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SHOCK, Vol. 33, No. 3, pp.

247Y252, 2010

Chih-Hsiang Chang, Chan-Yu Lin, Ya-Chung Tian, Chang-Chyi Jenq, Ming-Yang Chang, Yung-Chang Chen, Ji-Tseng Fang, and Chih-Wei Yang
Department of Nephrology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
Received 10 Mar 2009; first review completed 26 Mar 2009; accepted in final form 4 Jun 2009 ABSTRACT—The Acute Kidney Injury Network (AKIN) group has recently proposed modifications to the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification system. The few studies that have compared the two classifications have revealed no substantial differences. This study aimed to compare the AKIN and RIFLE classifications for predicting outcome in critically ill patients. This retrospective study investigated the medical records of 291 critically ill patients who were treated in medical intensive care units of a tertiary care hospital between March 2003 and February 2006. This study compared performance of the RIFLE and AKIN criteria for diagnosing and classifying AKI and for predicting hospital mortality. Overall mortality rate was 60.8% (177/291). Increased mortality was progressive and significant (chi-square for trend; P G 0.001) based on the severity of AKIN and RIFLE classification. Hosmer and Lemeshow goodness-of-fit test results demonstrated good fit in both systems. The AKIN and RIFLE scoring systems displayed good areas under the receiver operating characteristic curves (0.720 T 0.030, P = 0.001; 0.738 T 0.030, P = 0.001, respectively). Compared with RIFLE criteria, this study indicated that AKIN classification does not improve the sensitivity and ability of outcome prediction in critically ill patients. KEYWORDS—Acute renal failure, intensive care unit, scoring system, outcome

INTRODUCTION Acute kidney injury (AKI) is a common and serious complication in critically ill patients. The mortality rate remains high despite improved renal replacement techniques. A possible cause of the high mortality rate is that intensive care unit (ICU) patients tend to be older and more debilitated than before. Pathophysiological factors associated with AKI are also incriminated in the failure of other organs, indicating that AKI is often part of a multiple organ failure syndrome (1, 2). Before the development of the RIFLE classification (acronym indicating Risk of renal failure, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal failure) system, widely varying definitions of AKI limited epidemiologic investigations of incidence and outcomes in critically ill patients (3). These varying definitions also have generated clinical confusion and complicated comparisons of data between studies (4, 5). The RIFLE classification was first proposed by the Acute Dialysis Quality Initiative (ADQI) group to standardize acute renal failure study in 2004 (Table 1) (6). To date, the classification has proven useful not only for unique populations such as cirrhotic patients and those requiring extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock (7, 8), but also for diagnosing and classifying the severity of AKI in heterogeneous hospitalized patients in wards and ICUs (9Y12).
Address reprint requests to Yung-Chang Chen, MD, Department of Nephrology, Chang Gung Memorial Hospital, 199 Tung Hwa North Road, Taipei, 105 Taiwan. E-mail: DOI: 10.1097/SHK.0b013e3181b2fe0c Copyright Ó 2010 by the Shock Society

Recently, the Acute Kidney Injury Network (AKIN) group, which is composed pf nephrologists and intensivists, has proposed modifying the RIFLE criteria. In AKIN stage 1 (analogous to RIFLE-Risk), a smaller change within 48 h in serum creatinine (SCr) greater than 0.3 mg/dL (Q26.2 2mol/L) was suggested as an AKI threshold (Tables 1 and 2). Additionally, patients receiving renal replacement therapy were reclassified as AKIN stage 3 (RIFLE-Failure). Finally, the loss and end-stage kidney disease classification were deleted from the RIFLE system. The reason for these changes was to increase the sensitivity of the RIFLE criteria (13). The few reported studies comparing the two measures have shown little difference between them (14, 15). Therefore, this retrospective study compared the efficacy of each scoring system in predicting outcome in ICU patients. MATERIALS AND METHODS
Patient information and data collection
