AKIHelper: Acute Kidney Injury Diagnostic Tool

Using KDIGO Guideline Approach

Issariya Uboltham
Department of Computer Engineering
Faculty of Engineering,
Chulalongkorn University,
Bangkok 10330, Thailand
Issariya.u@student.chula.ac.th
Nakornthip Prompoon
Department of Computer Engineering
Faculty of Engineering,
Chulalongkorn University,
Bangkok 10330, Thailand
Nakornthip.S@chula.ac.th
Wirichada Pan-ngum
Mahidol-Oxford Tropical Medicine
Research Unit (MORU)
Faculty of Tropical Medicine,
Mahidol University
Bangkok 10400, Thailand
Pan@tropmedres.ac

Abstract— Acute Kidney Injury (AKI) is common and
harmful disorder in hospitalized patients. It is associated with
poor outcomes such as a decrease chance of survival, longer
hospital stays and an increase progression of chronic kidney
disease. To diagnosis AKI, the KDIGO clinical practice guideline
has been published for providing standardized criteria of AKI
definition and the recommendation in medical pathway.
Moreover, early detection of AKI in patient at risk can also
improve the outcomes. This paper presents an approach to assist
the doctor in diagnosis and decision making process. First, the
risk factors of AKI were identified using data mining approach
based on Decision Tree classification technique. Simple Cart and
J48 were selected as the algorithms for this process. Second, a
concept of tool requirements and design named “AKIHelper” is
presented. This tool is created based on KDIGO guideline which
is expected to use for diagnosis and staging severity of AKI.
Keywords— Acute Kidney Injury; AKI; KDIGO; E-Health;
Healthcare; Risk Factors; Diagnostic Tool; Data Mining; Decision
Tree; Classification
I. INTRODUCTION
Acute Kidney Injury (AKI) is a common disorder with a
rapid reduction of kidney function over hours, days or weeks.
The result of the treatment is unsatisfied and the cause is
unclear, this is accounted for more than 10% of all hospitalized
patients and more than 2/3 of all Intensive Care Unit (ICU)
admissions [1]. Besides this, AKI leads to a consequence of
other acute illness, such as Fluid Overload, Electrolyte
Abnormalities, Impaired Innate Immunity and Progression of
Chronic Kidney Disease (CKD). These can also cause the
extension of hospital stay, increasing mortality rate and higher
cost of care.
To date, serum creatinine and urine output criteria have
been developed and used to define the development of AKI.
Level rise of serum creatinine compared with the baseline and
duration of oliguria can be used to define the stage of disease.
Early detection of AKI in patients at risk can be helpful in
improving outcomes of the treatment. Unfortunately, the
diagnosis and monitoring are often neglected or missed during
hospital/ICU admission. Moreover, the measurement and
documentation of creatinine level or urine output are either
inaccurate or delayed [2]. These explain why early detection of
AKI and risk identification are often failed.
The clinical practice guidelines for defining AKI have been
published in various definitions such as RIFLE, AKIN (Acute
Kidney Injury Network) and KDIGO (Kidney Disease
Improving Global Outcomes). However, the incidence rate of
AKI is still increasing because it is not a single disease. The
progression of AKI comes from multiple clinical conditions
that make the diagnostic of this disease become more complex.
Furthermore, the implementation of these guidelines is not
successful as it should be. This is because of the difference in
viewpoints from multidisciplinary stakeholders, barriers in
knowledge and a lack of understanding how to apply these
guidelines in clinical practice [3].
This paper proposes an approach to identify the risk factors
of AKI using data mining techniques. The result will be used
for providing information in case of monitoring and caring of
focused patients. Furthermore, the paper presents an idea to
develop tool for staging AKI severity based on KDIGO
guideline named “AKIHelper” that AKI risk factors retrieved
from data mining process is also planned to be a part of it. This
tool is hoped to systematically identify stage of disease, assist
the clinical decision making processes, improve the outcome or
clinical care practice and reduce hospital mortality rate as well
as medical expenses.
The rest of the paper is structured as follows. In Section II,
background of KDIGO guideline and data mining in healthcare
are presented. Section III briefly reviews related works of AKI.
Section IV describes the proposed approach to identify the risk
factors of AKI and presents a concept to develop tool based on
KDIGO guideline, including evaluation. Section V discusses
the limitation of the approach. Finally, section VI provides
conclusion and plan for future work.
II. BACKGROUND
A. KDIGO Guideline for AKI
KDIGO (Kidney Disease Improving Global Outcomes)
was established in 2003 as non-profit global organization
managed by the National Kidney Foundation. The objectives
of KDIGO are to develop and implement evidence-based

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ICIS 2016, June 26-29, 2016, Okayama, Japan
clinical practice guideline in kidney disease. This organization
has Global Network members made up of volunteers from
every part of the globe and also has a respected record of
achievement and accomplishment to improve the care and
outcomes for patients worldwide.
For AKI, KDIGO provides the guideline for clinical
practice with recommendations [4] to assist decision making,
caring for patient at risk and for selecting treatment to improve
patient survival and preserve or recover kidney function.
B. Data Mining in Healthcare
Nowadays, data mining becomes necessity for healthcare
industry in many aspects e.g. predicting disease, diagnosis
treatment planning and healthcare resource management. There
are massive volumes of information from this sector that was
produced and collected on daily basis activities such as
personal information of patient, laboratory results, underlying
disease and so on. With the use of implementing information
technologies, the large amounts of data can be automatically
classified, processed and extracted into the useful patterns
which help to get interesting knowledge or hidden pieces of
information.
Different from standard practices of data mining which
simply begins with obscure dataset, data mining in healthcare
is initiated from the hypothesis. The discovered information
that is not in accordance with patterns and trends will be
focused [5] for investigation purpose. Well-known data mining
techniques which are successfully applied in healthcare include
Artificial Neural Networks, Decision Tree, Genetic Algorithms
and Nearest Neighbor method [5,6]. The information which is
retrieved from data mining process will be used for decision
making process, prognoses, improve clinical practice and
provide treatment recommendation for patients in healthcare
organizations
III. RELATED WORKS
AKI has been studied by many researchers in different area
such as risk, definition and efficiency of tool applied. N.
Srisawat et al. [7] studied variation in risk and mortality of AKI
by cohort study of the 15,132 critically ill patients admitted to
ICU at 6 hospitals in 4 countries and used KDIGO to define
AKI. The result was the incidence and outcomes for AKI
varied after adjusting for age, sex, baseline severity of illness,
and also associated with incremental mortality risk across
centers. Likewise, Kai Singbartl et al. [8] study, the detrimental
effects of AKI were exposed that they were not limited to
classical symptoms such as fluid overload and electrolyte
abnormalities but also caused higher rates of infection, CKD
(Chronic Kidney Disease) progression and impaired innate
immunity. The study has also shown that the death cases
among ICU patients, who died of AKI, often involved various
factors. Even small changes in serum creatinine concentrations
can increase the risk of death.
Dilhari DeAlmeida et al. [9] proposed an approach to
develop and extract AKI from Electronic Medical Record
(EMR) and presented the methodology to evaluate the effect of
electronic alerts (e-alerts) system of AKI. The study collected
data on AKI e-alerts in university medical center in November
2013 with a sample of 100 non-ICU patients who were
analyzed for possible AKI. AKI was defined per KDIGO
guideline. The result was found that all cases examined were
true cases of AKI with 100% Specificity and 97% Sensitivity.
F.Perry Wilson et al. [10] assessed the effectiveness of an
automated electronic alert system for AKI to determine injury
severity reduction and outcomes improvement. The study was
designed to a single-blind, parallel-group and randomized
controlled trial. The 23,664 patients were recruited from the
hospital of the University of Pennsylvania in Philadelphia
between September 2013 and April 2014. After exclusion
criteria, 2,393 patients were randomized as 1,201 eligible
participants were assigned to AKI alert group and 1,192 were
assigned to the usual care group. The result of this study was
concluded that the randomized controlled study did not show
any advantages of an electronic alert system, nor did it improve
the clinical outcomes among patients in a hospital.
The application of data mining in healthcare has been
developed for various purposes. Asmaa S. Hussein et al. [11]
proposed the recommender systems for Chronic Disease
Diagnosis (CDD) using data mining techniques in the hybrid
way such as multiple classifications and Unified Collaborative
Filtering method. The first approach based on decision tree
algorithms was applied for monitoring cases by generating
disease risk diagnosis prediction. The second approach based
on learning classification which was suggested to be used for
increasing accuracy of medical advices recommendation. The
results were exposed that the system can assist the physicians
and patients to decrease chronic disease risk factor and to
provide high accuracy of medical advices recommendation
which will be benefit for patients.
Feixiang Huang et al. [12] applied data mining techniques
to predict hypertension from 8 diseases. The 9,862 cases of
patient medical record were selected and studied. The approach
adopted Under-sampling technique to generate training data
sets and used data mining tool Weka to generate the Naive
Bayesian and J-48 classifiers. The experimental results were
shown that there was a little improvement of the ensemble
approach over pure Naive Bayesian and J-48 in prediction
performance such as accuracy, sensitivity, and F-measure.
These related works were studied and used as a reference
and guideline about how to analyze patient data received from
hospitals with an appropriate methods and way to design and
develop “AKIHelper” tool which is planned to use in specific
area, hospitals in Thailand. It will be a challenge of this study
because the current standard approach to diagnosis AKI in
Thailand is done manually without the aid of systems or tools.
IV. PROPOSED APPROACH
This section describes the proposed study which aims to
assist the doctor for decision making process or to provide the
information and recommendations for improving the clinical
outcomes. The approach is divided into 3 sections. Section A
provides an approach to identify AKI risk factors by applying
Classification tree technique of data mining such as J48 and
Simple Cart to be used for patient dataset processing. Section B
presents an idea for developing diagnostic tool named
“AKIHelper” using KDIGO guideline. Lastly, section C
describes the method for evaluating this approach using 2x2 characteristics, underlying diseases, types of ICU, laboratory
contingency table. The conceptual framework is illustrated in results and outcomes that contain their own attributes. These
Fig. 1 which is separated into two sections, A and B. Each of attributes are considered for identifying risk factors as shown
the section is explained further in description below. in Table 1.

