RE: Acute kidney Injury Criteria
Hello, Dr. Gold
Regarding the RIFLE and KDIGO criteria often used in conjunction w/ renal injury/failure, is there a statement in either consensus publication documenting that when the Cr may appear to meet criteria for AKI, Stage 1, if the changes in Serum Cr are easily and promptly reversed w/ fluids, the diagnosis is not valid? (hypovolemic, pre-renal)
(I can't find that statement or restrictions in the definitions, and need to ensure I have not overlooked this important concept).
Specifically referring to the concept that serum Cr should 'rise at least 0.3' from baseline in order for the diagnosis to be entertained.
I know many consider such changes only dehydration, not meeting criteria for AKI.
Thank you!
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Regarding the RIFLE and KDIGO criteria often used in conjunction w/ renal injury/failure, is there a statement in either consensus publication documenting that when the Cr may appear to meet criteria for AKI, Stage 1, if the changes in Serum Cr are easily and promptly reversed w/ fluids, the diagnosis is not valid? (hypovolemic, pre-renal)
(I can't find that statement or restrictions in the definitions, and need to ensure I have not overlooked this important concept).
Specifically referring to the concept that serum Cr should 'rise at least 0.3' from baseline in order for the diagnosis to be entertained.
I know many consider such changes only dehydration, not meeting criteria for AKI.
Thank you!
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Comments
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E037E0--
http://www.acphospitalist.org/archives/2013/10/coding.htm
Ask Dr. Pinson
Q: Our Clinical Documentation Improvement (CDI) program has struggled with the clinical definition of acute renal failure because we seem to get conflicting information and advice. Can you help us?
A: The most current professional terminology for acute renal failure is now “acute kidney injury” (AKI).
According to a Kidney Disease Improving Global Outcomes (KDIGO) consensus statement published in 2012, AKI occurs when one of the following is identified:
An increase in serum creatinine by 0.3 mg/dL or more from baseline within 48 hours, or
An increase in serum creatinine to 1.5 times baseline, which is known or presumed to have occurred within the previous seven days, or
Urine volume (output) of less than 0.5 mL/kg/h for six hours or more.
These criteria are based on recent surprising research findings that even small incremental changes in creatinine of 0.3 to 0.5 mg/dL over a short period of time are associated with statistically significant adverse complications and outcomes including progression to end stage renal disease.
If the baseline creatinine is unknown, KDIGO recommends that the lowest creatinine level reached during hospitalization be considered “baseline” to determine if AKI has occurred using the “1.5 times baseline” criterion. For example, admission creatinine is 2.0; after hydration, the lowest creatinine reached is 1.2 (taken to be the baseline). 1.5 times 1.2 is 1.8. Since 2.0 is greater than 1.8, this patient had AKI at the time of admission.
KDIGO also offers physicians broad discretion to “presume” that the increase may have occurred within seven days. When a patient is admitted with an acute illness and his creatinine is elevated, the guidelines suggest it may be considered to have occurred during the acute illness, so long as there is no particular history of pre-existing kidney disease. Even a baseline obtained a year ago may be used for the 1.5 criterion, if there is no reason to suspect a change prior to the acute illness.
On the other hand, the “0.3 mg/dL increase from baseline” criterion is quite restrictive and may only be applied prospectively or when the baseline has been measured within the 48 hours preceding admission. Likewise the urine output must be measured over at least six hours for this criterion to be used.
KDIGO guidelines are available online .
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http://www.uptodate.com/contents/definition-of-acute-kidney-injury-acute-renal-failure?source=search_result&search=acute+renal+failue&selectedTitle=4~150
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
I love uptodate and it is great. I still cannot find the citing for aki REQUIRING FLUID to diagnsose Aki- in KDIGO. In fact what I had learned was creatinine not responsive to fluid after 72 hours (3 days) we would be looking at the possibility of ATN… this article from UpToDate supports that… It seems to list dehydration as a reason for AKI. But there are patients who come in to the ED with elevated BUN without elevated Creatinine, that seems to make sense to dx dehydration and not aki…and then would they be inpatient??
