The RIFLE and AKIN Classifications for Acute Kidney Injury

8/9/2019 The RIFLE and AKIN Classifications for Acute Kidney Injury

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The RIFLE and AKIN classifications foracute kidney injury: a critical and

comprehensive revie 1. José António Lopes and2. Sofa Jorge

+Author Afliations1. Department o Nephrology and Renal Transplantation, Hospital de Santa Maria,

Centro Hospitalar de is!oa Norte, "#", is!oa, #ortugal

1. Correspondence and ofprint requests to: $os% Ant&nio opes' "(mail) *alopes+-hotmail.om

• Reei/ed Septem!er 1, 010.

• Aepted 2to!er 13, 010.

Ne4t Setion

Abstract

5n May 06, a ne7 lassi8ation, the R59" :Ris;, 5n*ury, 9ailure, oss o ;idneyuntion, and "nd(stage ;idney disease< lassi8ation, 7as proposed in order tode8ne and stratiy the se/erity o aute ;idney in*ury :A=5or urineoutput, and it has !een largely demonstrated that the R59" riteria allo7s theidenti8ation o a signi8ant proportion o A=5 patients hospitali?ed in numeroussettings, ena!les monitoring o A=5 se/erity, and is a good preditor o patientoutome. Three years later :Marh 0@


2/18

Multiple de8nitions or A=5 ha/e o!/iously led to a great disparity in the reportedinidene o A=5 ma;ing it difult or e/en impossi!le to ompare the /ariouspu!lished studies ousing on A=5 J@E. Thereore, it !eame ruial to esta!lish aonsensual and aurate de8nition o A=5 that ould ideally !e used 7orld7ide.#re/ious SetionNe4t Setion

The RIFLE classification

5n May 00, the Aute Dialysis Kuality 5nitiati/e :ADK5< group or the study o A=5,omposed o nephrologists and intensi/ists, ame together o/er 0 days in aonerene in Lien?a :5taly#monhs

•aP9R, glomerular 8ltration rate' 2, urine output' SCr, serum reatinine.

Table 1.

http://ckj.oxfordjournals.org/content/6/1/8.full#ref-3http://ckj.oxfordjournals.org/content/6/1/8.full#ref-7http://ckj.oxfordjournals.org/content/6/1/8.full#sec-1http://ckj.oxfordjournals.org/content/6/1/8.full#sec-6http://ckj.oxfordjournals.org/content/6/1/8.full#ref-8http://ckj.oxfordjournals.org/content/6/1/8.full#T1http://ckj.oxfordjournals.org/content/6/1/8.full#ref-3http://ckj.oxfordjournals.org/content/6/1/8.full#ref-7http://ckj.oxfordjournals.org/content/6/1/8.full#sec-1http://ckj.oxfordjournals.org/content/6/1/8.full#sec-6http://ckj.oxfordjournals.org/content/6/1/8.full#ref-8http://ckj.oxfordjournals.org/content/6/1/8.full#T1


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Ris;, 5n*ury, 9ailure, oss o ;idney untion and "nd(stage ;idney disease :R59"<lassi8ation 3Ea

The temporal pattern o the SCr and>or 2 /ariation is also rele/ant or de8ning A=5)the deterioration o renal untion must !e sudden :1J@ days< and sustained:persisting Q06 h1.@m0.

!tren"ths and limitations of the RIFLE classification

Strengths of the RIFLE classification

R59" has !een largely /alidated in terms o determining the inidene o A=5 and itsprognosti strati8ation in se/eral settings o hospitali?ed patients 1J0E.

5n these studies, R59" ailitated the identi8ation o a large proportion o A=5patients and there 7as an independent and step7ise inrease in mortality as A=5se/erity inreased' R59" also e4hi!ited a good prognosti auray in terms omortality : Ta!le 0


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Setting N Design CriteriaIncidence(%)

Mortality (%/relativerisk) AUROC

F )2, F )8S,

:uiun"n et al. 41 ;1#@ros"-i"7 sing!"-"nr" Cr7 3

8o 9:I );1,R )11,

I )#,F )5,

0+y mor!iy

8o 9:I )0.,R );.0/8S,

I )21.*/8S,F )#2.5/8S, 0.;2*

Lin et al. 41@ *6

R"ros"-i"7 sing!"

-"nr" Cr7 3

8o 9:I )22,

R )15,I )#,

F )2*,

=osi! mor!iy

8o 9:I )25,

R )5$/5.#,I )$2/10.*,

F )100/Ininiy, 0.;6;

Aortic arch surgery

9rnoukis et al.

413 26$

R"ros"-i"7 sing!"

-"nr" Cr7 GFR

8o 9:I )52,

R )20,I )12,

F )16,

#0+y mor!iy8o 9:I )#,

R )/8S,I )12/8S,

F )#;/8S, 8S

Cirrhosis

B"n et al. 41+ 1#*

@ros"-i"7 sing!"

