New Criterion to Evaluate Acute-on-Chronic Kidney Injury Based on the Creatinine Reference Change

Abstract

Background: The lack of consensus criteria of acute on chronic kidney injury (ACKI) affects the judgment for its clinical prognosis. Methods: In this study, we analyzed the data from 711,615 hospitalized adults who had at least 2 serum creatinine (SCr) tests within 30 days. We estimated the reference change value (RCV) of SCr given initial SCr level in adults without known risks of acute kidney injury other than chronic kidney disease (CKD). We proposed a criterion for ACKI based on the RCV of SCr (cROCK), which defined ACKI as a ≥25% increase in SCr in 7 days. We validated cROCK by its association with the risks of in-hospital mortality, death after discharge, and CKD progression in a large cohort of patients Xu et al. with CKD stage 3. Results: In 21,661 patients with CKD stage 3, a total of 3,145 (14.5%), 1,512 (7.0%), and 221 (1.0%) ACKI events were detected by both cROCK and Kidney Disease Improving Global Outcomes (KDIGO), cROCK only, and KDI-GO only, respectively. cROCK detected 40% more ACKI events than KDIGO. Compared with patients without ACKI by both definitions, those with cROCK-but not KDIGO-defined ACKI had a significantly increased risk of in-hospital mortality (hazard ratio [HR] 5.53; 95% CI 3.75-8.16), death after discharge (HR 1.51; 95% CI 1.21-1.83), and CKD progression (OR 5.65; 95% CI 3.05-10.48). Conclusions: RCVbased criterion (cROCK) for ACKI is clinically valid in that it has a substantially improved sensitivity in identifying patients with high risk of adverse outcomes.

Acute kidney injury in hospitalized adults with chronic kidney disease: comparing cROCK, KDIGO, and combined criteria

“…An ideal AKI definition might have the following features: 1) limited complexity, 2) diagnosis associated with short- or long-term outcomes, 3) high diagnostic accuracy with high sensitivity and specificity, and 4) relatively low cost of diagnosis [ 15 ]. The cROCK criteria were designed based on data from a large-scale multicenter study cohort of Chinese hospitalized adult patients, and a significant proportion of these participants was adult CKD patients with initial eGFR of ≤60 mL/min/1.73 m 2 [ 10 ]. Theoretically, the cROCK criteria might be more suitable than the KDIGO criteria for AKI detection in Chinese CKD patients, and the combination of cROCK and KDIGO criteria might perform even better than a single AKI criterion.…”

“…It has been proven that even a mild increase of 25% in sCr level was associated with a 70% increase in mortality [ 9 ]. Xu et al [ 10 ] set up a reference change value (RCV) of the sCr optimized criteria for AKI in CKD (cROCK) based on data from 344,694 Chinese hospitalized adults, including 27,303 CKD patients with baseline estimated glomerular filtration rate (eGFR) of ≤60 mL/min/1.73 m 2 . The cROCK criteria are defined as a >25% increase of sCr over 7 days.…”

“…The cROCK criteria are defined as a >25% increase of sCr over 7 days. Compared to the most popular KDIGO criteria, the cROCK criteria has been confirmed to improve the sensitivity in identifying patients with high risk of CKD progression in 90 days after admission, based on data from 2,383 CKD patients [ 10 ].…”

Epidemiology and outcomes of post-AKI proteinuria

“…The rates of AKI recovery stratified by new-onset and worsening proteinuria after AKI were assessed by interval censoring, with comparisons by log-rank tests. We were unable to obtain the exact timing of kidney disease progression, which was very dependent on the frequency of creatinine tests the patient had, thus the associations of new-onset and worsening proteinuria after AKI with kidney disease progression were analyzed by logistic regression models which has also been used in our previous study [ 23 ], after adjustment for age, gender, smoking and drinking status, baseline eGFR, intensive care unit (ICU) admission, Charlson Comorbidity Index (CCI), AKI stage, hospital, division, hypertension and diabetes. In sensitivity analysis, we performed an imputation process using a random forest model for variables with missing rates <30% (see details in Supplementary Methods ), to verify the robustness of the above results.…”

Variations of urinary N-acetyl-β-D-glucosaminidase levels and its performance in detecting acute kidney injury under different thyroid hormones levels: a prospectively recruited, observational study

“…[3][4][5][6] However, individual differences in serum creatinine (SCr) levels and clinical inconveniences in recording hourly urine output usually lead to delayed initiation of treatments. [7][8][9] Therefore, confronting the challenges of AKI management demands a biomarker that can predict AKI onset as early as possible. 10 Urinary N-acetyl-β-D-glucosaminidase (uNAG) is a lysosomal enzyme that is secreted predominantly by the proximal renal tubules.…”