Background
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. [1, 2, 3, 4] Despite a broad consensus of support, however, the nephrology community continues to point out the shortcomings of these classification systems. [5]
For more information, see Acute Kidney Injury and Acute Tubular Necrosis
RIFLE Classification
In 2002, the Acute Dialysis Quality Initiative (ADQI) was created with the primary goal of developing consensus and evidence-based guidelines for the treatment and prevention of acute kidney injury (AKI). The first order of business was to create a uniform, accepted definition of AKI; hence, the RIFLE criteria were born (see the table below). RIFLE is an acronym of Risk, Injury, and Failure; and Loss; and End-stage kidney disease.Table 1. RIFLE Classification System for Acute Kidney Injury [6]
Table. (Open Table in a new window)
Stage |
GFRa Criteria |
UOb Criteria |
Risk |
SCrc increased 1.5-2 times baseline or GFR decreased >25% |
UO < 0.5 mL/kg/h < 6 h |
Injury |
SCr increased 2-3 times baseline or GFR decreased >50% |
UO < 0.5 mL/kg/h >12 h |
Failure |
SCr increased >3 times baseline or GFR decreased 75% or SCr ≥4 mg/dL; acute rise ≥0.5 mg/dL |
UO < 0.3 mL/kg/h 24 h (oliguria) or anuria 12 h |
Loss of function |
Persistent acute renal failure: complete loss of kidney function >4 wk (requiring dialysis) |
|
ESRDd |
Complete loss of kidney function >3 mo (requiring dialysis) |
|
a GFR = glomerular filtration rate. b UO = urine output. c SCr = serum creatinine. d ESRD = end-stage renal disease. Note: Patients can be classified either by GFR criteria or by UO criteria. The criteria that support the most severe classification should be used. The superimposition of acute on chronic failure is indicated with the designation RIFLE-FC; failure is present in such cases even if the increase in SCr is less than 3-fold, provided that the new SCr is greater than 4 mg/dL (350 μmol/L) and results from an acute increase of at least 0.5 mg/dL (44 μmol/L). When the failure classification is achieved by UO criteria, the designation of RIFLE-FO is used to denote oliguria. The initial stage, "risk," has high sensitivity; more patients are classified in this mild category, including some who do not actually have renal failure. Progression through the increasingly severe stages of RIFLE is marked by decreasing sensitivity and increasing specificity. |
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A study to assess RIFLE urine output criteria based on creatinine concentrations for the development of contrast-induced acute kidney injury (CA-AKI) in intensive care (ICU) patients found low predictive value. The authors concluded that there was limited use for assessing the effects of therapeutic interventions on the development and progression of AKI in this population. [7]
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]). [8]
A report by the AKIN proposed the following criteria for AKI [8, 9] :
-
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. [10]
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. [11]
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
he KDIGO has also recommended a staging system for the severity of the AKI.
The KDIGO consensus classification has yet to be validated.
Table 2. KDIGO Staging for AKI Severity (Open Table in a new window)
Stage |
Serum Creatinine |
Urine Output |
1 |
1.5-1.9 times baseline or ≥0.3 mg/dL increase |
< 0.5 mL/kg/h for 6 h |
2 |
2-2.9 times baseline |
< 0.5 mL/kg/h for 12 h |
3 |
3 times baseline or Increase in serum creatinine to ≥4 mg/dL or Initiation of renal replacement therapy |
< 0.3 mL/kg/h for 24 h or Anuria for ≥12 h |
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 [12] :
-
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
In a comparison of RIFLE, AKIN, and KDIGO in 303 consecutive patients admitted to a medical intensive care unit of a tertiary university hospital, the calculated incidence of AKI was similar with all three systems (47.9 %, 44.6%, and 50.2%; respectively). The three systems had similar abilities to predict in-hospital mortality. [13]
Questions & Answers
Overview
What is acute kidney injury (AKI)?
What are the RIFLE criteria for acute kidney injury (AKI)?
What is the AKIN classification system for acute kidney injury (AKI)?
What are the AKIN criteria for acute kidney injury (AKI)?
How do the AKIN criteria differ from the RIFLE criteria for acute kidney injury (AKI)?
What are the KDIGO criteria of acute kidney injury (AKI)?
Tables
Stage |
GFRa Criteria |
UOb Criteria |
Risk |
SCrc increased 1.5-2 times baseline or GFR decreased >25% |
UO < 0.5 mL/kg/h < 6 h |
Injury |
SCr increased 2-3 times baseline or GFR decreased >50% |
UO < 0.5 mL/kg/h >12 h |
Failure |
SCr increased >3 times baseline or GFR decreased 75% or SCr ≥4 mg/dL; acute rise ≥0.5 mg/dL |
UO < 0.3 mL/kg/h 24 h (oliguria) or anuria 12 h |
Loss of function |
Persistent acute renal failure: complete loss of kidney function >4 wk (requiring dialysis) |
|
ESRDd |
Complete loss of kidney function >3 mo (requiring dialysis) |
|
a GFR = glomerular filtration rate. b UO = urine output. c SCr = serum creatinine. d ESRD = end-stage renal disease. Note: Patients can be classified either by GFR criteria or by UO criteria. The criteria that support the most severe classification should be used. The superimposition of acute on chronic failure is indicated with the designation RIFLE-FC; failure is present in such cases even if the increase in SCr is less than 3-fold, provided that the new SCr is greater than 4 mg/dL (350 μmol/L) and results from an acute increase of at least 0.5 mg/dL (44 μmol/L). When the failure classification is achieved by UO criteria, the designation of RIFLE-FO is used to denote oliguria. The initial stage, "risk," has high sensitivity; more patients are classified in this mild category, including some who do not actually have renal failure. Progression through the increasingly severe stages of RIFLE is marked by decreasing sensitivity and increasing specificity. |
||
Stage |
Serum Creatinine |
Urine Output |
1 |
1.5-1.9 times baseline or ≥0.3 mg/dL increase |
< 0.5 mL/kg/h for 6 h |
2 |
2-2.9 times baseline |
< 0.5 mL/kg/h for 12 h |
3 |
3 times baseline or Increase in serum creatinine to ≥4 mg/dL or Initiation of renal replacement therapy |
< 0.3 mL/kg/h for 24 h or Anuria for ≥12 h |
