Applying KDIGO criteria to AKI

mthornell2013

There is much debate in my company concerning the application of the "Increase in creatinine >0.3 mg/dl" criteria. KDIGO notes that the 0.3 criterion can only be applied "prospectively" when the baseline has been measured whtin the "preceding 48 hours." Some say this can be applied in the situation where a pt. is admitted with Cr 1.2 which decreases during the stay to 0.9. I argue that the term "prospectively" would apply to an increase after the 1.2 creatinine but would not apply to the 0.3 decrease. If so, why do they specifically say that the x1.5 criterion works both prostpectively AND retrospectively? Please- if someone can provide us with "official" clarification and examples? That would be wonderful. It seems clear to me, but it apparently seems clear to them also.

evanspx@sutterhealth.org

Here is what “I” do.  Others may disagree.  On pad, excuse typos.

If SCr increases 0.3 or greater over 48 hours after admission,  it is N17.9.  The increase meets KDIGO and SCr increased by 0.3 or greater within 48 hour period.  

Example: Admit SCr of 1.0 increases suddenly to 1.4, and returns to 1.0 with fluids.

Or

 Change in SCr  increase of 1.5 or greater in baseline over seven days.  

Admitted with SCr of 3.6 which decreases to 1.8 on discharge meets definition fo N17.9

Not sure if this answers your questions and interested to see any other opinions.

Paul Evans, RHIA, CCDS

afloyd24

We have also debated at our facility regarding the increase/decrease serum Cr on admission to which I have asked if that means AKI will always be not POA?? Some have argued that it did not "increase" after admission but decreased so the patient does not have AKI. I use the below criteria with the CDS and Coding Teams and have used this for denials with success (not 100% - I'm not superhuman).  I would recommend anyone who does question this to take the time to read the KDIGO Guidelines.   From the current CDI Journal Jan/Feb 2019 on page 11 - KDIGO says that many AKI cases begin prior to hospitalization, so clinicians “may be faced with patients in whom kidney function is already decreased and, during the hospitalization, improves rather than worsens.”  From KDIGO, page 18 -  "University of Pittsburgh suggests that roughly a third of AKI cases are community-acquired  and many cases may be missed by limiting analysis to documented increases in SCr.  Indeed, the majority of cases of AKI in the developing world are likely to be community-acquired."  From KDIGO, page 33 -  "Importantly, excluding some cases of hemodilution secondary to massive fluid resuscitation (discussed below), the lowest SCr obtained during a hospitalization is usually equal to or greater than the baseline. This SCr should be used to diagnose (and stage) AKI."  VOLUME 2 | ISSUE 1 | MARCH 2012 http://www.kidney-international.org 

proddy@clarionhospital.org

when it is a patient who usually gets labs done at our hospital, I look at the old labs and calculate a baseline, if they have a creatinine >1.5 the baseline, then I query giving a range of the creat and GFR over the past 6 months or so as well as an average from that same time-frame.  I am using the word 'average" and not the terminology "baseline" (unless the progress notes or H/P has already documented a baseline)  

mthornell2013

Thanks everyone! Very helpful especially the KDIGO info!