Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury
© Mehta et al.; licensee BioMed Central Ltd. 2007
Received: 8 December 2006
Accepted: 1 March 2007
Published: 1 March 2007
Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI.
Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results.
The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed.
We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.
Acute renal failure (ARF) is a complex disorder that occurs in a variety of settings with clinical manifestations ranging from a minimal elevation in serum creatinine to anuric renal failure. It is often under-recognized and is associated with severe consequences [1–4]. Recent epidemiological studies demonstrate the wide variation in etiologies and risk factors [1, 5–7], describe the increased mortality associated with this disease (particularly when dialysis is required) [1, 4, 6, 8, 9], and suggest a relationship to the subsequent development of chronic kidney disease (CKD) and progression to dialysis dependency [1, 4, 8, 10–12]. Emerging evidence suggests that even minor changes in serum creatinine are associated with increased in-patient mortality [13–20]. ARF has been the focus of extensive clinical and basic research efforts over the last decades. The lack of a universally recognized definition of ARF has posed a significant limitation. Despite the significant progress made in understanding the biology and mechanism of ARF in animal models, translation of this knowledge into improved management and outcomes for patients has been limited.
During the last five years, several groups have recognized these limitations and have worked to identify the knowledge gaps and define the necessary steps to correct these deficiencies. These efforts have included consensus conferences and publications from the Acute Dialysis Quality Initiative (ADQI) group [19, 21–25], the American Society of Nephrology (ASN) ARF Advisory group , the International Society of Nephrology (ISN), and the National Kidney Foundation (NKF) and KDIGO (Kidney Disease: Improving Global Outcomes) groups . Additionally, the critical care societies have developed formal intersociety collaborations such as the International Consensus Conferences in Critical Care . Recognizing that future clinical and translational research in ARF will require multidisciplinary collaborative networks, the ADQI group and representatives from three nephrology societies (ASN, ISN, and NKF) and the European Society of Intensive Care Medicine met in Vicenza, Italy, in September 2004. They proposed the term acute kidney injury (AKI) to reflect the entire spectrum of ARF, recognizing that an acute decline in kidney function is often secondary to an injury that causes functional or structural changes in the kidneys. The group established the Acute Kidney Injury Network (AKIN) as an independent collaborative network comprised of experts selected by the participating societies to represent both their area of expertise and their sponsoring organization. AKIN is intended to facilitate international, interdisciplinary, and intersocietal collaborations to ensure progress in the field of AKI and obtain the best outcomes for patients with or at risk for AKI.
This report describes an interim definition and staging system for AKI and a plan for further activities of the collaborative network which were developed at the first AKIN conference held in Amsterdam, The Netherlands, in September 2005.
Materials and methods
Representatives of the major critical care and nephrology societies and associations and invited content experts were assigned to workgroups to consider three topics: (a) the development of uniform standards for definition and classification of AKI, (b) joint conference topics, and (c) the interdisciplinary collaborative research network. Each workgroup had an assigned chair and co-chair to facilitate the discussion and develop summary recommendations of the workgroup. The draft recommendations were then refined and improved during discussion with the larger group. Key points and issues were noted and then discussed a second time if no resolution was reached initially. When a majority view was not evident or when the area was felt to be of extreme importance, votes were tallied. Dissenting opinions were also noted. The final recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. After an iterative process of revisions, the final manuscript was presented to each of the respective societies for endorsement. Societies were asked to facilitate dissemination of the findings to their membership through presentations in society conferences and publication of summary reports in society journals, Web sites, and other forms of communication.
1. Proposal for uniform standards for definition and classification of AKI
Definition and diagnostic criteria of AKI
For any condition, the clinician needs to know whether the disease is present and, if so, where and when the patient falls in the natural history of the disease. The former facilitates recognition whereas the latter defines time points for intervention. Unfortunately, there has been no uniformly accepted definition of AKI. Studies describe ARF or AKI based on serum creatinine changes, absolute levels of serum creatinine, changes in blood urea nitrogen or urine output, or the need for dialysis [1, 11, 20, 29–36]. The wide variation in definitions has made it difficult to compare information across studies and populations .
Diagnostic criteria for acute kidney injury
An abrupt (within 48 hours) reduction in kidney function currently defined as an absolute increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l), a percentage increase in serum creatinine of more than or equal to 50% (1.5-fold from baseline), or a reduction in urine output (documented oliguria of less than 0.5 ml/kg per hour for more than six hours).
1. The definition needs to be broad enough to accommodate variations in clinical presentation over age groups, locations, and clinical situations.
2. Sensitive and specific markers for kidney injury are not currently available in clinical practice. Several groups are working on developing and validating biomarkers of kidney injury and GFR which may be used in the future for diagnosis and prognosis.
3. There is accumulating evidence that small increments in serum creatinine are associated, in a variety of settings, with adverse outcomes [13–20] that are manifest in short-term morbidity and mortality and in longer-term outcomes, including 1-year mortality [15–17]. Current clinical practice does not focus much attention on small increments in serum creatinine, which are often attributed to lab variations. However, the coefficient of variation of serum creatinine with modern analyzers is relatively small and therefore increments of 0.3 mg/dl (25 μmol/l) are unlikely to be due to assay variation . Changes in volume status can influence serum creatinine levels . Because the amount of fluid resuscitation depends on the underlying clinical situation , the group agreed that application of the diagnostic criteria would be used only after an optimal state of hydration had been achieved.
4. A time constraint of 48 hours for diagnosis was selected based on the evidence that adverse outcomes with small changes in creatinine were observed when the creatinine elevation occurred within 24 to 48 hours [15, 16] and to ensure that the process was acute and representative of events within a clinically relevant time period. In the two aforementioned studies, there was no distinction of underlying CKD or de novo AKI. However, in the study by Chertow and colleagues , the odds ratio for mortality with a change in creatinine of 0.3 mg/dl (25 μmol/l) was 4.1 (confidence interval 3.1 to 5.5) adjusting for CKD. There is no requirement to wait 48 hours to diagnose AKI or initiate appropriate measures to treat AKI. Instead, the time period is designed to eliminate situations in which the increase in serum creatinine by 0.3 is very slow and thus is not 'acute.'
5. It was recognized that AKI is often superimposed on pre-existing CKD. Further validation will be required to determine whether the criterion of a creatinine elevation of 0.3 mg/dl (25 μmol/l) is applicable to these patients (that is, whether a creatinine increase of more than 0.3 mg/dl from an elevated baseline represents AKI and has the same risks as a creatinine increase from a normal baseline).
6. The need for including urine output as a diagnostic criterion is based on the knowledge of critically ill patients in whom this parameter often heralds renal dysfunction before serum creatinine increases.
A minority of group members, both intensivists and nephrologists, felt that a urine output reduction of less than 0.5 ml/kg per hour over the span of six hours was not specific enough to lead confidently to the designation of AKI. It was recognized that the hydration state, use of diuretics, and presence of obstruction could influence the urine volume, hence the need to consider the clinical context. Additionally, accurate measurements of urine output may not be easily available in all cases, particularly in patients in non-intensive care unit settings. Despite these limitations, it was felt that the use of changes in urine offers a sensitive and easily discernible means of identifying patients, but its value as an independent criterion for diagnosis of AKI will need to be validated.
The proposed diagnostic criteria for AKI are designed to facilitate acquisition of new knowledge and validate the emerging concept that small alterations in kidney function may contribute to adverse outcomes. The goal of adopting these explicit diagnostic criteria is to increase the clinical awareness and diagnosis of AKI. It is recognized that there may be an increase in false-positives, so that some patients labeled with AKI will not have the condition. There was consensus that adopting the more inclusive criteria is preferable to the current situation, in which the condition is under-recognized and many people are identified late in the course of their illness and potentially miss the opportunity for prevention or application of strategies to minimize further kidney damage.
