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ACUTE KIDNEY INJURY IN POST-OP NEUROSURGERY PATIENTS IN

ICU: A COMPARISON BETWEEN RIFLE AND AKIN CLASSIFICATIONS


1
Joshi

Dr. Vidit

Col(Dr) R

2
Ramprasad ,

Brig (Dr)G S

3
Ramesh

1Resident Anesthesiology, AFMC

Pune.
2Associate Professor, Department of Anaesthesiology AFMC Pune
3Professor & HOD, Department of Anaesthesiology AFMC Pune

Introduction

Observation

Acute kidney injury (AKI) is commonly


seen in the perioperative period and in
the intensive care unit (ICU). It is
associated with a prolonged hospital stay,
high morbidity and mortality.1
To date, there is no universally accepted
definition for acute kidney dysfunction.
The criteria for AKI was first published
with acronym RIFLE (Risk, Injury, Failure,
Loss of kidney function, and End-stage
renal failure), to overcome different
definitions for AKI2
More recently, a modified version was
proposed by the Acute Kidney injury
Network (AKIN)3
Neurosurgical patients are more prone to
kidney stress due to blood loss & major
fluid shift, water imbalance in peri-op
period and excessive use of diuretics.

Figure-1: Distribution according to Sex

Results

Figure-2: Distribution according to Age


25
20
4
9

11

11

31-45 yrs

46-60 yrs

15
FEMALE
29 (40%)

10
5
0
< 30 yrs

No AKI

Figure-3: Incidence of AKI


by AKIN

Figure-4: Incidence of AKI


by RIFLE criteria
Injury
3 (4%)

Failure
2 (3%)

Stage 2
1 (1%)

RISK
10 (14%)

> 60 yrs

AKI

Figure-5: Comparison of
AKIN & RIFLE
RIFLE
only
3 (4%)

Stage 3
4 (6%)

AKIN +
RIFLE
12 (17%)

Stage 1
19 (26%)

Objectives

AKIN
only
12 (17%)

No AKI
57 (79%)

No AKI
45 (62%)

1.To study the incidence of AKI in post op


Neurosurgery patients in ICU using RIFLE
& AKIN criteria

15
5

IM

DAY 1

0
DAY3

DAY4

RIFLE

AKIN

DAY2

1
DAY5

AKI
Non AKI pMean(sd) Mean(sd) Value

Pre-op Cr (mg/dl)

Study Design: Prospective observational


study
Study Place: ICU CH(SC), AFMC, Pune
Study Population: All adult Neurosurgical
patients with ICU admission post-op for >
24 hrs
Study Period: DEC 2012 - SEPT 2013
Sample Size: 72 patient
All patients assessed daily for 7 post-op
day using both the RIFLE and AKIN
criteria

0.83
(0.24)
Pre- Op Urea
29.11
(mg/dl)
(10.25)
Pre- Op K+ (mmol) 4.267
( 0.38)
Intra-Op Urine
1082.59
output (ml)
(963)
Intra-Op Blood loss 653.33
(ml)
(256)
Duration of Surgery 5.74
(hr)
(1.14)
APACHE score
8.33
(3.96)

Table-3 :RIFLE & AKIN criteria

0.96
(0.20)
22.68
(8.08)
4.193
(0.43)
956.89
(418)
529.33
(190)
4.84
(1.84)
6.04
(4.95)

0.018
0.795
0.470
0.446
0.022
0.013
0.045

Criteria

AKIN

RIFLE

Sr Creatinine
changes

Change
Within a 48hour

Over a one-week
period from
Baseline

Absolute S.Cr
increment in Stage 1

Rise of 0.3
mg/dL in 48
hrs

Renal replacement
therapy

Stage 3

No severity class
assigned

0
RIFLE

AKIN

RECOVERY

Criteria

Non
AKI(45)

AKI(27)

p-Value

Hypertension

16(22.2%)

8(29.6%)

8(17.8%)

0.258

Diabetes

15(20.8%)

10(37.0%)

5(11.1%)

0.015

Liver diseases

2(2.8%)

2(7.4%)

0(0%)

0.047

LVH/ CAD

3(4.2%)

3(11.1%)

0(0%)

0.049

Malignancy

12(16.7%)

4(14.8%)

8(17.8%)

1.000

Seizures

20(27.8%)

8(29.6%)

12(26.7%)

0.792

Immobilization

7(9.7%)

