Wald R, Chertow GM, Levin A, Waikar SS, Murray PT, Parikh CR, Shaw AD, Go AS, Chawla LS, Kaufman JS, Devarajan P, Toto RM, Hsu CY, Greene TH, Mehta RL, Stokes JB, Thompson AM, Thompson BT, Westenfelder CS, Tumlin JA, Warnock DG, Shah SV, Xie Y, Duggan EG, Kimmel PL, Star RA: Design of clinical trials in acute kidney Injury: A report from an NIDDK workshop–prevention trials. Clin J Am Soc Nephrol 7: 851–855, 2012
    1. Molitoris BA, Okusa MD, Palevsky PM, Chawla LS, Kaufman JS, Devarajan P, Toto RM, Hsu CY, Greene TH, Faubel SG, Kellum JA, Wald R, Chertow GM, Levin A, Waikar SS, Murray PT, Parikh CR, Shaw AD, Go AS, Chinchilli VM, Liu KD, Cheung AK, Weisbord SD, Mehta RL, Stokes JB, Thompson AM, Thompson BT, Westenfelder CS, Tumlin JA, Warnock DG, Shah SV, Xie Y, Duggan EG, Kimmel PL, Star RA: Design of clinical trials in AKI: A report from an NIDDK workshop. Trials of patients with sepsis and in selected hospital settings. Clin J Am Soc Nephrol 7: 856–860, 2012
    1. Murugan R, Kellum JA: Acute kidney injury: What’s the prognosis? Nat Rev Nephrol 7: 209–217, 2011
    1. Md Ralib A, Pickering JW, Shaw GM, Endre ZH: The urine output definition of acute kidney injury is too liberal. Crit Care 17: R112, 2013
    1. Macedo E, Malhotra R, Bouchard J, Wynn SK, Mehta RL: Oliguria is an early predictor of higher mortality in critically ill patients. Kidney Int 80: 760–767, 2011
    1. Chawla LS, Davison DL, Brasha-Mitchell E, Koyner JL, Arthur JM, Shaw AD, Tumlin JA, Trevino SA, Kimmel PL, Seneff MG: Development and standardization of a furosemide stress test to predict the severity of acute kidney injury. Crit Care 17: R207, 2013
    1. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL, Program to Improve Care in Acute Renal Disease (PICARD) Study Group : Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 76: 422–427, 2009
    1. Boyd JH, Forbes J, Nakada TA, Walley KR, Russell JA: Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 39: 259–265, 2011
    1. Liu KD, Thompson BT, Ancukiewicz M, Steingrub JS, Douglas IS, Matthay MA, Wright P, Peterson MW, Rock P, Hyzy RC, Anzueto A, Truwit JD, National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network : Acute kidney injury in patients with acute lung injury: Impact of fluid accumulation on classification of acute kidney injury and associated outcomes. Crit Care Med 39: 2665–2671, 2011
    1. Coca SG, King JT, Jr, Rosenthal RA, Perkal MF, Parikh CR: The duration of postoperative acute kidney injury is an additional parameter predicting long-term survival in diabetic veterans. Kidney Int 78: 926–933, 2010
    1. Zeng X, McMahon GM, Brunelli SM, Bates DW, Waikar SS: Incidence, outcomes, and comparisons across definitions of AKI in hospitalized individuals. Clin J Am Soc Nephrol 9: 12–20, 2014
    1. US Renal Data System: 2013 USRDS Annual Data Report. Available at: . Accessed December 19, 2014
    1. Waikar SS, Wald R, Chertow GM, Curhan GC, Winkelmayer WC, Liangos O, Sosa MA, Jaber BL: Validity of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Acute Renal Failure. J Am Soc Nephrol 17: 1688–1694, 2006
    1. Knaus WA, Wagner DP, Draper EA, Zimmerman JE, Bergner M, Bastos PG, Sirio CA, Murphy DJ, Lotring T, Damiano A: The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 100: 1619–1636, 1991
    1. Sileanu FE, Murugan R, Lucko N, Clermont G, Kane-Gill SL, Handler SM, Kellum JA: AKI in Low-Risk versus High-Risk Patients in Intensive Care. Clin J Am Soc Nephrol 10: XXX–XXX, 2014
    1. Hoste EAJ, Clermont G, Kersten A, Venkataraman R, Angus DC, De Bacquer D, Kellum JA: RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: A cohort analysis. Crit Care 10: R73, 2006
    1. Závada J, Hoste E, Cartin-Ceba R, Calzavacca P, Gajic O, Clermont G, Bellomo R, Kellum JA, AKI6 investigators : A comparison of three methods to estimate baseline creatinine for RIFLE classification. Nephrol Dial Transplant 25: 3911–3918, 2010
    1. KDIGO AKI Workgroup : Kidney Disease: Improving Global Outcomes (KDIGO) clinical practice guideline for acute kidney injury. Kidney Int Suppl 2: 1–138, 2012

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться