New definition of AKI: shifting the focus beyond mortality

IF 8.8 1区 医学 Q1 CRITICAL CARE MEDICINE Critical Care Pub Date : 2024-11-20 DOI:10.1186/s13054-024-05170-0
Lihong Zhu, Juan Lin
{"title":"New definition of AKI: shifting the focus beyond mortality","authors":"Lihong Zhu, Juan Lin","doi":"10.1186/s13054-024-05170-0","DOIUrl":null,"url":null,"abstract":"<p>To the editor,</p><p>We read with great interest the recent study [1] by Dr. Machado et al., which proposed a new definition for acute kidney injury (AKI) in critically Ill patients, based on varied urine output thresholds and time frames. This study uses in-hospital mortality as an outcome-oriented approach to compose the proposed UO-AKI classification, applying different time frames (3 h, 6 h, 12 h, and 24 h) and distinct cutoff points. Ultimately, the average UO over 6-h frame was used for the new classification, and AKI was redefined as follows: stage 1 (0.2–0.3 mL/kg/h), stage 2 (0.1–0.2 mL/kg/h), and stage 3 (&lt; 0.1 mL/kg/h) over 6 h. this proposed classification demonstrated superior predictive accuracy over the KDIGO criteria, with improved NRI and IDI for mortality. However, some details need to be considered carefully when interpreting and applying the findings.</p><p>First, in the current study, the ability to predict death was used as a criterion to evaluate the quality of AKI criteria. However, the essence of the AKI definition is to reflect impaired excretion of metabolic waste due to damage to the renal tubules and/or renal interstitium. Moreover, not all AKI stages are associated with increased mortality. For instance, in a prospective study [2] including 4683 patients, Kaddourah et al. reported that severe AKI (stage 2–3) conferred an increased risk of death by day 28 after adjustment for 16 covariates while mild AKI stage 1 was not. Similarly, an analysis [3] of two large trials (COVID-19 Critical Care Consortium and LUNG-SAFE studies) showed that both 28-day and 90-day mortality risk was increased for patients with stage 2 (HR 2.00, <i>p</i> &lt; 0.001) and stage 3 AKI (HR 1.95, <i>p</i> &lt; 0.001), but not for stage 1. Therefore, using a mortality-oriented approach to define AKI may overlook the significance of mild AKI (stage 1) and may explain why the proposed classification's urine volume threshold for AKI stage 1 (0.2–0.3 mL/kg/h) is similar to the stage 3 threshold (0.3 mL/kg/h) in the KDIGO guidelines, albeit with different time frames. Also, this approach could introduce bias into the understanding of AKI’s clinical significance, as it focuses solely on the risk of death while neglecting the kidney dysfunction and injury that are essential to the definition of AKI. In addition, we are also somewhat unclear about the time frame definition. Were all time frames measured as the corresponding hours after ICU admission, or were they sliding windows? This distinction may be important for accurately defining AKI.</p><p>Finally, we commend Dr. Machado et al. for their significant work, and we hope our perspectives will help in the interpretation of these findings.</p><p>No datasets were generated or analysed during the current study.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Machado GD, Santos LL, Liborio AB. Redefining urine output thresholds for acute kidney injury criteria in critically Ill patients: a derivation and validation study. Crit Care. 2024;28(1):272.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"2.\"><p>Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically Ill children and young adults. N Engl J Med. 2017;376(1):11–20.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"3.\"><p>McNicholas BA, Rezoagli E, Simpkin AJ, Khanna S, Suen JY, Yeung P, Brodie D, Li Bassi G, Pham T, Bellani G, et al. Epidemiology and outcomes of early-onset AKI in COVID-19-related ARDS in comparison with non-COVID-19-related ARDS: insights from two prospective global cohort studies. Crit Care. 2023;27(1):3.</p><p>Article PubMed PubMed Central Google Scholar </p></li></ol><p>Download references<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><p>Not applicable.</p><h3>Authors and Affiliations</h3><ol><li><p>Department of Intensive Care, Zhejiang Hospital, 12# Linyin Road, No. 1229, Gudun Road, Hangzhou, 310013, Zhejiang, People’s Republic of China</p><p>Lihong Zhu &amp; Juan Lin</p></li></ol><span>Authors</span><ol><li><span>Lihong Zhu</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li><li><span>Juan Lin</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li></ol><h3>Contributions</h3><p>Lihong Zhu raised the question and Juan Lin wrote the letter. All authors have reviewed and approved the letter.</p><h3>Corresponding author</h3><p>Correspondence to Juan Lin.</p><h3>Ethics approval and consent to participate</h3>\n<p>Not applicable.</p>\n<h3>Consent for publication</h3>\n<p>Not applicable.</p>\n<h3>Competing interests</h3>\n<p>The authors declare no competing interests.</p><h3>Publisher's Note</h3><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p><p><b>Open Access</b> This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.</p>\n<p>Reprints and permissions</p><img alt=\"Check for updates. 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New definition of AKI: shifting the focus beyond mortality. <i>Crit Care</i> <b>28</b>, 379 (2024). https://doi.org/10.1186/s13054-024-05170-0</p><p>Download citation<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><ul data-test=\"publication-history\"><li><p>Received<span>: </span><span><time datetime=\"2024-11-07\">07 November 2024</time></span></p></li><li><p>Accepted<span>: </span><span><time datetime=\"2024-11-11\">11 November 2024</time></span></p></li><li><p>Published<span>: </span><span><time datetime=\"2024-11-20\">20 November 2024</time></span></p></li><li><p>DOI</abbr><span>: </span><span>https://doi.org/10.1186/s13054-024-05170-0</span></p></li></ul><h3>Share this article</h3><p>Anyone you share the following link with will be able to read this content:</p><button data-track=\"click\" data-track-action=\"get shareable link\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Get shareable link</button><p>Sorry, a shareable link is not currently available for this article.</p><p data-track=\"click\" data-track-action=\"select share url\" data-track-label=\"button\"></p><button data-track=\"click\" data-track-action=\"copy share url\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Copy to clipboard</button><p> Provided by the Springer Nature SharedIt content-sharing initiative </p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":"74 1","pages":""},"PeriodicalIF":8.8000,"publicationDate":"2024-11-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Critical Care","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1186/s13054-024-05170-0","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CRITICAL CARE MEDICINE","Score":null,"Total":0}
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Abstract