Classification/staging system for acute kidney injurya
Serum creatinine criteria
Urine output criteria
Increase in serum creatinine of more than or equal to 0.3 mg/dl (≥ 26.4 μmol/l) or increase to more than or equal to 150% to 200% (1.5- to 2-fold) from baseline
Less than 0.5 ml/kg per hour for more than 6 hours
Increase in serum creatinine to more than 200% to 300% (> 2- to 3-fold) from baseline
Less than 0.5 ml/kg per hour for more than 12 hours
Increase in serum creatinine to more than 300% (> 3-fold) from baseline (or serum creatinine of more than or equal to 4.0 mg/dl [≥ 354 μmol/l] with an acute increase of at least 0.5 mg/dl [44 μmol/l])
Less than 0.3 ml/kg per hour for 24 hours or anuria for 12 hours
1. Although diagnosis of AKI is based on changes over the course of 48 hours, staging occurs over a slightly longer time frame. One week was proposed by the ADQI group in the original RIFLE criteria .
2. There was a conscious decision not to include the therapy for AKI (that is, renal replacement therapy [RRT]) as a distinct stage because this constitutes an outcome of AKI.
3. The new staging system maps to the RIFLE stages as follows:
3a. RIFLE 'Risk' category should have the same criteria as for the diagnosis of stage 1 AKI.
3b. Those who are classified as having 'Injury' and 'Failure' categories map to stages 2 and 3 of AKI.
3c. The 'Loss' and 'End-stage kidney disease' categories were removed from the staging system and remain outcomes.
3d. Given the variability inherent in commencing RRT and due to variability in resources in different populations and countries, patients receiving RRT are to be included in stage 3 (analogous to stage 5 CKD, GFR of less than 15, or dialysis).
2. Future joint conference topics and key collaborative research questions
Potential topics identified for future consensus conferences
Epidemiology of AKI
What is a 'nomenclature' that is based on simple, universally available data and that can identify all patients globally with AKI irrespective of location and age?
What are the data to help determine etiology once AKI is identified?
What are the correlates of AKI in regard to pathology/physiology?
Is there a validated method for assessing severity of AKI separate from multiple organ failure?
What is the relationship between degree of severity and outcomes?
Outcomes from AKI
What are the clinically meaningful outcomes that are important in clinical studies of AKI?
Strategies to change outcomes
Timing of initiation
Modality selection (CRRT, IHD, PD)
Intensity of therapy (dose)
Cessation of renal replacement therapy
Data needed to advance knowledge in AKI
Datasets collected at contact with health care system
Intensive care unit admission
Biological sample repositories
Measures of effectiveness of current processes for changing behavior/attitude of caregivers and ultimately patient outcomes from AKI.
3. Need for an international collaborative network
Recommendations for establishing a collaborative network for acute kidney injury (AKI) research
Principles and approach
Identify the key roles of the participating groups
a. The collaborative effort should be inclusive and open to all interested societies/organizations.
b. Participation in the collaborative organization will require commitment of time, expertise, and/or resources as appropriate to the specific initiative and in accordance with the means of the organization/group.
c. An organizational structure will be required to coordinate the activities.
d. Work products from the collaborative effort will require a mechanism for recognizing the contributions of each group.
Scope of collaborations
a. Identify topics in AKI areas of mutual interest and of wide application.
b. Develop consensus statements for best practice where there is limited or no evidence and where, due to accepted practices, it will be difficult to get evidence.
c. Develop tools to standardize the management of AKI.
d. Develop evidence through clinical research where feasible.
e. Develop practice recommendations/guidelines.
f. Implement guidelines.
Define infrastructure needs
a. Identify key components needed (for example, database, protocols for Web-based information transfer).
b. Establish the requirements for sharing information with regulatory agencies.
c. Define training needs for developing researchers and the resources that are required and define what hurdles will need to be overcome.
d. International collaboration will require identification of peer-reviewed, public, and commercial sources of financial support.
e. Develop an inventory of current collaborative efforts and establish relationships with these existing networks.
Identify common unifying principles that would form the basis of ongoing collaboration
a. Establish protocols for consistent data entry that allows benchmarking of participating units.
b. Identify questions that interest the majority of the participants.
c. Initiate a short-term collaborative project to validate proposed AKI definition as an initial project.
