A comparison of observed versus estimated baseline creatinine for determination of RIFLE class in patients with acute kidney injury.
BACKGROUND
The RIFLE classification scheme for acute kidney injury (AKI) is based on relative changes in serum creatinine (SCr) and on urine output. The SCr criteria, therefore, require a pre-morbid baseline value. When unknown, current recommendations are to estimate a baseline SCr by the MDRD equation. However, the MDRD approach assumes a glomerular filtration rate of approximately 75 mL/min/1.73 m(2). This method has not been validated.


METHODS
Data from the Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study, a prospective observational study from 54 ICUs in 23 countries of critically ill patients with severe AKI, were analysed. The RIFLE class was determined by using observed (o) pre-morbid and estimated (e) baseline SCr values. Agreement was evaluated by correlation coefficients and Bland-Altman plots. Sensitivity analysis by chronic kidney disease (CKD) status was performed.


RESULTS
Seventy-six percent of patients (n = 1327) had a pre-morbid baseline SCr, and 1314 had complete data for evaluation. Forty-six percent had CKD. The median (IQR) values were 97 micromol/L (79-150) for oSCr and 88 micromol/L (71-97) for eSCr. The oSCr and eSCr determined at ICU admission and at study enrolment showed only a modest correlation (r = 0.49, r = 0.39). At ICU admission and study enrolment, eSCr misclassified 18.8% and 11.7% of patients as having AKI compared with oSCr. Exclusion of CKD patients improved the correlation between oSCr and eSCr at ICU admission and study enrolment (r = 0.90, r = 0.84) resulting in 6.6% and 4.0% being misclassified, respectively.


CONCLUSIONS
While limited, estimating baseline SCr by the MDRD equation when pre-morbid SCr is unavailable would appear to perform reasonably well for determining the RIFLE categories only if and when pre-morbid GFR was near normal. However, in patients with suspected CKD, the use of MDRD to estimate baseline SCr overestimates the incidence of AKI and should not likely be used. Improved methods to estimate baseline SCr are needed.
Bagshaw
Sean M
SM
Department of Intensive Care, Austin & Repatriation Medical Centre, Melbourne, Australia. bagshaw@ualberta.ca
Uchino
Shigehiko
S
Cruz
Dinna
D
Bellomo
Rinaldo
R
Morimatsu
Hiroshi
H
Morgera
Stanislao
S
Schetz
Miet
M
Tan
Ian
I
Bouman
Catherine
C
Macedo
Etienne
E
Gibney
Noel
N
Tolwani
Ashita
A
Oudemans-van Straaten
Heleen M
HM
Ronco
Claudio
C
Kellum
John A
JA
D000208:Acute Disease; D058186:Acute Kidney Injury / Q000097:blood* / Q000145:classification / Q000175:diagnosis; D000368:Aged; D015331:Cohort Studies; D003404:Creatinine / Q000097:blood*; D016208:Databases, Factual; D005260:Female; D006801:Humans; D007668:Kidney / Q000293:injuries* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies
D003404:Creatinine