The local institutional review board approved this study and waived the need for informed consent. This investigation was performed in ICUs at a tertiary care referral center in Taiwan. Post hoc analysis of an accumulated database enrolled 291 heterogeneous critically ill patients with septic shock (16), acute respiratory distress syndrome (ARDS) (17), or hepatic cirrhosis (8) requiring intensive monitoring and/or treatment unavailable elsewhere. The following patients were excluded: pediatric patients (aged e18 years), chronic uremic patients undergoing renal replacement therapy, and patients whose hospital stay was less than 24 h. Readmitted patients were also excluded from this study. The RIFLE, AKIN category, Acute Physiology and Chronic Health Evaluation (APACHE) II (18), and Sequential Organ Failure Assessment (SOFA) (19) were also evaluated in the study. Records were collected from patients admitted to medical ICUs between March 2003 and February 2006. Retrospectively collected data were the following: demographic information; underlying diseases; AKIN, RIFLE category, APACHE II, and SOFA scores at admission to an ICU; and length of hospitalization. The primary outcome was hospital mortality. Follow-up at 6 months after hospital discharge was performed via a 247

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loss and end-stage kidney disease. When acute renal failure was severe or progressive and measured to improve renal function had been unsuccessful. Copyright @ 2010 by the Shock Society. The ADQI group first proposed the RIFLE system at the second ADQI Conference in Vicenza. Patients are classified into three severity categories (risk. vasoactive agents with or without the addition of a loop diuretic were prescribed. vasopressor preference for norepinephrine and dopamine. TABLE 2. peak airway pressure ranged from 26 to 38 cm of water. Definitions Septic shock was defined according to modified American College of Chest Physicians and Society of Critical Care Medicine consensus criteria (112 patients) (20). Patients were classified by RIFLE into risk. Blood transfusion was administered according to the criteria of the attending physician or whenever the hemoglobin decreased below 8 g/dL.248 SHOCK VOL. a semirecumbent bed position unless contraindicated.9 to 1 in all patients. GFR. the Mann-Whitney U test was used. 3 TABLE 1. Unauthorized reproduction of this article is prohibited. glomerular filtration rate. The Student t test was applied to compare the means of continuous variables and normally distributed data. The ventilatory rate ranged from 20 to 25/min. the strategy for the ventilation consists of an initial low tidal volume of 6 to 8 mL/kg for either volume. RIFLE-I and AKIN stage 2 (2 points).5 mL kg j1 AKIN criteria for Q6 h Stage 1 Serum creatinine criteria Increase in serum creatinine Q0. stress-dose steroid therapy for septic shock.or pressure-controlled ventilation. and maintenance of blood glucose G150 mg/dL after initial stabilization. In patients developing signs of acute renal failure (oliguria and/or increase in serum creatinine). renal replacement therapy. biochemical. This classification system uses individual criteria for SCr levels and urine output (UO). Statistical analysis Descriptive statistics were expressed as mean T SE. Notably. Patients were then started on appropriate empiric antibiotic therapy intravenously. appropriate diagnostic studies to ascertain causative organisms before starting antibiotics.3 mg dLj1 (Q26.0 mg Q12 h dLj1 (354 2mol Lj1) with an acute rise of at least 0. the early goal-directed resuscitation of the septic patient during the first 6 h after recognition. Cirrhosis (122 patients) was diagnosed by liver histology or by combined findings of physical.5 mg/dL (44 2mol/L). Categorical Clinical management Briefly.3 mL kgj1 hj1 Q24 h or anuria Q12 h Stage 3 Increase in serum creatinine Q3Â G0. and aggressive fluid challenge to restore mean circulating filling pressure.4 2mol Lj1) or increase Q1. When necessary. cirrhosis patients with gastrointestinal bleeding caused by esophageal varices were initially treated with emergency sclerotherapy combined with vasopressin derivatives administration. For sepsis patients. and RIFLE-F and AKIN stage 3 (3 points) for day 1 of ICU admission (7.4 2mol Lj1) Same as RIFLE-Injury Same as RIFLE-Failure plus initiation of RRT UO criteria Same as