-"nr" Cr7 3

8o 9:I )*0,

R )12,I )5,

F )*#,

=osi! mor!iy8o 9:I )#2.1,

R )6;.;/*.$,I )$1.*/5.#,

F )*/#;.;, 0.;#$

Liver Transplantation

DRior+n et al. 40 *

R"ros"-i"7 sing!"

-"nr" #5

8o 9:I )8S,

R )8S,

I )11.1,

F )25.$,

#0+y mor!iy8o 9:I )8S,

R )8S,

I );.;/8S,

F )2#.$/2.;, 8S

1y"r mor!iy

8o 9:I )8S,R )8S,

I )2#.5/8S,

F )52.5/2.6, 8S

Sepsis

Lo"s et al. 401 1;2

R"ros"-i"7 sing!"

-"nr" 8S

8o 9:I )62,R )6,

I )12,

F )20,

60+y mor!iy

8o 9:I ).6,R )2$.#/8S,

I )2;.6/8S,

F )55/#.6, 0.$50

Ch"n et al. 400 121

R"ros"-i"7 sing!"

-"nr" Cr

8o 9:I )**,

R )26,I )16,

F )20,

=osi! mor!iy

8o 9:I )#*,

R )*0.0/1.#,I )$#.$/5.*,

F )$6.5/6.#, 0.6$;

Burn

Lo"s et al. 40 126

R"ros"-i"7 sing!"

-"nr" 8S

8o 9:I )6*,

R )1*,I ),

F )1#,

=osi! mor!iy8o 9:I )6,

R )11.1/5.6,I )6#.6/6.2,

F )$5/8S, 0.;#*

HIV

Lo"s et al. 406 $

R"ros"-i"7 sing!"

-"nr" 8S

8o 9:I )5#,

R )12,I ),

F )26,

60+y mor!iy8o 9:I )2#.5,

R )50/8S,I )66.6/5.1,

F )$2/*.6, 0.$#2

Traua

Agsh et al. 40 **

R"ros"-i"7 mu!i

-"nr" Cr7 3

8o 9:I );1.,

R ).*,

I )$.2,

F )1.5,

=osi! mor!iy8o 9:I )$.;,

R )16/1.$,

I )15./1.,

F )2*.$/2.#, 8S


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Setting N Design CriteriaIncidence(%)

Mortality (%/relativerisk) AUROC

HCT

Lo"s et al. 40 ;2

R"ros"-i"7 sing!"

-"nr" Cr7 GFR

8o 9:I )*6,R )1#,

I )2*,

F )1$,

5y"r mor!iy8o 9:I )#2.,

R )**.*/1.62,

I E F )66.$/1.6*, 8S

•aAR2C, area under the reei/er operating harateristi' Cr, reatinine' P9R,

glomerular 8ltration rate' A=5, aute ;idney in*ury' R, ris;' 5, in*ury' 9, ailure' NS,nonspei8ed' 5C, intensi/e are unit' 2, urine output' H5L, humanimmunode8ieny /irus' HCT, haematopoieti ell transplantation.

•!R as the reerene.

Table 2.

5nidene and ategori?ation o A=5 and its assoiation 7ith mortalitya

2riginally, the R59" riteria 7as esta!lished to standardi?e the de8nition andstrati8ation o A=5 se/erity. Se/eral studies, ho7e/er, ha/e determined the a!ility othe R59" in prediting mortality using the area under the reei/er operatingharateristi :AR2C< ur/e, and some o them ha/e inlusi/ely ompared it 7ith

other general or spei8 soring systems 1, 1@, 01, 0, 06, 0@, 03E. Ta;ing intoaount that the R59" relies only on renal untion it 7ould !e onei/a!le that theR59" prognosti apaity 7as inerior to that o other general sores :i.e. Aute#hysiology and Chroni Health "/aluation, Simpli8ed Aute #athophysiology Sore


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i. Sensiti/ity and spei8ity o 2 an !e signi8antly hanged !y the use odiuretis, and this issue is not spei8ally onsidered in the R59"lassi8ation'

ii. the 2 an only !e determined in patients 7ith a !ladder atheter inplae, 7hih, despite !eing ommon in 5C patients, is not reuent in other

hospitali?ed patients'iii. 5t is possi!le that the prediti/e a!ility o 2 ould !e inerior to that o

SCr, 7hih an e4plain the diBerene in terms o mortality !et7een the samelasses de8ned !y eah one o those riteria, o!ser/ed in studies that utili?ed!oth riteria to de8ne and lassiy A=5 11, 1, 6E. The apaity o the R59":using !oth riteria< to predit mortality an !e more sta!le than the a!ility othis lassi8ation employing only SCr 1E, 7hih orro!orates the linialutility o using simultaneously !oth riteria as proposed !y the ADK5 7or;group 3E.

