Editorial
Usefulness and need for standardized criteria in diagnosing acute renal dysfunction in critical patients
Necesidad y utilidad del empleo de criterios estandarizados para el diagnóstico de la disfunción renal aguda en pacientes críticos
V. Barrio
Servicio de Nefrología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain
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Piacentini, R. Ferrer" "autores" => array:2 [ 0 => array:2 [ "nombre" => "E." "apellidos" => "Piacentini" ] 1 => array:2 [ "nombre" => "R." "apellidos" => "Ferrer" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173572712000719?idApp=WMIE" "url" => "/21735727/0000003600000004/v1_201212101018/S2173572712000719/v1_201212101018/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Usefulness and need for standardized criteria in diagnosing acute renal dysfunction in critical patients" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "247" "paginaFinal" => "249" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "V. Barrio" "autores" => array:1 [ 0 => array:3 [ "nombre" => "V." "apellidos" => "Barrio" "email" => array:1 [ 0 => "vbarriol@senefro.org" ] ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Servicio de Nefrología, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Madrid, Spain" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Necesidad y utilidad del empleo de criterios estandarizados para el diagnóstico de la disfunción renal aguda en pacientes críticos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the year 2004, publication was made of the recommendations of the Acute Dialysis Quality Initiative (ADQI), developed by a group of intensivists and nephrologists for diagnosis and risk stratification in acute renal dysfunction (ARD) according to the RIFLE criteria.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> These criteria comprise three levels of dysfunction (risk, injury and failure) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>), in accordance to the magnitude of the increase in serum creatinine (Crs) or the decrease in estimated glomerular filtration (eGF) and urine volume, and two outcome measures (loss and end-stage renal disease), according to the dependence upon renal replacement therapy (RRT).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The RIFLE criteria have been validated with respect to mortality in many studies, with a progressive increase in risk parallel to the rise in degree of ARD.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, they also have important limitations, such as the need for a previous Crs determination in order to assess the change, a lack of correspondence between serum creatinine and glomerular filtration due to the open hyperbolic relationship between these two variables, the time delay in Crs elevation—with the consequent possibility of erroneously stratifying the patient on the RIFLE scale—and particularly the absence of equivalence in terms of vital prognosis between the two components of the definition with equal weighting (only one having to be met in order to be stratified). In effect, while the Crs criterion is a potent marker of mortality in the ICU, the same cannot be said of the urine volume (diuresis) criterion.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Because of these limitations, in 2007 the Acute Kidney Injury Network (AKIN) proposed a revision of the diagnostic criteria and severity classification based on a modification of the RIFLE criteria for acute renal failure (ARF),<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> along with a change in nomenclature to replace ARF with “acute renal dysfunction” (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The diagnostic criteria include a time profile (<48<span class="elsevierStyleHsp" style=""></span>h), contemplate the Crs elevation (>50%) and urine volume (diuresis) reduction criteria (<0.5<span class="elsevierStyleHsp" style=""></span>ml/h<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>h) of the RIFLE risk stratification, and add an absolute Crs increment (>0.3<span class="elsevierStyleHsp" style=""></span>mg/dl)—since epidemiological studies have shown such small Crs elevations to be independent predictors of mortality, mean hospital stay and cost.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Furthermore, these diagnostic criteria would only be applicable after optimizing extracellular volume status and discarding obstruction, if only the diuresis criterion is used. Stages 2 and 3 only define more severe degrees of ARD according to Crs elevation and/or diuresis reduction criteria. However, compared with the RIFLE system, adoption of the AKIN classification does not substantially improve the sensitivity and early predictability of ARD in patients admitted to the ICU,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> since it remains dependent upon surrogate variables of renal injury that manifest relatively late and which do not reflect the nature or location of the injury.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In any case, the adoption of these definitions and standardizations of the severity of ARD has represented an important advance when it comes to comparing epidemiological incidence data in different places and circumstances, and to using them as outcome variables in clinical intervention or prevention studies. In turn, a significant observation is the important clinical impact exerted by even small changes in Crs concentration, with the advised consideration of drug dose adjustment in these patients.