Acute kidney injury post operatively in intensive care unit patients: A comparison between the RIFLE and the

Acute Kidney Injury Network ( AKIN) classifications

Introduction Acute kidney injury (AKI) is a common complication after surgery and is associated with substantial morbidity and mortality. Early recognition of AKI and standardized reporting on it are of importance. Multiple definitions have until recently been used for acute kidney injury with more than 30 published definitions of AKI in use, and therefore the wide variation in definitions has made it difficult for comparisons of and conclusions from studies in this field with regard to epidemiology, success of prevention or intervention, early recognition, and prognosis difficult if not impossible. Recently, however, the Acute Dialysis Quality Initiative group proposed a classification for AKI the Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease (RIFLE) classification in order to have a uniform standard for diagnosing and classifying AKI. The standard defines three grades of severity risk (Class R), injury (Class I) and failure (Class F) and two outcome classes loss of kidney function and end-stage kidney disease. This classification system includes separate criteria for creatinine and urine output. A patient can fulfill the criteria through changes in serum creatinine or changes in urine output, or both. The criteria that lead to the worst possible classification should be used. The details of the classification is appended in Table 1.

Table 1 Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease classification class Risk Injury Failure GFR criteria Serum creatinine 1.5 or GFR decrease > 25% Serum creatinine 2 or GFR decrease > 50% Serum creatinine 3, GFR decrease > 75% or serum creatinine 4 mg/dl with an acute rise > 0.5 mg/dl Urine output criteria < 0.5 ml/kg/hour 6 hours < 0.5 ml/kg/hour 12 hours < 0.3 ml/kg/hour 24 hours, or anuria 12 hours

Loss End-stage kidney disease

Persistent acute renal failure = complete loss of kidney function > 4 weeks End-stage kidney disease > 3 months

For conversion of creatinine expressed in conventional units to standard units, multiply by 88.4. Patients are categorized on serum creatinine or urinary output, or both, and the criteria that lead to the worst classification are used. Glomerular filtration rate (GFR) criteria are calculated as an increase of serum creatinine above the baseline serum creatinine level. When the baseline serum creatinine is unknown and there is no past history of chronic kidney disease, serum creatinine is calculated using the Modification of Diet in Renal Disease formula for assessment of kidney function, assuming a GFR of 75 ml/min/1.73 m2. A more recent classification for AKI based on the RIFLE system has been proposed by the Acute Kidney Injury Network (AKIN) . This new staging system (Table 2) differs from the RIFLE classification as follows: it reduces the need for baseline creatinine but does require at least two creatinine values within 48 hours; AKI is defined as an abrupt (within 48 hours) reduction in kidney function, currently defined as an absolute increase in serum creatinine 0.3 mg/dl (26.4 mol/l), a percentage increase in serum creatinine 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria < 0.5 ml/kg/hour for > 6 hours); risk maps to Stage 1, but it also considers an increase in serum creatinine 0.3 mg/dl (26.4 mol/l); injury and failure map to Stages 2 and 3, respectively; Stage 3 also includes patients who need renal replacement therapy irrespective of the stage they are in at the time of renal replacement therapy; and the two outcome classes loss and end-stage kidney disease have been removed. Table 2 Classification/staging system for acute kidney injury modified from the Risk, Injury, Failure, Loss of Kidney Function, End-stage Kidney Disease criteria Stage 1 Serum creatinine criteria Urine output criteria

Increase in serum creatinine 0.3 < 0.5 ml/kg/hour for > 6 mg/dl (26.4 mol/l) or increase to hours 150% to 200% (1.5-fold to 2-fold) from baseline

Increase in serum creatinine to > 200% < 0.5 ml/kg/hour for > 12 to 300% (> 2-fold to 3-fold) from hours baseline Increase in serum creatinine to > 300% < 0.3 ml/kg/hour for 24 (> 3-fold) from baseline, or serum hours, or anuria for 12 creatinine 4.0 mg/dl (354 mol/l) hours with an acute increase of at least 0.5 mg/dl (44 mol/l)