Acute Kidney Injury Network summit meeting participants and workgroups
Interdisciplinary collaborative research network
Interim proposals for terminology, diagnosis, classification, and staging
Acute Dialysis Quality Initiative
Sudhir V Shah
Bruce A Molitoris
American Society of Pediatric Nephrologists
Emmanuel A Burdmann
European Dialysis and Transplant Association-European Renal Association
International Society of Nephrology
Ravindra L Mehta
International Society of Nephrology
David G Warnock
Indian Society of Nephrology
Asian Pacific Society of Nephrology
European Society of Intensive Care Medicine
Charles G Durbin Jr.
Society of Critical Care Medicine
Patrick SK Tan
Asia Pacific Association of Critical Care Medicine
American Thoracic Society
John A Kellum
American College of Chest Physicians
Jean-Roger Le Gall
Joseph V Bonventre
AKI is a complex disorder, and we have proposed uniform standards for diagnosing and classifying AKI on the basis of existing systems (that is, RIFLE). These proposals will require validation.
Our recommendations have been endorsed by participating societies that represent the majority of critical care and nephrology societies worldwide.
These recommendations provide a stepping stone to standardizing the care of patients with AKI and will greatly enhance our ability to design prospective studies to evaluate potential prevention and treatment strategies.
Future clinical and translational research in AKI will require the development of collaborative networks. The AKIN was formed to provide an effective mechanism for facilitating such efforts.
Acute Dialysis Quality Initiative
acute kidney injury
Acute Kidney Injury Network
acute renal failure
American Society of Nephrology
chronic kidney disease
glomerular filtration rate
International Society of Nephrology
National Kidney Foundation
Risk, Injury, Failure, Loss, and End-stage kidney disease
renal replacement therapy.
We would like to recognize the financial support provided by the ASN, ISN, and NKF for the AKIN conference. We are grateful for the logistical support provided by the NKF and the special efforts of Sue Levey for the meeting arrangements. Members from participating societies were supported by their respective societies (see Table 5).
Society and organization endorsements
Acute Dialysis Quality Initiative
American Society of Nephrology, American Society of Pediatric Nephrologists, Asian Pacific Society of nephrology, Chinese Society of Nephrology, European Dialysis and Transplant Association-European Renal Association, Indian Society of Nephrology, International Pediatric Nephrology Association, International Society of Nephrology, National Kidney Foundation, and Sociedade Latino-Americana de Nefrologia e Hipertensão.
American College of Chest Physicians, American Thoracic Society, Asia Pacific Association of Critical Care Medicine, Australian and New Zealand Intensive Care Society, European Society of Intensive Care Medicine, Société de Réanimation de Langue Française, and Society of Critical Care Medicine.
- Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, Paganini EP, Chertow GM: Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int 2004, 66: 1613-1621. 10.1111/j.1523-1755.2004.00927.xView ArticlePubMedGoogle Scholar
- Palevsky PM: Epidemiology of acute renal failure: the tip of the iceberg. Clin J Am Soc Nephrol 2006, 1: 6-7. 10.2215/CJN.01521005View ArticlePubMedGoogle Scholar
- Ympa YP, Sakr Y, Reinhart K, Vincent JL: Has mortality from acute renal failure decreased? A systematic review of the literature. Am J Med 2005, 118: 827-832. 10.1016/j.amjmed.2005.01.069View ArticlePubMedGoogle Scholar
- Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le Gall JR, Druml W: Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 2002, 30: 2051-2058. 10.1097/00003246-200209000-00016View ArticlePubMedGoogle Scholar
