Acute kidney injury (AKI) is associated with significantly increased morbidity and mortality. To provide a uniformly accepted definition, the RIFLE classification was introduced by the Acute Dialysis Quality Initiative, recently modified by the Acute Kidney Injury Network (AKIN), suggesting staging of AKI based on dynamic changes within 48 h. This study compares these two classification systems with regard to outcome.
Cohort analysis of SAPS 3 database.
Sixteen thousand seven hundred and eighty-four ICU patients from 303 ICUs were analysed. Classification was performed according to RIFLE (Risk, Injury, Failure) or according to AKIN (stage 1, 2, 3) without including a requirement of renal replacement therapy in the analysis. Changes of serum creatinine as well as urinary output were assessed for both AKIN and RIFLE during the first 48 h of ICU admission. Primary endpoint was hospital mortality.
Incidence of AKI in our population of critically ill patients was found to range between 28.5 and 35.5% when applying AKIN and RIFLE criteria, respectively, associated with increased hospital mortality averaging 36.4%. Observed-to-expected mortality ratios revealed excess mortality conferred by any degree of AKI increasing from 0.81 for patients classified as non-AKI up to 1.31 and 1.23 with AKIN stage 3 or RIFLE Failure, respectively. AKIN misclassified 1,504 patients as non-AKI compared to RIFLE which misclassified 504 patients.
Acute kidney injury classified by either RIFLE or AKIN is associated with increased hospital mortality. Despite presumed increased sensitivity by the AKIN classification, RIFLE shows better robustness and a higher detection rate of AKI during the first 48 h of ICU admission.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le G Jr, Druml W (2002) Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med 30:2051–2058
Clermont G, Acker CG, Angus DC, Sirio CA, Pinsky MR, Johnson JP (2002) Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 62:986–996
Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P (2004) 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 8:R204–R212
Joannidis M, Metnitz PG (2005) Epidemiology and natural history of acute renal failure in the ICU. Crit Care Clin 21:239–249
Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M (2004) Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 15:1597–1605
Kellum JA, Levin N, Bouman C, Lameire N (2002) Developing a consensus classification system for acute renal failure. Curr Opin Crit Care 8:509–514
Ricci Z, Cruz D, Ronco C (2008) The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney Int 73:538–546
Hoste EA, Clermont G, Kersten A, Venkataraman R, Angus DC, De BD, Kellum JA (2006) RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care 10:R73
Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C (2006) An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med 34:1913–1917
Bagshaw SM, George C, Dinu I, Bellomo R (2008) A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant 23:1203–1210
Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A (2007) Acute kidney injury network (AKIN): report of an initiative to improve outcomes in acute kidney injury. Crit Care 11:R31
Ostermann ME, Chang RW (2005) Prognosis of acute renal failure: an evaluation of proposed consensus criteria. Intensive Care Med 31:250–256
Bagshaw SM, George C, Bellomo R (2008) A comparison of the RIFLE and AKIN criteria for acute kidney injury in critically ill patients. Nephrol Dial Transplant 23:1569–1574
Lopes JA, Fernandes P, Jorge S, Goncalves S, Alvarez A, Costa e Silva Z, Franca C, Prata MM (2008) Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the acute kidney injury network classifications. Crit Care 12:R110
Ostermann M, Chang R (2008) Correlation between the AKI classification and outcome. Crit Care 12:R144
Joannidis M, Jordan B, Bauer P, Druml W, Metnitz PG (2007) Comparison of RIFLE versus AKIN for classification of acute kidney injury. Intensive Care Med 33:S98 (Abstract)
Metnitz PG, Moreno RP, Almeida E, Jordan B, Bauer P, Campos RA, Iapichino G, Edbrooke D, Capuzzo M, Le G Jr (2005) SAPS 3—from evaluation of the patient to evaluation of the intensive care unit. Part 1: objectives, methods and cohort description. Intensive Care Med 31:1336–1344
Hosmer DW, Lemeshow S (1995) Confidence interval estimates of an index of quality performance based on logistic regression models. Stat Med 14:2161–2172
Kellum JA, Bellomo R, Ronco C (2007) The concept of acute kidney injury and the RIFLE criteria. Contrib Nephrol 156:10–16
Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW (2005) Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 16:3365–3370
Levy MM, Macias WL, Vincent JL, Russell JA, Silva E, Trzaskoma B, Williams MD (2005) Early changes in organ function predict eventual survival in severe sepsis. Crit Care Med 33:2194–2201
Kuitunen A, Vento A, Suojaranta-Ylinen R, Pettila V (2006) Acute renal failure after cardiac surgery: evaluation of the RIFLE classification. Ann Thorac Surg 81:542–546
Bouman C, Kellum JA, Lameire N, Levin N (2003) Definition for acute renal failure. In: Acute dialysis quality initiative-2nd international consensus conference. http://www.adqi.net
Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D (1999) A more accurate method to estimate glomerular filtration rate from serum creatinine: a new prediction equation Modification of Diet in Renal Disease Study Group. Ann Intern Med 130:461–470
Abosaif NY, Tolba YA, Heap M, Russell J, El Nahas AM (2005) The outcome of acute renal failure in the intensive care unit according to RIFLE: model application, sensitivity, and predictability. Am J Kidney Dis 46:1038–1048
Ostermann M, Chang RW (2007) Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 35:1837–1843
Guitard J, Cointault O, Kamar N, Muscari F, Lavayssiere L, Suc B, Ribes D, Esposito L, Barange K, Durand D, Rostaing L (2006) Acute renal failure following liver transplantation with induction therapy. Clin Nephrol 65:103–112
Hoste EA, Kellum JA (2006) Acute kidney injury: epidemiology and diagnostic criteria. Curr Opin Crit Care 12:531–537
Joannidis M (2007) Classification of acute kidney injury: are we there yet? Intensive Care Med 33:572–574
Cruz DN, Bolgan I, Perazella MA, Bonello M, de CM, Corradi V, Polanco N, Ocampo C, Nalesso F, Piccinni P, Ronco C (2007) North East Italian Prospective Hospital Renal Outcome Survey on acute kidney injury (NEiPHROS-AKI): targeting the problem with the RIFLE criteria. Clin J Am Soc Nephrol 2:418–425
Barrantes F, Tian J, Vazquez R, moateng-Adjepong Y, Manthous CA (2008) Acute kidney injury criteria predict outcomes of critically ill patients. Crit Care Med 36:1397–1403
Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-van SH, Ronco C, Kellum JA (2007) Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators. Intensive Care Med 33:1563–1570
Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20
This work was supported by the Oesterrreichische Nationalbank Jubilaeumsfondsprojekt Nr. 12690 (P. M.) and Nr. 12094 (M. J.).
Conflict of interest statement
Electronic supplementary material
Below is the link to the electronic supplementary material.
About this article
Cite this article
Joannidis, M., Metnitz, B., Bauer, P. et al. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. Intensive Care Med 35, 1692–1702 (2009). https://doi.org/10.1007/s00134-009-1530-4
- Acute kidney injury
- Urinary output