I would like to ask you for help in interpretation of KDIGO criteria for AKI in periprocedural settings.
I have problem with criterium: increase in Scr by at least 26.1 mg/dl within 48 hours, when applying it to periprocedural AKI. Does the increase need to appear within 48h with baseline as reference? Or may the reference be a postprocedural measurement. Below you can find examples of both scenarios:
PATIENT1: baseline Cr: 100 mmol/l;
postprocedural Cr: 0h: 105 mmol/l; 12h: 110 mmol/l; 24h: 140mmol/l
PATIENT2: baseline Cr: 100 mmol/l;
postprocedural Cr: 0h: 80 mmol/l; 12h: 110 mmol/l; 24h: 120mmol/l
In both cases there is Scr increase over 26.1 mmol/l but in PATIENT 1 the reference is baseline and in PATIENT it is 0h.
Do they both have periprocedural AKI according to KDIGO criteria or is it only the first one?
Looking forward to your replies
I would use the baseline value as reference. The postoprocedural value (0h) may be influenced by hemodilution from the surgery. You want a "stable" Scr as baseline. Therefore, in my opininon, PATIENT 2 does not have AKI.
Agree with Kristian. If it is a routine procedure then baseline can be taken immediately before. However, if it is a procedure associated with an acute event, then perhaps look to a pre-hospitalisation creatinine for baseline.
In the attached you'll see I've quantified the extent of hemodilution (from a clinical standpoint the advice that comes out of it is not to measure creatinine within ~30 min or so of completion of a bolus). Also, at least in the case of cardiac arrest, there appears to be a loss of production of creatinine meaning that the norm *should* be a loss of creatinine concentration - ie in such cases stable creatinine may be AKI.(!)
Article Combining creatinine and volume kinetics identifies missed c...
I completely agree with Kristian and John. Moreover, I would refrain from using postprocedural serum creatinine as reference not just because it could have been influenced (in this case lowered) by hemodilution, but because procedures such as, e.g., percutaneous cardiac interventions with x-ray contrast and surgery with cardiopulmonary bypass may induce an immediate drop in glomerular filtration rate, such that serum creatinine increases during the procedure already.
agree fully with colleagues that first patient has already developed AKI by KDIGO demonstrating increase in cr of 40mmol/l, within 24 hours, however second patient can not be excluded from AKI as the creatinine values given are only for first 24 hours and definitely showing a rising trend which in next 24 hour may be more than 26.5mmol/l increase from baseline of 100 unless documented to show a reduction within defined time limit of 48 hours.
I agree that the baseline value is the most correct to calculate the delta
Thank you for your replies.
John W Pickering thank you for the interesting paper.
It is very intuitive to refer to the baseline value. However, the 48h criterium (in KDIGO guidelines) is thought to be a moveable window. I feel that guidelines should precisely define periprocedural AKI.
Czesc Marta, nie ma za co.
Yes, the 48 moveable window is part of the definition, but I think caution should be applied when using it, especially in dynamic situations. For example, following many procedures there is a fall in creatinine, if the new lower creatinine is used as a new reference and there is a >0.3 mg/dl rise in creatinine over the next 48 hours it is not necessarily due to AKI. As you suggest, there may need to be some changes to guidelines to reflect such phenomena.
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