RIFLE GFR indicates glomerular filtration rate.5Â baseline Increase in serum creatinine Q2Â baseline UO criteria G0. are omitted. RRT. RIFLE and AKIN classification schemes for AKI CHANG ET AL. For ARDS patients.3 mg dLj1 (Q26. Comparison of the RIFLE and AKIN definition and classification schemes for acute kidney injury AKIN Stage 1 Stage 2 Stage 3 GFR criteria Same as RIFLE-Risk plus increase in SCr Q0. Primary analysis compared hospital survivors with nonsurvivors. otherwise. and their SCr concentrations at admission were unknown (6). and failure) and two clinical outcome categories (loss and end-stage renal disease).3 mg/dL). respectively. or failure categories. We used a simple model for mortalityVnon-AKI and AKIN stage 0 (0 points). Italy in May 2002. The AKIN classification (13) differs from the RIFLE classification as follows: it reduces the need for baseline creatinine but does require at least two creatinine values within 48 h. RRT.5 mg dLj1 (44 2mol Lj1) or initiation of RRT Loss ESKD Complete loss of kidney function 94 wk Complete loss of kidney function 93 mo ESKD indicates end-stage kidney disease. If oliguria persisted after volume depletion had been corrected or excluded. blood volume expansion with packed red blood cells. and ultrasonographic examination. 33. reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage. the presence of bacterial infections at admission and their development during hospitalization were investigated with appropriate diagnostic methods and cultures. avoidance of supranormal oxygen delivery as a goal of therapy.5 mL kgj1 hj1 for Q12 h h j1 Injury G0. Fifty-seven patients met ARDS criteria defined by the AmericanEuropean consensus conference (21). appropriate use of fresh frozen plasma and platelets. The fraction of inspirited oxygen ranged from 0. injury. renal replacement therapy was performed. injury. early administration of broadspectrum antibiotic therapy.0 mg/dL (350 2mol/L) in the setting of an acute increase of greater than 0.0Â baseline or decrease in GFR Q75% G0.5Â baseline or decrease in GFR Q25% Injury increase in serum creatinine Q2.5 mL kgj1 hj1 for Q6 h G0. Pulse oximetry is used to monitor oxygen saturation. AKIN stage 1 is similar to RIFLE-R but includes abrupt (within 48 h) reduction in kidney function (increase in SCr Q0. All variables were tested for normal distributions using the Kolmogorov-Smirnov test. Patients with peptic ulcer either with active bleeding or clot were treated with injection of sclerosing agents. stage 3 also includes patients who need renal replacement therapy in any stage. and peak end-expiratory pressure ranged from 10 to 16 cm of water. . albumin. the F component of RIFLE is present even when the increase in SCr is less than 3-fold as long as the subsequent SCr is greater than 4.0Â baseline or decrease in GFR Q50% UO criteria G0. colloid resuscitation. The worst physiological and biochemical values on day of initial ICU admission were recorded. baseline SCr concentration was measured first during hospitalization. and the FIO2 is adjusted to maintain pulse oximetric saturation greater than 90% and avoid raising the plateau airway pressure greater than 35 cm of water.3 mL kgj1 hj1 Q24 h or anuria baseline or serum creatinine Q 4. RIFLE Risk Serum creatinine criteria Increase in serum creatinine Q1. injury and failure are the same as stages 2 and 3. Intravenous fluids were administered to all patients depending on their volume status. renal replacement therapy.5 mL kgj1 hj1 for Q12 h Stage 2 Failure Failure increase in serum creatinine Q3. targeting a hemoglobin of 7 to 9 g/dL. the hospital registry office provided information regarding patient survival or date of death. two outcome classes. In all patients. followed by proton pump inhibitors. RIFLE-R and AKIN stage 1 (1 point). a usual 7 to 10 days of antibiotic therapy guided by clinical response. In this study. 8). use of crystalloid. and/or artificial plasma expanders was given to improve renal function and increase urine volume. The Modification of Diet in Renal Disease formula was applied for 20 patients who were admitted directly to an ICU. when appropriate. The criteria resulting in the worst possible classification are used. telephone interview. Mechanical ventilatory adequacy is monitored by arterial blood gas measurements with the ventilator settings changed as needed. NO.