TABLE I. INFORMATION GROUPS AND ITS ATTRIBUTES

Select Data
Section A
Collect Data
Type Attribute
Birth Date
Clean Data Age
Transform Data Gender
Dataset
Patient Information Weight (kg.)
Integrate Data Height (cm.)
Preprocessing Data Length of ICU stay (days)
Apply
Data Mining Diagnosis (At ICU admission)
Technique Identify the result Hypertension
(AKI Risk factors) Diabetes Mellitus
Coronary Artery Disease
Underlying Disease
Cerebrovascular Disease
Section B Section C Malignancy
Chronic Kidney Disease (CKD)
Create Study KDIGO Medical
the Result
Evaluate

Staging Model Guideline Surgical

Develop Tool
Design Tool AKIHelper
Fig. 1. Conceptual framework of proposed approach
A. Identify the Risk Factors of AKI
1) Setting: Data used to perform data mining analysis was
collected from 14 hospitals in regions across Thailand by
registration in web-based format where demographic, clinical
and laboratorial data were recorded.
2) Dataset: Sequence of data collection is everyday for the
first 7 days and then weekly collected on day 14, 21 and 28 of
ICU admission date. The initial dataset included 2,480 records
during April to December 2014 of patient admission. A
sample of patient data is shown in Fig. 2.
Types of ICU
Coronary Care Unit
Mixed
Glasgow Coma Scores (GCS)
Laboratory Investigations APACHE II
SOFA Scores
AKI (Y/N)
Outcomes
Stages of AKI (1-3)
To identify the risk factors of AKI based on Table 1.
attributes, classification data mining technique including J48
and Simple Cart are applied in data mining process.
a) J48: is a tree based learning approach which uses
divide and conquer approach to construct univariate decision
tree by spliting a root node into a subset of two partitions till
leaf nodes (target node) occur in a tree. [13]
Random samples of 100 patient records were applied
with J48 technique and the result of execution are represented
in Fig. 3. It was found that Chronic Kidney Disease (CKD)
patients is associated with a high risk of AKI. In addition, it
was indicated that the patient with Sofa (Sepsis-related Organ
Failure Assessment) score less than or equal to 11 and age
greater than 82 years old with no hypertension also increases
the risk of AKI.