Acute kidney injury is defined as an abrupt (within 48 hours) reduction in kidney function, currently defined as an absolute increase in serum creatinine 0.3 mg/dl (26.4 mol/l), a percentage increase in serum creatinine 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria < 0.5 ml/kg/hour for > 6 hours). aIndividuals who receive renal replacement therapy are considered to have met the criteria of Stage 3 irrespective of the stage they are in at the time of renal replacement therapy. These modifications were based on the accumulating evidence that small increases in serum creatinine are associated with adverse outcomes, and on the variability inherent in commencing renal replacement therapy and inherent to resources in different populations and countries. Despite the AKIN criteria possibly having greater sensitivity and specificity, it is currently unknown whether discernible advantages exist with one approach towards definition and classification versus the other. In most studies the RIFLE and AKIN classifications and their classes are found to be associated with progressively increasing mortality. To date, there is a raging debate over which definition and staging system that should be used for AKI in post op ICU patient.

Neither classification, however, has been compared with the other regarding its ability to measure the incidence of AKI and predict patient outcomes in ICU patient after surgery. In the present study, we will evaluate the incidence of AKI and compared the ability of the maximum RIFLE and of the maximum AKIN within ICU hospitalization in post operative patient with regard to the detection of AKI, their agreement according to grading of AKI across classes, and their prognostic value.

AIM The aim of this study is to compare the diagnostic ability & power in the early identification of Acute Kidney Injury in ICU patients undergoing elective or emergency surgical procedures, using a RIFLE and AKIN criteria.

OBJECTIVES 1. 2. To study the Incidence of AKI in post op ICU patients To note the ability for the early identification of Acute Kidney injury in post op ICU

patients using RIFLE and AKIN criteria 3. To study, 28 day mortality, ICU length of stay and need of renal replacement therapy

MATERIALS AND METHODS Patients

Prospective observational study Study period : October 2012- september 2013( 12 month) Study Population: All consecutive, adult, Post operative ICU patient during 12 months in Command hospital , Pune .

MEASUREMENTS The basic demographic data such as age, gender, body weight would be noted along with the primary diagnosis and surgical procedure performed. Details on the presence of co-morbid conditions such as presence or absence of arterial hypertension, history of cardiovascular disease - angina pectoris, myocardial infarction, cerebrovascular disease, and diabetes mellitus and any other condition would be collected. APACHE II score at ICU admission & SOFA (Sequential Organ Function Assessment) score noted daily. The duration of surgery, hemodynamic status in the intraop period, quantity and type of IV fluids administered during surgery, the use of diuretics during intraop period and ICU stay would be noted. The length of stay in the ICU, the need for mechanical ventilation its duration in hours post op would be noted. The baseline & daily record of renal functions along with the post op urine output every hour and would be noted. The maximum daily score in the RIFLE and AKIN criteria would be noted. There shall be no interference in the treatment plan being followed by the treating physician. Treatment shall not be modified or dictated by the readings and the treating clinician allowed to carry on necessary treatments as per his judgement. All patients shall be assessed daily using both the RIFLE and AKIN criteria to identify renal function derangement during the period of the ICU stay. For the RIFLE classification, the maximal RIFLE class according to postoperative changes in renal function by using changes in creatinine value and changes in hourly urine output. For the AKIN classification,the maximal AKIN class according to postoperative changes in renal function by using creatinine increase, need for renal replacement therapy, and urine output decrease within 48 hours postoperatively. Exclusion Criteria Patients on chronic dialysis; Readmissions; Age less than l8 years;

Age more than 75 years, Renal transplant patients; patients enrolled in a conflicting research study

Ethical approval This is a prospective observational study that did not evaluate a specific therapeutic or prophylactic intervention. Institutional ethical approval will be taken according to our institution's guidelines. Informed consent will be obtained from each participant before enrollment.

Patient Treatment Clinical practice was not changed or modified for study purposes. No special treatment in an attempt to prevent AKI was applied. Patients will be intra-operatively hemodynamic ally monitored. Postoperatively in the intensive care unit (ICU), Urine output will be maintained at 0.5 to 1 mL kg1 h1 by using fluids or furosemide, mannitol if necessary. Renal replacement therapy will be initiated if the patient fulfilled at least 1 of the following clinical criteria: oliguria (urine output <100 mL for >6 hrs) that has been unresponsive to fluid resuscitation measures, hyperkalemia ([K+] >6.5 mmol/L), severe acidemia (pH <7.2), or clinically significant organ edema (eg, lung) in the setting of renal failure.