2) 14 (12.632) NS (0.2% (36/52) for RIFLE-I (injury).3 P NS (0.1 18.0) 33 (18.0 T 0. 3.001) according to less than and greater than TABLE 4. ICU first day (mean T SE) SOFA. mean T SE APACHE II.405) 0. Median patient age was 62 years.4 T 0.7 T 0.0) 27 (23. P G 0. NS. or hepatic cirrhosis were enrolled.3 155 T 7 13.0 for Windows (SPSS Inc. Odds ratios for RIFLE criteria were 2.9) 87 (29. ICU first day (mg dLj1) Total bilirubin.2% (75/87) for RIFLE-F (failure.75 1.0) 14 (12.3) 75 (42.07 22.2) 36 (20.4 140 T 9 13. Glasgow coma scale.3 T 0. risk factors were assessed by univariate analysis.1) 52 (17.6) 49 (16. This study used the chi-square test for trend to assess categorical data associated with RIFLE classification. clinical characteristics. specificity.0 T 0. Discrimination was assessed using the area under a receiver operating characteristic curve (AUROC).7 10.011 NS (0.86 T 0.2 T 0.1 269 T 8 35/256 122/169 80/211 160/131 1.9) 291 72 (63. kg Length of ICU stay. 122 (42%) patients had liver cirrhosis.001 0. and overall correctness.5 9.38 T 0.6 9.929) 0.3 75. GCS.8) RESULTS Subject characteristics Between March 2003 and April 2006. Cumulative survival curves as a function of time were generated using the Kaplan-Meier approach and compared using the log-rank test.004 0.6 T 0. mmHg Serum creatinine.3) 114 (39.2 268 T 12 25/152 76/101 53/124 51/63 1. 204 (70%) were men and 87 (30%) were female.2 2. data were tested using the chi-square test. and 80 (28%) patients had diabetes mellitus. The AUROC analysis was also conducted to calculate cutoff values. Hospital mortality and short-term prognosis In RIFLE classification.9 9. In this study. yr Sex (M/F) Body weight on ICU admission. Thirty-five (12%) patients had underlying cancer.6) 78 (44. P G 0.89 T 0.001. Patient demographic data and clinical characteristics All patients (n = 291) Age.4 71.0 2. ICU first day (mg dL Albumin.3) 16 (14.7 9.7) 24 (13.3) 30 (17.023 NS (0.001) for RIFLE-F versus non-AKI (Table 5).72 T 0..2 T 0.001.6) 291 57 (50.4 T 0. and 10.6 T 0.9 1. M.6 T 0.SHOCK MARCH 2010 TABLE 3.005 0.8 T 0.71 (P G 0.3 T 0.68 T 0. Finally.006) for RIFLE-R versus non-AKI.228) 0. days GCS.25 ) F indicates female.8 10.001 NS (0.0) 57 (19. hospital mortality was 36. n (%) RIFLE* Non-AKI Risk Injury Failure Total AKIN* Stage 0 Stage 1 Stage 2 Stage 3 Total 93 (32.1 0. male. not significant.9 T 0. 160 (55%) patients were in sepsis.7) 16 (14.9 2.6 T 0.001 0. Table 4). Clinical outcomes stratified by the RIFLE and AKI definition/classification schemes All patients Hospital survivors Hospital nonsurvivors (n = 291).5 9.1 11.81 T 0. ICU first day (g dLj1) Pao2/Fio2 ratio Cancer (yes/no) Liver cirrhosis (yes/no) Diabetes mellitus (yes/no) Sepsis (yes/no) RIFLE. points MAP.1 6.94 (P = 0. Table 3 lists patient demographic data.5) 114 (39.2) 38 (13.181) 0. Overall in-hospital mortality was 60.1 T 1.8% (42/114) for non-AKI patients.2% (24/38) for RIFLE-R *Chi-square for trend. Unauthorized reproduction of this article is prohibited. a value of P G 0. ICU first day.6 2.810) NS (0.3 Nonsurvivors (n = 177) 61 T 1 123/54 61 T 1 10. chi-square for trend.1) 177 (60.19 T 0.8% (177/291). n (%) (n = 114). Areas under receiver operating characteristic curves were compared by a nonparametric approach.5 178 T 11 13.708) NS (0.1 25. ICU first day.2) 42 (23. All statistical tests were twotailed.6 6.2 T 0.001 0.67 T 0. Ill).2 9.1 T 0.8) 114 (39. ICU first day (g dLj1) Platelets.5 T 0. Data were analyzed using SPSS 12. .48 T 0.3 T 0. (risk). Copyright @ 2010 by the Shock Society. mean T SE AKIN.8 T 0.6) 36 (20. Chicago. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test to compare the number of observed and predicted deaths in risk groups for the entire range of death probabilities. cutoff points were calculated by acquiring the best Youden index (sensitivity + specificity .1). 