- Waikar SS, Curhan GC, Wald R, McCarthy EP, Chertow GM: Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 2006, 17: 1143-1150. 10.1681/ASN.2005091017View ArticlePubMedGoogle Scholar
- Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, et al.: Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005, 294: 813-818. 10.1001/jama.294.7.813View ArticlePubMedGoogle Scholar
- Liangos O, Wald R, O'Bell JW, Price L, Pereira BJ, Jaber BL: Epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey. Clin J Am Soc Nephrol 2006, 1: 43-51. 10.2215/CJN.00220605View ArticlePubMedGoogle Scholar
- Clermont G, Acker CG, Angus DC, Sirio CA, Pinsky MR, Johnson JP: Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 2002, 62: 986-996. 10.1046/j.1523-1755.2002.00509.xView ArticlePubMedGoogle Scholar
- Thakar CV, Worley S, Arrigain S, Yared JP, Paganini EP: Influence of renal dysfunction on mortality after cardiac surgery: modifying effect of preoperative renal function. Kidney Int 2005, 67: 1112-1119. 10.1111/j.1523-1755.2005.00177.xView ArticlePubMedGoogle Scholar
- Druml W: Long term prognosis of patients with acute renal failure: is intensive care worth it? Intensive Care Med 2005, 31: 1145-1147. 10.1007/s00134-005-2682-5View ArticlePubMedGoogle Scholar
- Liano F, Junco E, Pascual J, Madero R, Verde E: The spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. The Madrid Acute Renal Failure Study Group. Kidney Int Suppl 1998, 66: S16-24.PubMedGoogle Scholar
- Mehta RL, Pascual MT, Soroko S, Chertow GM: Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002, 288: 2547-2553. 10.1001/jama.288.20.2547View ArticlePubMedGoogle Scholar
- Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW: Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 2005, 16: 3365-3370. 10.1681/ASN.2004090740View ArticlePubMedGoogle Scholar
- Gruberg L, Mintz GS, Mehran R, Gangas G, Lansky AJ, Kent KM, Pichard AD, Satler LF, Leon MB: The prognostic implications of further renal function deterioration within 48 h of interventional coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000, 36: 1542-1548. 10.1016/S0735-1097(00)00917-7View ArticlePubMedGoogle Scholar
- Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M: Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004, 15: 1597-1605. 10.1097/01.ASN.0000130340.93930.DDView ArticlePubMedGoogle Scholar
- Levy MM, Macias WL, Vincent JL, Russell JA, Silva E, Trzaskoma B, Williams MD: Early changes in organ function predict eventual survival in severe sepsis. Crit Care Med 2005, 33: 2194-2201. 10.1097/01.CCM.0000182798.39709.84View ArticlePubMedGoogle Scholar
- McCullough PA, Soman SS: Contrast-induced nephropathy. Crit Care Clin 2005, 21: 261-280. 10.1016/j.ccc.2004.12.003View ArticlePubMedGoogle Scholar
- Praught ML, Shlipak MG: Are small changes in serum creatinine an important risk factor? Curr Opin Nephrol Hypertens 2005, 14: 265-270.View ArticlePubMedGoogle Scholar
- Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P: Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004, 8: R204-212. 10.1186/cc2872PubMed CentralView ArticlePubMedGoogle Scholar
- Hoste EAJ, Clermont G, Kersten A, Venkataraman R, Angus DC, De Bacquer D, Kellum JA: RIFLE criteria for acute kidney injury is associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care 2006, 10: R73-82. 10.1186/cc4915PubMed CentralView ArticlePubMedGoogle Scholar
- Palevsky PM, Metnitz PG, Piccinni P, Vinsonneau C: Selection of endpoints for clinical trials of acute renal failure in critically ill patients. Curr Opin Crit Care 2002, 8: 515-518. 10.1097/00075198-200212000-00006View ArticlePubMedGoogle Scholar
- Kellum JA, Leblanc M, Gibney RT, Tumlin J, Lieberthal W, Ronco C: Primary prevention of acute renal failure in the critically ill. Curr Opin Crit Care 2005, 11: 537-541. 10.1097/01.ccx.0000179934.76152.02PubMedGoogle Scholar
- Kellum JA, Ronco C, Mehta R, Bellomo R: Consensus development in acute renal failure: The Acute Dialysis Quality Initiative. Curr Opin Crit Care 2005, 11: 527-532. 10.1097/01.ccx.0000179935.14271.22View ArticlePubMedGoogle Scholar