9ith, the aetiology o A=5 and the reuirement or RRT are not onsidered in the R59"lassi8ation. 5n t7o studies that e/aluated 5C patients 7ith A=5 reuiringontinuous RRT, the R59" lassi8ation sho7ed less auity in prediting mortality

, E. 2ne possi!le e4planation or this phenomenon is that in !oth the studies,the linial se/erity o patients 7as so high that it ould not allo7 R59" todisriminate mortality aording to A=5 se/erity :i.e. !et7een the three lasses


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!aseline /alue;g>h ormore than hstaging system o aute ;idney in*ury 6Ea

Stage SCr UO

1↑ SCr '26.5 (mo!/L )'0.# mg/+L, or ↑SCr '150 200%

)1.5 2×, 6 h,

2 ↑ SCr >200 #00% )>2 #×, 12 h,

#!↑ SCr >#00% )>#×, or i &s"!in" SCr '#5#.6 (mo!/L )'*

mg/+L, ↑SCr '**.2 (mo!/L )'0.5 mg/+L,


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Setting

Incidence andcategoriation o!

A"I (%)

Mortality (%/relative

risk) AUROC

N Design RIF#$ A"I RIF#$ A"I RIF#$ A"I

F )1;.1,

Sg" 2

)10.1,Sg" #

)1.2,

)*1.#/2.;,

R )#0./2.$,I )#2.;/2.0,

F )55/#.6,

)#.;/#.6,

Sg" 1

)#0.$/#.5,Sg" 2

)#2.;/2.$,Sg" #

)5#.5/#.6,

Lssnigg et al.41 $.2*1 @ros"-i"7mu!i-"nr"

9:I )ny

-!ss,

)#.0,

R )2.2,

I )0.6,F )0.2,

9:I )nysg",

);.2,Sg" 1

)6.*,

Sg" 2

)0.0*,

Sg" #)1.;,

#0+ymor!iy

8o 9:I )#.6,9:I )ny

-!ss,

)2$.5/8S,

R )2/8S,

I )1/8S,F )##/8S,

#0+y

mor!iy

8o 9:I )2.;,

9:I )nysg",

)2#.1/8S,Sg" 1

)16.*/8S,

Sg" 2

)66.$/8S,

Sg" #)#;.2/8S, 8S 8S

Bonni+is et al.

40 16.$;*

R"ros"-i"7mu!i

-"nr"

9:I )ny

-!ss,

)#5.5,

R )$.6,I )11.1,

F )16.;,

9:I )ny

sg",

)2;.5,

Sg" 1

)$.5,

Sg" 2

)$.2,Sg" #

)1#.;,

=osi!

mor!iy

8o 9:I )1#.6,

9:I )ny

-!ss,)#6.5/

8S,

R )2.2/1.*,I )#2.#/1.,

F )*2.6/#.0,

=osi!

mor!iy8o 9:I )15.,

9:I )ny

sg",

)#6.*/8S,

Sg" )1

#*.5/2.0,

Sg" )2

2/1.,Sg" )#

*1.2/#.0, 8S 8S

s"rmmnn e

t al. 4 *1.1$2

R"ros"-i"7mu!i

-"nr"

9:I )ny

-!ss,)#5.,

R )1$.2,

I )11,

F )$.6,

9:I )ny

sg",

)#5.*,Sg" 1

)1.1,Sg" 2

)#.;,

Sg" #

)12.5,

=osi!

mor!iy

8o 9:I )8S,9:I )ny

-!ss,)#6.1/8S,

R )20./1.*,

I )*5.6/1.,

F )56.;/1.6,

=osi!

mor!iy8o 9:I )8S,

9:I )ny

sg",

)*0.*/8S,Sg" 1

)2./0.;,Sg" 2

)#5.;/1.1,

Sg" #

)5$./2.01, 0.;$ 0.;*0

Cardiac surgery

=s" et al.

46 2;2@ros"-i"7sing!"-"nr"

9:I )ny-!ss,

)*5.;0R )#0.1,

I )12.1,F )#.5,

9:I )ny

sg",

)**.$,

Sg" 1)##.$,

Sg" 2)6.$,

Sg" #)*.#,

=osi!

mor!iy

8o 9:I )0,

9:I )ny-!ss,

)*.$/8S,R )1.2/8S,

I );.;/8S,F )20/8S,

=osi!

mor!iy

8o 9:I )0,

9:I )ny

sg",

)*.;/8S,

Sg" 1)1.1/8S,

Sg" 2)0/8S,

Sg" #)*1.$/8S, 0.10 0.*0

ng!&"rg"r et

al. 4

*.;#6 R"ros"-i"7sing!"