69. mean T SE j1 AKIN VERSUS RIFLE 249 Survivors (n = 114) 62 T 2 81/33 58 T 1 12.2 T 1.3 2.8) 92 (31.4 2.001 62 T 1 204/87 60 T 1 11.001 0.05 was considered statistically significant.8 T 0.5 2.9 T 0.4) 177 (60.001 NS (0.7 T 1. Hospital mortality differed significantly (P G 0. n (%) (n = 177). sensitivity. Finally.4 T 0. ARDS. 291 ICU patients with septic shock. ICU first day (Â103 2Lj1) Hemoglobin.0) 12 (10. and underlying diseases of both survivors and nonsurvivors. and 86.6 T 1.078) NS (0.171) 0.001 0.4 80.86 (P G 0. 63.2 272 T 12 10/104 32/82 27/87 109/68 0. ICU first day (Â103 2Lj1) Leukocytes. A progressive and significant elevation in mortality was correlated with increasing RIFLE classification severity among all patients.001) for RIFLE-I versus non-AKI.

680Y0.6% (30/57) for stage 1.94 (1. and 9 SOFA points. AKIN criteria identified 7. P V NS (0.074 7.690Y0. Cumulative survival rates differed significantly (P G 0.720 T 0. 61.3% (33/49) for stage 2.738 T 0. 0.76 (P = 0.53) AKIN CHANG ET AL.680Y0. specificity.001) less than and greater than cutoffs of AKIN stage 0/AKIN stages 1 to 3 for septic shock (41. compared with RIFLE.746Y0. 82.22Y21. The ROC curve confirmed that the discriminatory power of the RIFLE classification (AUROC = 0.001) was superior to that of AKIN score (AUROC = 0.5% vs. 92. chi-square RIFLE AKIN APACHE II SOFA df indicates degree of freedom.250 SHOCK VOL. P G 0.001 0. Table 3).07 (1.473 5.9%). AKIN TABLE 6.030 [95% confidence interval {CI}. 95% CI 1* 1.8%).6%). RIFLE-I. and 84. Figure 1B also shows that cumulative survival rates differed significantly (P G 0.030 0. 67. 21 APACHE II points.6% vs. 58.690Y0. 52.001) had the best discrimination for ROC curve among them (APACHE II AUROC = 0.006 0. 71.9% more patients (RIFLE 60. and the predictive accuracy of the RIFLE category.097) for stage 1 versus stage 0. Hospital mortality rates differed significantly (P G 0. To compare the selected cutoff points for predicting hospital mortality.001 Non-AKI Risk Injury Failure *Reference category. which is consistent with that obtained by previous studies.846 P 0. The AKIN classification also correlated with progressive and significant elevation in mortality. Overall in-hospital mortality rate was 60. like those in earlier published studies. and 9. ARDS.746Y0. (15) found that AKIN criteria may not improve sensitivity and predictive ability. Table 6 also lists the discrimination for those scores.255 df 2 2 8 7 P 0.001 Stage 0 Stage 1 Stage 2 Stage 3 Odds ratios. All four scoring systems were tested by Youden index (Table 7). The AKIN group aimed to improve the sensitivity and reproducibility of the AKI criteria and defined the AKIN classification.29) 3.001 0.779 0.796].001) for stage 3 versus stage 0 (Table 5). All patients were classified by RIFLE to identify and classify the severity of AKI and to compare its ability to predict hospital outcome in our study population. Lopes et al. In AKIN classification. 3.123 6. as measured by the Hosmer-Lemeshow chi-square for predicted mortality risk. 7. Predictive ability for hospital mortality by separate logistic regression models for the RIFLE and AKIN definition/classification schemes RIFLE Odds ratios. 8.796 0. P G 0.747 T 0. (14) later compared both scoring systems and found that AKIN classification had superior sensitivity to AKI but was inferior for outcome prediction in critically ill patients.002 0. which.796 T 0.029 0. P G 0. AKIN stage 1.796 T 0.05) for stage 0 versus stages 1 to 3 in the AKIN group.846]. 0. 22Y31).2%).738 T 0. AKIN classification.50 (4.750 0.803 0.026 Discrimination 95% CI 0.1% vs. 0. 12. Odds ratios for RIFLE criteria were 1. DISCUSSION This retrospective study included 291 heterogeneous patients with critical illnesses.509 AUROC T SE 0. APACHE II. indicating poor prognosis of ICU patients with septic shock.3% vs.9%). Unauthorized reproduction of this article is prohibited. liver cirrhosis (38.030 [95% CI.31) 9. hospital mortality was 38.001 Copyright @ 2010 by the Shock Society.50Y6.747 T 0. SOFA score (AUROC = 0.91Y7.026 [95% CI. P G 0. 3 TABLE 5. In the present study. the sensitivity.50 (P G 0.039 0. . RIFLE-I.097) 0.001). 