- Leblanc M, Kellum JA, Gibney RT, Lieberthal W, Tumlin J, Mehta R: Risk factors for acute renal failure: inherent and modifiable risks. Curr Opin Crit Care 2005, 11: 533-536. 10.1097/01.ccx.0000183666.54717.3dView ArticlePubMedGoogle Scholar
- Kellum JA, Mehta RL, Angus DC, Palevsky P, Ronco C: The first international consensus conference on continuous renal replacement therapy. Kidney Int 2002, 62: 1855-1863. 10.1046/j.1523-1755.2002.00613.xView ArticlePubMedGoogle Scholar
- American Society of Nephrology Renal Research Report J Am Soc Nephrol 2005, 16: 1886-1903. 10.1681/ASN.2005030285
- Eknoyan G, Lameire N, Barsoum R, Eckardt KU, Levin A, Levin N, Locatelli F, MacLeod A, Vanholder R, Walker R, et al.: The burden of kidney disease: improving global outcomes. Kidney Int 2004, 66: 1310-1314. 10.1111/j.1523-1755.2004.00894.xView ArticlePubMedGoogle Scholar
- Thompson BT, Cox PN, Antonelli M, Carlet JM, Cassell J, Hill NS, Hinds CJ, Pimentel JM, Reinhart K, Thijs LG: Challenges in end-of-life care in the ICU: statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: executive summary. Crit Care Med 2004, 32: 1781-1784. 10.1097/01.CCM.0000126895.66850.14View ArticlePubMedGoogle Scholar
- Lameire N, Van Biesen W, Vanholder R: Acute renal failure. Lancet 2005, 365: 417-430.View ArticlePubMedGoogle Scholar
- Brivet FG, Kleinknecht DJ, Loirat P, Landais PJ: Acute renal failure in intensive care units – causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure. Crit Care Med 1996, 24: 192-198. 10.1097/00003246-199602000-00003View ArticlePubMedGoogle Scholar
- Chertow GM, Lazarus JM, Christiansen CL, Cook EF, Hammermeister KE, Grover F, Daley J: Preoperative renal risk stratification. Circulation 1997, 95: 878-884.View ArticlePubMedGoogle Scholar
- Mehta RL, McDonald B, Gabbai F, Pahl M, Farkas A, Pascual MT, Zhuang S, Kaplan RM, Chertow GM: Nephrology consultation in acute renal failure: does timing matter? Am J Med 2002, 113: 456-461. 10.1016/S0002-9343(02)01230-5View ArticlePubMedGoogle Scholar
- Mehta RL, Pascual MT, Gruta CG, Zhuang S, Chertow GM: Refining predictive models in critically ill patients with acute renal failure. J Am Soc Nephrol 2002, 13: 1350-1357. 10.1097/01.ASN.0000014692.19351.52View ArticlePubMedGoogle Scholar
- Vincent JL: Incidence of acute renal failure in the intensive care unit. Contrib Nephrol 2001, (132):1-6.
- Hoste EA, Lameire NH, Vanholder RC, Benoit DD, Decruyenaere JM, Colardyn FA: Acute renal failure in patients with sepsis in a surgical ICU: predictive factors, incidence, comorbidity, and outcome. J Am Soc Nephrol 2003, 14: 1022-1030. 10.1097/01.ASN.0000059863.48590.E9View ArticlePubMedGoogle Scholar
- Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C: An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med 2006, 34: 1913-1917. 10.1097/01.CCM.0000224227.70642.4FView ArticlePubMedGoogle Scholar
- Bellomo R, Kellum JA, Ronco C: Defining acute renal failure: physiological principles. Intensive Care Med 2004, 30: 33-37. 10.1007/s00134-003-2078-3View ArticlePubMedGoogle Scholar
- Perrone RD, Madias NE, Levey AS: Serum creatinine as an index of renal function: new insights into old concepts. Clin Chem 1992, 38: 1933-1953.PubMedGoogle Scholar
- Moran SM, Myers BD: Course of acute renal failure studied by a model of creatinine kinetics. Kidney Int 1985, 27: 928-937.View ArticlePubMedGoogle Scholar
- Rivers EP: Early goal-directed therapy in severe sepsis and septic shock: converting science to reality. Chest 2006, 129: 217-218. 10.1378/chest.129.2.217View ArticlePubMedGoogle Scholar
- Mehta RL, Chertow GM: Acute renal failure definitions and classification: time for change? J Am Soc Nephrol 2003, 14: 2178-2187. 10.1097/01.ASN.0000079042.13465.1AView ArticlePubMedGoogle Scholar
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