Maybe my recall is wrong but I thought I had seen an article saying that the KDIGO was the most recent consensus and that is what the standard to should be used ( I will keep looking). I thought one of the point of KDIGO criteria was that smaller insults have a great significance to impacting mortality.
http://www.uptodate.com/contents/etiology-and-diagnosis-of-prerenal-disease-and-acute-tubular-necrosis-in-acute-kidney-injury-acute-renal-failure?source=see_link
PATHOPHYSIOLOGY — AKI is characterized by an abrupt decrease in renal function. The etiology can be classified into prerenal, intrinsic renal, and postrenal causes…. common cause of prerenal disease is true volume depletion, which includes hypovolemia caused by dehydration,hemorrhage, or renal (diuretics) or gastrointestinal (vomiting, diarrhea) fluid loss. Renal perfusion can also be reduced in edematous states such as heart failure and cirrhosis due to myocardial dysfunction and splanchnic venous pooling and systemic vasodilation, respectively….Response to fluid repletion — The gold standard for the distinction between prerenal disease secondary to volume depletion and postischemic or nephrotoxic ATN is the response to fluid repletion. If sufficient fluid is given to reverse any signs of volume depletion (eg, hypotension, cool extremities, low FENa and urine-sodium concentration), return of the serum creatinine to the previous baseline within 24 to 72 hours is considered to represent correction of prerenal disease, whereas persistent AKI is considered to represent ATN…
Ann
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This is my go to reference with test yourself questions at the end.
http://www.hcpro.com/content/280215.ppt
Charlie
Why is AKIN the only statement that mentions the need for hydration? and when KDIGO attempted to update AKIN and Rifle criteria in 2012… why did they not include this as a needed element for diagnosis?
The conference materials are from 2012…do they take into account KDIGOs 2012 recommendation?
In looking at the 2012 conference materials… the following slide says...Per KDIGO, “acute renal failure” terminology to be replaced by “acute kidney injury” (((( my words not conference— then why the change in terminology if it’s not meant to indicate a change? This is really not clear to me...
Problem: “AKI” currently codes to “ARF”
Therefore, physicians should not document AKI unless they truly mean ARF
Watch for clinicians using AKI to describe any acute renal abnormality even if does not meet ARF criteria
Some physicians will adopt this new terminology regardless of coding implications
May increase need for query clarifications, so do not report ARF when not actually present…
i
If the term AKI was developed to include that smaller increments MATTER??? this seems counterintuitive to introducing a new term in the first place…. I feel like I am missing something here???
and this slide… seems totally irrelevant??????
Presently, no documentation benefit for physicians documenting stage of AKI
Hopefully … ICD-9 or ICD-10 codes will be created for AKI stages
Suspect … Stages 1 & 2 will be CCs while Stage 3 will be an MCC
Start medical staff education of stages when AKI codes definitively arrive
Teaching new failure definitions tough enough without confusing issue with stages
slide 32- talks about a 1.0 increase over baseline..
Charlie- i am confused on what you are saying here.
I have a feeling this is another are where while the answer SEEMS like it should have a clear definition, there really is not conscensus. IF Hydration IS REQUIRED, it seems the consensus statements would clarify. I wrote to KDIGO askign for clarificaiton on the subject… maybe if others did so they would see that it would be a helpful clarification to medical personel in making sure the most accurate diagnosisis is included, without inaccurately over diagnosing.
Thanks!
We took the RIFLE and KDIGO to our medical staff and Nephrologist, and they endorse KDIGO, which is silent regarding hydration. I’d suggest one take the definitions to staff and ask for confirmation of validity..probably we have all done this. Place the definition approved by your medical staff (and Compliance) and include on query forms.
RIFLE was written a few years prior to KDIGO, our staff endorsed KDIGO as more relevant.
Regarding the term “AKI” – I’d caution you to get documentation of Acute Kidney Injury or Failure ‘at least once’ in the chart and do not assume the abbreviation defaults to 584.9 – it does not – it could be used to mean acute kidney insufficiency.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
Am I wrong to state that medicine has advanced, and now has new tools to help clinicians recognize, diagnosis, and treat conditions earlier than in the past? Think about Troponin in context of AMI as an example. In a similar fashion, have advances in Radiological Diagnostic Imaging tools helped clinicians diagnosis new, albeit small areas of brain infarct that may have been classified as TIA 20 years ago?
I think that CMS has a well-stated policy of being ‘revenue neutral’. When KDIGO published the new definition for AKI, this lead to more documentation of a disorder than it the past. CMS analyzed cost data, resulting in a downgrade from MCC to CC based upon increased incidence of documentation and subsequent coding.
If our staff are documenting the disease as per the guidelines that have endorsed, how is that over documentation?
“CDI and Coding’ did not kill the MCC…medical practice evolved, and CDI and Coding followed. Medicare made an adjustment in order to save their budget as the incidence of AKI rose.
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org