</p><p id="par0025" class="elsevierStylePara elsevierViewall">For all these reasons, the findings of the COFRADE study, published in this issue of <span class="elsevierStyleItalic">Medicina Intensiva</span>,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> come as a surprise. This study reflects the data of a survey of 42 ICUs with 836 beds in 32 hospitals throughout Spain, and contains clear screening bias due to the participation of ICUs which have a special interest in ARD—as evidenced by their participation for a number of years in the FRAMI study on the incidence of ARD among critical patients in our setting.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The main results of the study show the estimation of glomerular filtration to be based on Crs in 37% of the Units, minute clearance in 42%, and equations in 22%—when in fact it has been clearly demonstrated that these approaches are of little use in this population of critical patients with ARD.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> Furthermore, only 39% of the ICUs use ARD defining and risk stratification systems (RIFLE in 13 and AKIN in 3). In contrast, 64% of the Units follow written protocols for the management of RRT, 71% have adopted training programs in RRT, and 54% follow some drug dose adjustment method in patients subjected to RRT.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on the conclusions and recommendations of Herrera-Gutie¿rrez et al., from here we stress the need for a change in strategy for addressing ARD in the ICU with the incorporation of the RIFLE and AKIN criteria to routine clinical practice, with the purpose of promoting the early detection of ARD and thus being able to establish secondary prevention protocols to limit the damage and improve patient safety, avoiding drug dosing errors. All this applies while we await the development of new and more sensitive and specific biomarkers<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> than those used to date by the ADQI and AKIN conferences (i.e., Crs and diuresis) for diagnosis and risk stratification in ARD.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Barrio V. Necesidad y utilidad del empleo de criterios estandarizados para el diagnóstico de la disfunción renal aguda en pacientes críticos. Med Intensiva. 2012;36:247–9.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Crs: serum creatinine; GF: glomerular filtration; RRT: renal replacement therapy.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">GF criterion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urine volume (diuresis) criterion \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>1.5 over baseline and/or reduction of GF 25% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.5<span class="elsevierStyleHsp" style=""></span>ml/kg/h in 6<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>2 over baseline and/or reduction of GF 50% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.5<span class="elsevierStyleHsp" style=""></span>ml/kg/h in 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>3 over baseline and/or reduction of GF 75% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.3 ml/kg/h in 24<span class="elsevierStyleHsp" style=""></span>h or anuria 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for RRT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>4 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">End-stage renal disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Need for RRT<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>3 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab8605.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">RIFLE criteria for diagnosis and risk stratification in acute renal dysfunction.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Crs: serum creatinine.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Stage \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Crs criterion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Urine volume (diuresis) criterion \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>0.3<span class="elsevierStyleHsp" style=""></span>mg/dl (26.4<span class="elsevierStyleHsp" style=""></span>μmol/l) or 1.5- to 2-fold increase over baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.5<span class="elsevierStyleHsp" style=""></span>ml/kg/h in 6<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs 2- to 3-fold over baseline \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.5<span class="elsevierStyleHsp" style=""></span>ml/kg/h in 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Increase in Crs<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>3-fold over baseline or Crs<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>4.0<span class="elsevierStyleHsp" style=""></span>mg/dl (>354<span class="elsevierStyleHsp" style=""></span>μmol/l) with an increase of at least 0.5<span class="elsevierStyleHsp" style=""></span>mg/dl (44<span class="elsevierStyleHsp" style=""></span>μmol/l) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.3<span class="elsevierStyleHsp" style=""></span>ml/kg/h in 24<span class="elsevierStyleHsp" style=""></span>h or anuria 12<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab8606.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AKIN criteria for diagnosis and risk stratification in acute renal dysfunction.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute renal 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| Year/Month | Html | Total | |
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| 2024 November | 8 | 16 | 24 |
| 2024 October | 33 | 46 | 79 |
| 2024 September | 40 | 32 | 72 |
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| 2024 May | 37 | 23 | 60 |
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| 2023 October | 21 | 29 | 50 |
| 2023 September | 28 | 38 | 66 |
| 2023 August | 19 | 12 | 31 |
| 2023 July | 40 | 31 | 71 |
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