Fig. 2. A sample of patient data

3) Data Mining Process: Dataset was prepared for using

in this process. All data of the patients who were under 15
years old or with end stage renal disease (ESRD) on chronic
dialysis and unnecessary data such as name, patient number
and reimbursement were cut-off. The remaining data were
categorized into patient information groups including baseline Fig. 3. Result of sample patient dataset applied with J48 decision tree
 b) Simple Cart (Classification and Regression Tree): is In Fig. 5, severity staging model approach is presented. It
a classification technique for generating the binary decision was created based on KDIGO guideline which will focus on
tree. This algorithm based on learning approach. The results changing in serum creatinine level or urine output. The
can be either classification or regression trees, depending on proportional increase indicates the AKI stage. The attributes
categorical or numeric dataset[14]. Fig. 4 represents the result such as baseline, admission time and urine output were
from applying Simple Cart technique with a sample of 100 mapped with column in the records.
patient records that the patient who was admitted to Medical
ICU type has a high risk of AKI.
Input Patient
CART Decision Tree
[ESRD]
ICUType=(CCU)|(Mixed)|(Surgical): No(52.0/7.0)
ICUType!=(CCU)|(Mixed)|(Surgical): Yes(22.0/7.0) [Not ESRD]
[Diagnose by Creatinine Level] [Diagnose by Urine Output
Number of Leaf Nodes: 2
[Weight Available] [Weight N/A]
Size of the Tree: 3 Check Time of Creatinine