95% CI P V 0. and RIFLE-F (Fig.680Y0. 1* 2.660Y0. NO. and ARDS (27. Table 6 shows the goodness of fit.6% vs.07 (P = 0. In addition.030 0. 16.2%).76 (0.803].05) for non-AKI versus RIFLE-R. Calibration of APACHE II and SOFA scores were superior to RIFLE category and AKIN classification. P G 0. 67.001) less than and greater than cutoffs of non-AKI category of RIFLE classification. 33.86 (1.7% (36/93) for stage 0 patients.001).002 0.43) 3.90Y3. 17.001 0. liver cirrhosis (40. 11.98) cutoffs of nonYacute renal failure/RIFLE-R. and SOFA scores.37Y6. was composed of homogeneous or heterogeneous patients (2.001 0. and ARDS (30% vs.029 [95% CI. Bagshaw et al.720 T 0. Calibration and discrimination for the scoring methods in predicting hospital mortality Calibration Goodness of fit.62Y19. 1A).8% (78/92) for stage 3 (chi-square for trend. Hospital mortality rates significantly differed (P G 0.001. 0. and RIFLE-F for septic shock (40% vs. and overall correctness of prediction were all determined.8%.002) for stage 2 versus stage 0.796]. or hepatic cirrhosis.78) 10.71 (5.

07. daily.50). 2. Analytical results in this study demonstrated that both RIFLE and AKIN criteria precisely predicted hospital mortality and short-term prognosis (Fig. 1. Table 5 shows a trend toward significantly increased mortality rates associated with increasing RIFLE score for all patients (risk.1%Y19. FIG. the results may not be directly extrapolated to other patient populations. Copyright @ 2010 by the Shock Society.86. the SOFA score had the highest overall predictive accuracy and discrimination. % 63 75 90 100 50 74 88 100 66 76 AKIN VERSUS RIFLE 251 Overall correctness. stage 2. the AKIN criteria do not improve the ability to predict a short-term outcome such as in-hospital mortality in critically ill patients.364 0. Second. CONCLUSION In summary.395 0. 1) in this heterogeneous subset of critically ill patients.297 0. the patient group was mainly collected from patients with septic shock. which was also observed in AKIN classification (stage 1. thus. Further study of the RIFLE criteria in prospective randomized controlled clinical trials is needed to establish specific interventions for controlling the progression of AKI. thus providing superior information on mortality risk. % 76 63 42 0 78 63 44 0 71 72 Specificity. Lack of extrarenal predictors in RIFLE and AKIN criteria may explain their discriminative inferiority to SOFA. Cumulative survival rate for 291 critically ill patients based on their RIFLE classification (2A) and AKIN stage (2B). and SOFA scores. sequential measurement of these scoring systems (e. or hepatic cirrhosis and were being treated in medical ICUs. 3. this retrospective study was performed at a single tertiary-care medical center.0%) as having AKI and classified more patients as stage 1 (RIFLE 13.79. Third. and failure. although capable of improving the sensitivity of the AKI diagnosis.46 Sensitivity. % 70 69 66 50 64 69 68 50 69 74 *Value giving the best Youden index.319 0 0. Finally. these conditions are associated with poor prognosis. several important limitations should be recognized. 3. No material differences were noted between RIFLE and AKIN (Tables 6 and 7). use of predicted mortality as a clinical performance benchmark is limited by factors not directly related to care quality.6%). AKIN. 10.g. weekly) may reflect the dynamic aspects of clinical diseases. stage 3.SHOCK MARCH 2010 TABLE 7. Among RIFLE. .37 0.71). injury. 9.381 0. Subsequent hospital mortality predicted after ICU admission Predictive factors RIFLE Cutoff point Non-AKI* R category I category F category AKIN Non-AKI Stage 1* Stage 2 Stage 3 APACHE II SOFA* 21* 9* Youden index 0.94. First. ARDS. 68. 1. which limits generalization of its findings. The RIFLE score had better discriminatory power and overall correctness than the AKIN score. Despite the promising analytical results obtained in this study. APACHE II. Unauthorized reproduction of this article is prohibited.318 0 0.