To the editor,

We read with great interest the recent study [1] by Dr. Machado et al., which proposed a new definition for acute kidney injury (AKI) in critically Ill patients, based on varied urine output thresholds and time frames. This study uses in-hospital mortality as an outcome-oriented approach to compose the proposed UO-AKI classification, applying different time frames (3 h, 6 h, 12 h, and 24 h) and distinct cutoff points. Ultimately, the average UO over 6-h frame was used for the new classification, and AKI was redefined as follows: stage 1 (0.2–0.3 mL/kg/h), stage 2 (0.1–0.2 mL/kg/h), and stage 3 (< 0.1 mL/kg/h) over 6 h. this proposed classification demonstrated superior predictive accuracy over the KDIGO criteria, with improved NRI and IDI for mortality. However, some details need to be considered carefully when interpreting and applying the findings.

First, in the current study, the ability to predict death was used as a criterion to evaluate the quality of AKI criteria. However, the essence of the AKI definition is to reflect impaired excretion of metabolic waste due to damage to the renal tubules and/or renal interstitium. Moreover, not all AKI stages are associated with increased mortality. For instance, in a prospective study [2] including 4683 patients, Kaddourah et al. reported that severe AKI (stage 2–3) conferred an increased risk of death by day 28 after adjustment for 16 covariates while mild AKI stage 1 was not. Similarly, an analysis [3] of two large trials (COVID-19 Critical Care Consortium and LUNG-SAFE studies) showed that both 28-day and 90-day mortality risk was increased for patients with stage 2 (HR 2.00, p < 0.001) and stage 3 AKI (HR 1.95, p < 0.001), but not for stage 1. Therefore, using a mortality-oriented approach to define AKI may overlook the significance of mild AKI (stage 1) and may explain why the proposed classification's urine volume threshold for AKI stage 1 (0.2–0.3 mL/kg/h) is similar to the stage 3 threshold (0.3 mL/kg/h) in the KDIGO guidelines, albeit with different time frames. Also, this approach could introduce bias into the understanding of AKI’s clinical significance, as it focuses solely on the risk of death while neglecting the kidney dysfunction and injury that are essential to the definition of AKI. In addition, we are also somewhat unclear about the time frame definition. Were all time frames measured as the corresponding hours after ICU admission, or were they sliding windows? This distinction may be important for accurately defining AKI.

Finally, we commend Dr. Machado et al. for their significant work, and we hope our perspectives will help in the interpretation of these findings.

No datasets were generated or analysed during the current study.

  1. Machado GD, Santos LL, Liborio AB. Redefining urine output thresholds for acute kidney injury criteria in critically Ill patients: a derivation and validation study. Crit Care. 2024;28(1):272.

    Article PubMed PubMed Central Google Scholar

  2. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically Ill children and young adults. N Engl J Med. 2017;376(1):11–20.

    Article PubMed Google Scholar

  3. McNicholas BA, Rezoagli E, Simpkin AJ, Khanna S, Suen JY, Yeung P, Brodie D, Li Bassi G, Pham T, Bellani G, et al. Epidemiology and outcomes of early-onset AKI in COVID-19-related ARDS in comparison with non-COVID-19-related ARDS: insights from two prospective global cohort studies. Crit Care. 2023;27(1):3.

    Article PubMed PubMed Central Google Scholar

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Authors and Affiliations

  1. Department of Intensive Care, Zhejiang Hospital, 12# Linyin Road, No. 1229, Gudun Road, Hangzhou, 310013, Zhejiang, People’s Republic of China

    Lihong Zhu & Juan Lin

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Lihong Zhu raised the question and Juan Lin wrote the letter. All authors have reviewed and approved the letter.

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Correspondence to Juan Lin.

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The authors declare no competing interests.