4(14.8%)

3(6.7%)

0.413

Chemotherapy

1(1.4%)

0(0%)

1(2.2%)

1.000

Contrast study

20(27.8%)

13(48.1%)

7(15.6%)

0.006

Transfusion
Reaction
Hypo
albuminemia

2(2.8%)

1(3.7%)

1(2.2%)

1.000

22(30.6%)

12(44.4%)

10(22.2%)

0.045

RIFLE GFR Criteria

UO Criteria

AKIN GFR
CRITERIA

AKIN
CLASS

RISK

Increase Cr 1.5 Or
GFR decreases
>25%

UO < 0.5
ml/kg/hr
6 hr

Increase Cr
1.5 Or
0.3 mg/dl

STAGE 1

Increase Cr 2 Or
GFR decreases
> 50%

UO < 0.5
ml/kg/hr
12 hr

Increase Cr
2

STAGE 2

Increase Cr 3 Or
GFR decreases
> 75% Or
Cr 4mg/dl ( with
acute rise of
0.5 mg/dl)

UO < 0.3
ml/kg/hr
24 hr Or
Anuria 12
hr

Increase Cr
3 Or
Cr 4mg/dl (
with acute rise
of 0.5 mg/dl)

STAGE 3

INJURY

FAILURE

LOSS
ESRD

Complete loss of renal function for >


4 weeks
END STAGE RENAL DISEASES

Diagnosis of early AKI was higher using


AKIN than RIFLE criteria.

Outcome prediction (recovery/failure) was


comparable in both. (Figure-7)

HIGHER GRADING

TABLE 2: Risk factors


ALL
cases(72)

RIFLE
CLASS

Table-4 : RIFLE v/s AKIN differences


Sr No.

DAY6

Association of Qualitative risk factor such


as Contrast, Diabetes, Hypo albuminemia,
CAD/LVH and Liver diseases was found
significant.

Discussion

10

5
1
0
DAY7

Association of Quantitative risk factor such


as Pre-op Sr Creatinine, Intra-op blood
loss, Duration of surgery and APACHE II
score on ICU admission was found
significant using un-paired test.

15

STAGE 1

TABLE 1: Peri-op risk factors


Criteria

The majority of patients had serum


creatinine value increases of greater than
50% or greater than 0.3 mg/Dl from
baseline within the first 48 hours
postoperatively (Figure-6)

19

10

More patients were diagnosed as early AKI


by AKIN (33.33%) than by RIFLE (20.83%)
criteria (P<0.0001). (Figure3-5)

23

20

Materials &
Methods

25

8
6

3.To study, associated risk factors in the


development of AKI

Figure-7: PROGRESS OF STAGE 1 / RISK

Figure-6: Incidence of AKI ON


Post-op Day by AKIN/RIFLE
10

Patients age > 60 yr are more prone to AKI


(Figure-2)

16

MALE
43 (60%)

Non AKI
48 (67%)

2.To note whether there are differences in


identification of Acute Kidney injury in postop Neurosurgery patients in ICU using
RIFLE and AKIN criteria

All data analysed using SPSS Version 20.0


software

Increased blood loss, increased operative


time,
higher APACHE
II score at
admission & hypoalbumenemia were found
to be associated with early AKI.
Limitations : Small sample size , single
center study and no sub group analysis has
been done.

Conclusion
Diagnosis of early AKI was found to be
higher using the AKIN than RIFLE criteria
Whether there is over-diagnosis by AKIN
than RIFLE criteria cannot be interpreted in
this study.

References
1.

Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW. Acute


kidney injury, mortality, length of stay, and costs in hospitalized
patients.J Am Soc Nephrol. 2005;16:3365-70.

2.

Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute


Dialysis Quality Initiative workgroup. Acute renal failuredefinition,
outcome measures, animal models, fluid therapy and information
technology needs:the Second International Consensus Conference of
the Acute Dialysis Quality Initiative (ADQI) .Crit Care. 2004;8:R20412.

3.

Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG,
et al. Acute Kidney Injury Network: report of an initiative to improve
outcomes in acute kidney injury.Crit Care. 2007;11:R31

Acknowledgement
We are grateful to the Col (Dr) S Singh, Gp Capt.(Dr) R M Sharma,
Lt Col. (Dr) R Goyal and Department of Anaesthesiology and
critical care, AFMC Pune for their kind guidence and support.