Chiang WC. Hsueh PR: Prognostic value of mortality in emergency department sepsis score. Lin CY. Draper EA. 2002. Bagshaw SM. 2005. Peck KR. 2. Jorge S. 15. 2007. fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Chang CC. Copyright @ 2010 by the Shock Society. Kellum JA. da Costa AG. Levin A: Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Lien JM. McCormick PA. NO.: RIFLE classification can predict short-term prognosis in critically ill cirrhotic patients. Jorge S. Guitard J. Carlet J. Ronco C. Prata MM: An assessment of the rifle criteria for acute renal failure in severely burned patients. Brigham KL. 31.: American-College of Chest Physicians Society of Critical Care Medicine Consensus ConferenceV definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Sun HY. Chen YC. et al. Wittlake WA. O’Riordan A. 2007. 2009. Sibbald WJ. Martins C. 8. Kellum JA. 4. 21. Fein AM. 14. Falke K. Ha BC. Takala J. Tsai FC. Huang CC. 13. Intensive Care Med 33:1921Y1930. Jorge S. 5.: Report of the American-European Consensus Conference on ARDSVdefinitions. Corbett SW: Mortality predictions using current physiologic scoring systems in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. 1996. Ronco C: The RIFLE criteria and mortality in acute kidney injury: A systematic review. Lee CC. 28. mechanisms. Ahlstrom A. de Almeida E. Chen SY. Hoste EAJ. Clin Nephrol 65:103Y112. Lin CY. Uchino S. Shock 30:23Y28. relevant outcomes and clinical-trial coordination. 1994. Kellum JA. 1985. Lancet 365:417Y430. Engle KM. Levin N. Wong V. Tian YC. Jenq CC. 29. Kellum JA: RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Barange K. J Clin Invest 114:5Y14. Ostermann M. Chen YC. Crit Care Med 13:818Y829. Jenq CC. 2007. Doig GS. Jenq CC. 3 REFERENCES CHANG ET AL. Nephrol Dial Transplant 22:285. 24. Morgera S. 2006. Tsai YH. Kersten A. Crit Care 10:R73. Burroughs K. Chang RWS: Acute kidney injury in the intensive care unit according to RIFLE. Ronco C: An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Lopes JA. Lopes JA. 2008. Legall JR. 2006. Curr Opin Crit Care 8:509Y514. Song JH: Scoring systems for prediction of mortality in patients with intensive care unitYacquired sepsis: a comparison of the Pitt bacteremia score and the acute physiology and chronic health evaluation ii scoring systems.252 SHOCK VOL. Lin SM: RIFLE classification for predicting in-hospital mortality in critically ill sepsis patients. Ribes D. 33. Goldsmith D. 2007. Kwon KT. Bellomo R: A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Fernandes P. Dellinger RP. Tsai MH. 2007. 2007. pathogenesis. Chen WJ. 26. Franca C. Costa e Silva Z. Angus DC. Vanholder R: Acute renal failure. 30. outcome measures. Yang CW: The RIFLE score increases the accuracy of outcome prediction in patients with acute respiratory distress syndrome undergoing open lung biopsy. et al. Goncalves S. Respiration 77:398Y406. Unauthorized reproduction of this article is prohibited. 25. do Carmo JA. Macedo E. Morimatsu H. 18. Muscari F. Lacerda JF. Artigas A. Van Biesen W. 2008. Bellomo R. Jenq CC. Shah SV. Ronco C. Poole B. Moreno R. Peltonen S. Shock 29:322Y327. Am J Transplant 7:168Y176. Lavayssiere L. Crit Care Med 35:1837Y1843. as defined by the RIFLE criteria. 