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Zhu, L., Lin, J. New definition of AKI: shifting the focus beyond mortality. Crit Care 28, 379 (2024). https://doi.org/10.1186/s13054-024-05170-0

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AKI 的新定义:将关注点从死亡率转移到其他方面
致编辑:我们饶有兴趣地阅读了马查多博士等人最近的研究[1],他们根据不同的尿量阈值和时间框架,提出了重症患者急性肾损伤(AKI)的新定义。本研究将院内死亡率作为结果导向的方法,应用不同的时间框架(3 小时、6 小时、12 小时和 24 小时)和不同的截断点来组成所提出的 UO-AKI 分类。最终,新的分类采用了 6 小时内的平均 UO 值,AKI 被重新定义为:6 小时内的 1 期(0.2-0.3 mL/kg/h)、2 期(0.1-0.2 mL/kg/h)和 3 期(&lt; 0.1 mL/kg/h)。与 KDIGO 标准相比,所提出的分类显示出更高的预测准确性,死亡率的 NRI 和 IDI 也有所提高。然而,在解释和应用研究结果时,需要仔细考虑一些细节。首先,在当前的研究中,预测死亡的能力被用作评估 AKI 标准质量的标准。然而,AKI 定义的本质是反映肾小管和/或肾间质受损导致的代谢废物排泄障碍。此外,并非所有的 AKI 阶段都与死亡率增加有关。例如,在一项包括 4683 名患者的前瞻性研究[2]中,Kaddourah 等人报告称,在对 16 个协变量进行调整后,重度 AKI(2-3 期)会增加第 28 天的死亡风险,而轻度 AKI 1 期则不会。同样,对两项大型试验(COVID-19 重症监护联盟和 LUNG-SAFE 研究)的分析[3]显示,AKI 第 2 期(HR 2.00,p &lt; 0.001)和第 3 期(HR 1.95,p &lt; 0.001)患者的 28 天和 90 天死亡风险均增加,而第 1 期患者则没有增加。因此,使用以死亡率为导向的方法来定义 AKI 可能会忽略轻度 AKI(1 期)的重要性,这也可以解释为什么拟议分类中 AKI 1 期的尿量阈值(0.2-0.3 mL/kg/h)与 KDIGO 指南中的 3 期阈值(0.3 mL/kg/h)相似,尽管时间范围不同。而且,这种方法可能会使人们对 AKI 临床意义的理解出现偏差,因为它只关注死亡风险,而忽视了对 AKI 定义至关重要的肾功能障碍和损伤。此外,我们对时间框架的定义也有些不清楚。所有的时间框架都是以 ICU 入院后的相应小时来衡量的,还是以滑动窗口来衡量的?这一区别对于准确定义 AKI 可能非常重要。最后,我们对 Machado 博士等人所做的重要工作表示赞赏,希望我们的观点有助于对这些研究结果的解释。重新定义重症患者急性肾损伤标准的尿量阈值:推导与验证研究》。Crit Care.2024; 28(1):272.Article PubMed PubMed Central Google Scholar Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A. Epidemiology of acute kidney injury in critically Ill children and young adults.N Engl J Med.2017;376(1):11-20.Article PubMed Google Scholar McNicholas BA, Rezoagli E, Simpkin AJ, Khanna S, Suen JY, Yeung P, Brodie D, Li Bassi G, Pham T, Bellani G, et al. Epidemiology and outcomes of early-onset AKI in COVID-19-related ARDS in comparison with non-COVID-19-related ARDS: insights from two prospective global cohort studies.Crit Care.2023;27(1):3.Article PubMed PubMed Central Google Scholar Download referencesNot applicable.作者及单位浙江医院重症医学科,浙江省杭州市古墩路1229号林荫路12#。作者朱丽红查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者林娟查看作者发表的论文您也可以在PubMed Google Scholar中搜索该作者供稿朱丽红提出问题,林娟撰写信函。伦理批准和参与同意书不适用.发表同意书不适用.利益冲突作者声明无利益冲突.出版者注释施普林格-自然(Springer Nature)对发表的地图中的管辖权主张和机构隶属关系保持中立。开放获取本文采用知识共享署名-非商业性-禁止衍生 4.0 国际许可协议进行许可,该协议允许以任何媒介或格式进行任何非商业性使用、共享、分发和复制,只要您适当注明原作者和来源,提供知识共享许可协议的链接,并说明您是否修改了许可材料。根据本许可协议,您无权分享从本文或其中部分内容衍生的改编材料。
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来源期刊
Critical Care
Critical Care 医学-危重病医学
CiteScore
20.60
自引率
3.30%
发文量
348
审稿时长
1.5 months
期刊介绍: Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.
期刊最新文献
D-PRISM: a global survey-based study to assess diagnostic and treatment approaches in pneumonia managed in intensive care Evaluation of severe rhabdomyolysis on day 30 mortality in trauma patients admitted to intensive care: a propensity score analysis of the Traumabase registry Do prolonged infusions of β-lactam antibiotics improve outcomes in critically ill patients with sepsis? It is time to say yes New definition of AKI: shifting the focus beyond mortality Three-year mortality of ICU survivors with sepsis, an infection or an inflammatory illness: an individually matched cohort study of ICU patients in the Netherlands from 2007 to 2019
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