Acute Kidney Injury: Classification and Staging

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ABSTRACT
Cedera ginjal akut (AKI) merupakan masalah klinis yang penting, terutama dalam
pengaturan pasien pada perawatan kritis dan penyakit kardiovaskular. Acute kidney
injury (AKI) is an important clinical issue, especially in the setting of critical care and
cardiovascular disease. the definition of AKI for clinical and translational research
purposes may be somewhat different than what is used for clinical or
epidemiological purposes. While clinicians can manage significant uncertainty in a
diagnosis and treat patients as diagnostic studies unfold, interventional studies
require operational definitions of disease that are more stringent, and specific
formal rules for inclusion, exclusion and outcome adjudication.
PENDAHULUAN

AKI has been shown in multiple studies to be a key independent risk factor for mortality,
even after adjustment for demographics, severity of illness and other relevant factors. 1,2 It is a
complex clinical syndrome for which there was no accepted definition for quite some time.
Reported incidence and mortality rates vary widely in the literature, with incidence ranging from
1 to 31% and mortality from 28 to 82%.3 This wide variation stems not only from the diverse
patient populations in the different studies, but also from the disparate criteria used to define AKI
in these studies. Over 30 definitions of acute renal failure/AKI have been used in the literature.
There is wide agreement that a generally applicable classification system is required for
AKI which helps to standardize estimation of severity of renal dysfunction and to predict
outcome associated with this condition.3,4 Such a classification was needed to bring order to the
AKI literature, in much the same way that consensus definitions for sepsis, 5 acute respiratory
distress syndrome and acute lung injury have done.6
The Acute Dialysis Quality Initiative,7 and subsequently the Acute Kidney Injury
Network (AKIN) [10], have recognized such requirements and have worked to identify a
uniform standard definition for diagnosing and classifying AKI. Hence, the RIFLE (Risk-InjuryFailure-Loss-End-stage renal disease) and AKIN classifications were developed. These
classifications are discussed in detail elsewhere.4,7,8
RIFLE and AKIN
In 2004, the Acute Dialysis Quality Initiative group published their consensus definition
for AKI, called the RIFLE classification. 7 Being a definition, it is intended to establish the
presence or absence of the clinical syndrome of AKI 26 Cruz Bagshaw Ronco Ricciin a
given patient or situation, and to describe the severity of this syndrome. RIFLE uses two criteria:

(1) change in blood creatinine or GFR from a baseline value, and (2) urine flow rates per body
weight over a specified time period (1). Patients are classified on the basis of the criteria which
places them in the worse category. Risk is the least severe category of AKI, followed by Injury,
and Failure is the most severe category. RIFLE is therefore also able to describe the change or
trend in AKI severity over time. Loss and ESRD are outcome categories; a patient with AKI is
considered to have a clinical outcome of loss if he continues to require renal replacement therapy
(RRT) for >4 weeks. If such a patient continues to require RRT for >3 months, he is considered
to have reached ESRD.
In 2007, a modified version of the RIFLE classification was published, also known as the
AKIN classification (table 1).8 Five modifications are readily recognized: (1) Risk, Injury, and
Failure have been replaced with stages 1, 2 and 3, respectively; (2) the change in GFR criteria
has been eliminated; (3) an absolute increase in creatinine of at least 0.3 mg/dl has been added to
stage 1; (4) patients starting RRT are automatically classified as stage 3, regardless of creatinine
and urine output, and (5) the outcome categories of Loss and ESRD have been eliminated. The
AKIN classification also introduces a dynamic component. It proposes an observation period of
48 h for the defined changes in each stage of AKI to occur, providing a measure of acuity which
can be used for differentiation from slow changes in renal function occurring over longer
periods. Additionally, by this definition changes in renal function may be determined
independent of the baseline creatinine values. Furthermore, AKIN attempts to exclude transient
changes in creatinine or urine output due to volume depletion or other easily reversible causes by
recommending the exclusion of urinary tract obstructions or easily reversible causes of
decreased urine output and application of the diagnostic criteria ideally following adequate
resuscitation.Since their publication, the use of these consensus definitions has increased
substantially in the medical literature.
To date, over 45 studies have used either RIFLE or AKIN to define AKI.9-15 Although,
as noted above, differences exist between the two classifications, these appear to be relatively
minor. In these studies, AKI diagnosed using either criteria is associated with poor clinical
outcome. Overall, worse RIFLE or AKIN class is associated with higher mortality, and longer
ICU or hospital stay. This biological gradient generally held true regardless of the type of patient
population studied.9 Furthermore, even mild AKI (RIFLE class Risk or AKIN stage I), is
significantly associated with adverse patient events. Therefore, the essential components of a
workable consensus definition are: (1) It should clearly establish the presence or absence of the
disease, (2) must give an idea of the severity of the disease, (3) should correlate disease severity
with outcome, and most importantly, (4) it should be easy to understand and apply in a variety of
clinical and research settings.4

Tabel 1.RIFLE and AKIN classifications for AKI

UO = Urine output; RRT = renal replacement therapy. Adapted from Bellomo et al.
and Mehta et al.
1

Patients who receive RRT are considered to have met the criteria for stage 3
irrespective of the stage they are in at the time of RRT commencement.
RINGKASAN
In recent years, the use of the consensus definitions of AKI (RIFLE and AKIN)
in the literature has increased substantially. This suggests a highly encouraging
acceptance by the medical community of a unifying definition for AKI.
DAFTAR PUSTAKA
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