3. Lin CY. 1. Kuitunen A. Bone Marrow Transplant 38:395. Bhandari V. Chen YC. Shock 31:139Y145. Shock 31:348Y353. 2006. Silva S. and C-reactive protein in patients with sepsis at the emergency department. Yang CW. Chen SC. Ronco C: Defining and classifying acute renal failure: from advocacy to consensus and validation of the RIFLE criteria. Prata MM: Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the Acute Kidney Injury Network classifications. JAMA 294:813Y818. Critical Care 12:R110. Fang JT. Lin HC. 11. Siner JM. Kuitunen A. De Bacquer D. et al. Nephrol Dial Transplant 23:1569Y1574. 2009. Suojaranta-Ylinen R. Esposito L. et al. 27. Bernard GR. Cerra FB. Mehta RL. Crit Care Med 20:864Y874. Elias JA. Chen PC. Intensive Care Med 22:707Y710. 6. Ricci Z. 2009. 2004. Hegarty JE. Kamar N. 19. Bone RC. Molitoris BA. Aaltonen J. Yang C. Kellum JA. Suc B. 16. 2005. Rhee JY. Morris A. Wagner DP. Fang JT. Nguyen HB. Pettila V: Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Intensive Care Med 20:225Y232. and therapy. Abrams JH. Van Ginkel C. Zimmerman JE: APACHE II: a severity of disease classification system. Bellomo R. 20. Clermont G. Kao KC. Liu NJ. 2009. 2008. Venkataraman R. Watson AJ: Acute renal disease. Intensive Care Med 33:409Y413. Chang MY. Chen YC. Bouman C: Developing a consensus classification system for acute renal failure. Fang JT. Tan I. Schrier RW. Tallgren M. Crit Care 8:R204YR212. Wu SC. Chung DR. 9. Bellomo R. Lameire N. Fang JT. Pettila V: Comparison of 2 acute renal failure severity scores to general scoring systems in the critically ill. Ann Thorac Surg 84:1256Y1263. Shock 31:146Y150. Ann Thorac Surg 81:542Y546. 7. Wang W. Mehta RL. diagnosis. Vento A. Siegel MD: Elevated serum angiopoietin 2 levels are associated with increased mortality in sepsis. Balk RA. Ferreira AC. Bouman C. Tsai CL. Uchino S. Vincent JL. Jung DS. McQuillan R. Crit Care Med 34:1913Y1917. Yang CW: Evaluation of outcome scoring systems for patients on extracorporeal membrane oxygenation. Schein RMH. 2006. Bruining H. Palevsky P. Neves FC. 17. Cho TW.: Acute renal failure following liver transplantation with induction therapy. Chang MY. Durand D. . Warnock DG. 23. Kellum JA. Hudson L. Spragg R. Bernard GR. 2006. post-liver transplantation. Ki HK. Caneira M. Tian YC. Hynninen M. 2004. De Mendonca A. 2008. Cointault O. Crit Care 11:R31. Lopes JA. procalcitonin. Kidney Int 73:538Y546. Alvarez A. Acute Dialysis Quality Initiative Workgroup: Acute renal failureVdefinition. Tian YC. Shin SY. 1992. George C. Wang JL. Lin CY. 2008. Reinhart CK. Knaus WA. Bates S. Tian YC. Cruz D. Banta JE. multicenter study. Schetz M. Willatts S. Prata MM: An assessment of the RIFLE criteria for acute renal failure following myeloablative autologous and allogeneic haematopoietic cell transplantation. Knaus WA. 12. Bellomo R. animal models. Am J Kidney Dis 48:262Y268. 22. et al. Bouman C. Thijs LG: The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Lamy M.: Acute renal failure in critically ill patientsVa multinational. 10. Mitra A: Acute renal failure: definitions. Suter PM. 2007. Abreu F. 2006.