Fig. 4. Result of sample patient dataset applied with Simple Cart [<Admission time] [> Admission time]
Estimate Weight
The result from this section will be used for monitoring by Height
Choose Lower Value Male = Height - 100,
patients at risk to increase the outcome and be applied to the Use colAE as
Female = Height - 105
“True baseline” (colAE VS (colBI))
tool for providing information purpose.
B. Developing Diagnostic Tool
To develop diagnostic tool “AKIHelper”, understanding the Obtain Reference Divide Urine Output per
KDIGO guideline is required because it will be used as the Creatinine (colBG) Day (colCK) by Weight
main structure of the tool, for example, definition, severity
staging and recommendations. The approach for developing Compare Creatinine Day Obtain Urine Output
the tool consists of 2 steps, as in (1) AKI Severity Staging 1 – 7, 14, 21, 28 with colBG per Kilogram
Model and (2) Tool Development Approach. Each of step is
presented seperately in the following subsections.
1) AKI Severity Staging Model: The model was created Each Time Determine Status of AKI
based on KDIGO guideline which provide the definition and (0 – 3 Using the Guideline)
the staging of AKI [4] as described in Table 2. and Table 3.
respectively.
Fig. 5. Model for staging AKI severity using KDIGO guideline
TABLE II. DEFINITION OF AKI (NOT GRADED)
Definition Period 2) Tool Development Approach: This approach is begin
Increase in SCr by ı0.3 mg/dl Within 48 hours with tool fuctions design. AKIHelper is expected to have 4
(ı26.5 lmol/l) main functions as follows:
Increase in SCr to ı1.5 times Known or presumed to have a) Patient Data: This function contains a record of
baseline occurred within the prior 7 days
Urine volume <0.5 ml/kg/h For 6 hours
patient which can be filled in by user or import from database.
The patient data such as date admission, creatinine level and
TABLE III. STAGING OF AKI urine output will be used for diagnosis AKI stage.
Stage Serum Creatinine (SCr) Urine Output
b) AKI Severity Staging: This function is based on AKI
1 1.5–1.9 times baseline < 0.5 ml/kg/h for 6–12 hours severity staging model. If any stage of AKI is detected, an
OR alert will be promptly displayed to notice the user.
• 0.3 mg/dl (•26.5 μmol/l)
increase within 48 hours c) AKI Recommendation: This function is for providing
2 2.0–2.9 times baseline < 0.5 ml/kg/h for •12 hours KDIGO information where the user can look up for reading
3 3 3.0 times baseline < 0.3 ml/kg/h for •24 hours guideline or considering appropriate medical advices.
OR OR
Increase in serum creatinine Anuria for •12 hour
d) Risk Factors: The risk factors are obtained from the
to •4.0 mg/dl (•353.6 μmol/l) result retrieved from data mining process and will be stored in
OR the tool for risk factors viewing. This part can be updated
Initiation of renal replacement depending on location setting or amount of dataset.
therapy
OR, In patients < 18 years, Use case diagram and user interface of the designed
decrease in eGFR to < 35 system are shown as in Fig. 6 and Fig. 7 respectively. The
ml/min per 1.73 m2 source of patient data come from 2 channels, Medical Staff
fill-in data directly to the system and retrieve from external proportion of negatives that are correctly identified. Accuracy
system for example, Electronic Medical Record (EMR). This value is used to show the precision of the system.
approach will be then used for developing AKIHelper tool.
V. LIMITATIONS
AKIHelper System
Although the approach is proposed for assisting doctor in
various expectations. One limitation of this tool is that it can
<< actor >> only be used in the part of diagnosis process for staging and
Record Data Medical Record
provide guideline information only, it is not able to handle and
System
manage all of the clinical processes especially decision
making, for example, the severity of AKI that AKIHelper can
Stage Severity detect may be missed if there are multiple serum creatinine
of AKI
results within a short time period. In this case, using such tool
is not effective. Doctor’s consideration and judgement on the
Doctor patient treatment will be required.
View
Recommendation In addition, the risk factors may various across the areas
due to source of patient data, location setting, differences in
Medical Staff clinical practice, process of care or residual confounding from
View Risk unmeasured factors. Therefore, using different dataset before
Factors applying data mining techniques would be effective to identify
the risk factors.
VI. CONCLUSION
Fig. 6. Use case diagram of AKIHelper
This paper presents the proposed approach to identify risk
factors using Decision Tree classification of data mining
technique. Simple Cart and J48 were selected as the algorithms
for this process. The findings from the study will be used to
improve monitoring and treatment pathway in patients at risk.
Next, an idea for developing diagnostic tool named AKIhelper
was presented. The model for building tool was created based
on KDIGO guideline for staging the severity of AKI. The
completed AKIhelper is expected to assist the doctor in
decision making processes and improve quality of medical
outcome which may result in a reduction in mortality and
Fig. 7. Example user interface of AKIHelper
medical expenses.
A further study is needed to provide better understanding of
C. Evaluation
the association between undisclosed factors and the increased
To evaluate the proposed approach, 2x2 contingency table risk of AKI and to develop tool to be plugged in with the
is planned to use as depicted in Table 4. electronic medical record system of the hospital or clinic.
TABLE IV. 2 X 2 CONTINGENCY TABLE
ACKNOWLEDGMENT
Actual Result This paper was supported by Dr. Nattachai S., Excellent
Disease Non-Disease Center for Critical Care Nephrology, Department of Medicine,
a b Chulalongkorn University, Thailand and Department of
Positive
True Positive False Positive Critical Care Medicine, University of Pittsburgh School of
Test Result
c d Medicine, USA and Dr. Wirichada P., Mathematical and
Negative
False Negative True Negative Economic Modelling group, Mahidol-Oxford Tropical
Medicine Research Unit, Mahidol University for advices and
With this table, sensitivity, specificity and accuracy value assistance with data collection.
can be measured as equations below.
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