-"nr"

9:I )ny

-!ss,

)1;.,R )1*.;,

I )#.5,F )0.6*,

9:I )ny

sg",

)26.#,Sg" 1

)2#.6,Sg" 2

)1.2,

Sg" #

=osi!

mor!iy

8o 9:I )0.6*,9:I )ny

-!ss, )$/*.5,R )#.;/8S,

I )1;.#/8S,

F )1.*/8S,

=osi!

mor!iy

8o 9:I )0.5#,9:I )ny

sg",)$.$/5.#,

Sg" 1

)2.6/8S,

0.;00 0.;20


9/18

Setting

Incidence andcategoriation o!

A"I (%)

Mortality (%/relative

risk) AUROC

N Design RIF#$ A"I RIF#$ A"I RIF#$ A"I

)1.5,

Sg" 2

)12.#/8S,

Sg" #)**.6/8S,

Ro&"r et al.

4 2*.$*$

@ros"-i"7sing!"

-"nr"

9:I )ny-!ss,

)#1.2,R )21.$,

I )5.,

F )#.6,

9:I )ny

sg",

)2.,

Sg" 1)22.,

Sg" 2)#.*,

Sg" #

)#.6,

=osi!

mor!iy

8o 9:I )1.*,

9:I )ny-!ss,

).;/8S,R )#.#/2.*0,

I )11.1/;.,

F )#6.*/*0.,

=osi!

mor!iy

8o 9:I )1.#,

9:I )ny

sg",

).1/8S,

Sg" 1)*.1/#.2,

Sg" 2)1*.2/12.*,

Sg" #

)#6.;/*#.;, 0.$;0 0.$0

•aA=5, aute ;idney in*ury' AR2C, area under the reei/er operating

harateristi' 5C, intensi/e are unit' R59", Ris; 5n*ury 9ailure oss o ;idneyuntion "nd(stage ;idney disease' A=5N' Aute =idney 5n*ury Net7or;' R, ris;' 5,in*ury' 9, ailure' NS, non(spei8ed.Table 4.

Comparison !et7een R59" and A=5N lassi8ations in terms o inidene andategori?ation o A=5 and its assoiation 7ith mortalitya

!tren"ths and limitations of the AKIN classification

The A=5N lassi8ation is a modi8ed /ersion o the R59" lassi8ation' thereore,their strengths and limitations are /ery similar to those aorementioned or the R59". The A=5N lassi8ation has, ho7e/er, some additional !ene8ts and limitations relatedto the modi8ations introdued to the R59" lassi8ation.

Strengths of the AKIN classification

9irst, the A=5 de8nition is only onsidered ater an adeuate status o hydration isahie/ed. Thereore, the A=5N lassi8ation, unli;e R59", adds important aetiologialinormation. Seond, the A=5N lassi8ation is !ased on SCr and not on P9R hanges. Third, the A=5N lassi8ation does not need !aseline SCr to de8ne A=5, although itreuires at least t7o SCr determinations 7ithin 63 h.

Limitations of the AKIN classification

9irst, the A=5N lassi8ation does not allo7 the identi8ation o A=5 7hen SCr

ele/ation ours in a time rame higher than 63 h. Seond, Stage o the A=5Nlassi8ation inludes three diagnosti riteria :Cr, 2 and RRT reuirement


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lassiying A=5, suh as the use :or non(use< o 2 and !aseline SCr, and o theestimated P9R instead o the /ariation in SCr.

The =idney Disease 5mpro/ing Plo!al 2utomes 7or; group reently om!ined theR59" and A=5N lassi8ations in order to esta!lish one lassi8ation o A=5 orpratie, researh and pu!li health. Thereore, A=5 has !een de8ned as an inrease

in SCr U. mg>d :U0. Fmol>< 7ithin 63 h' or an inrease in SCr to U1. times!aseline, 7hih is ;no7n or presumed to ha/e ourred 7ithin the prior @ days or aurine /olume o . m>;g>h or h. 9urthermore, A=5 has !een staged in se/erityaording to the A=5N riteria :Ta!le d :Q6 Wmol>d :U66Wmol>< o/er an unspei8ed time period, it instead reuire that the patient 8rstahie/e the reatinine(!ased hange spei8ed in the de8nition either U. mg>d:U0. Wmol>< 7ithin a 63(h time 7indo7 or an inrease o U1. times !aselineE. This hange !rings the de8nition and staging riteria to greater parity and simpli8esthe riteria @E. The integration o the ne7 !iomar;ers o A=5 into the liniallassi8ation ould inrease the sensiti/ity and spei8ity o A=5 diagnosis,

o/er7helming some o the limitations o the traditional mar;ers o ;idney untion,suh as Cr and 2 3E.#re/ious SetionNe4t Setion

#onflict of interest state$ent

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