7l ^ CL 7eo|thcore lR pub||cot|on - ^utumn 2008

0T T 0 P l C T L C N l C A L l NN0 vAT l 0 N
Rad|o|og|stsacrosstheg|obebeganrout|ne|yscreen|ng
pot|entb or k|dneh d|beobe oter NephroVen|c $hbtem|c
f|bros|s|NSflwas|n|t|a||yassoc|atedw|ththeuseo
Codo||n|um 1obed Controbt led|o |C1Cll |n pot|entb f|th
ocute or chron|c beeere reno| |nbunc|ench. Che ^mer|con
Co||egeoRad|o|ogy|ACRlhass|ncepub||shedscreen|ng
gu|de||nesto|dent|ypat|entsath|ghr|skodeve|op|ngNSf.
Thesegu|de||nescanbeoundatwww.acr.org/Secondary-
lo|nlenuCoteVor|eb/quo||thNboeth/controbtNmonuo|.obpg.
0ne o the too|b or bcreen|nV pot|entb |b C|omeru|or f||trot|on
Rate|CfRl.CfRhash|stor|ca||ybeencons|deredoneothe
pr|morh methodb ubed to meobure reno| unct|on. Lbt|moted
CfR|saa|r|yrap|dtoo|or|dent|y|ngandc|ass|y|ngpat|ents
w|thChron|cRena|fa||ure|CRflasdenedbytheNat|ona|
K|dneyfoundat|on|NKfl.
1ut fhot obout thobe f|th ^cute Reno| fo||ure |^Rfl, fh|ch
hasa|sobeen|dent|edasanat-r|skgrouporthoserece|v|ng
Vodo||n|um-bobed controbt oVentb. ^Rf con brood|h be
denedasanabruptdec||ne|nrena|unct|onresu|t|ng|n
on |nob|||th to egcrete metobo||c fobte ond mo|nto|n proper
fu|d ond e|ectro|hte bo|once. Che mojor|th o ^Rf cobeb ore
becondorh to ocute tubu|or necrob|b |^CNl rom bepb|b or
nephrotog|n egpobure. lobt pot|entb u||h recoeer |n o feek
totendaysbutCRfordeath|sposs|b|e.osp|ta||ength-o-
btoh ond one-heor morto||th roteb ore b|Vn|ncont|h h|Vher
ateraboutoARf.
By Eric Scott Cantor, MD
|n|gh-r|skPat|ents
ldent|y|ngAcute
K|dneh lnjurh
72 $|VnolUL$L - ^utumn 2008
T L C N l C A L l NN0 vAT l 0 N 0T T 0 P l C
Che |nc|dence o ^Rf fob reported bh ^|| to be 8 cobeb
per m||||on |n o retrobpect|ee hobp|to| btudh |n $cot|ond,
l
L|ono reported 20( cobeb per m||||on |n 3 tert|orh-core
hobp|to|b probpect|ee|h |n $po|n,
2
ond Gue reported 23.8
cobeb per 000 d|bchorVeb o hobp|to||ied U$ led|core
benec|ar|es.
3
^Rf, knofn to occur more requent|h |n o|der
peop|e, |b r|b|nV |n requench |n re|ot|onbh|p to the chonV|nV
demoVroph|cb o the popu|ot|on, f|th on ebt|moted |nc|dence
rote betfeen 2% to 5% o hobp|to||ied pot|entb.
^ ree|ef o the ||teroture c|eor|h |nd|coteb thot ep|dem|o|oV|c
btud|eb o ^Rf ore ef |n number, ore o|| bobed upon b|ck
hobp|to||ied pot|entb, ond rouVht f|th d|erenceb |n pot|ent
popu|ot|onb ond chorocter|bt|cb, ond there eg|bt d|er|nV
denn|t|onb o ^Rf. Fe con, hofeeer, d|bcern thot the
|nc|denceoARf|ntheoutpat|entsett|ng|srare.
^ proct|co| cho||enVe or|be, b|nce ^Rf hob trod|t|ono||h
been d|oVnobed oter the ocute |nbu|t ond domoVe occurb,
becoube o the de|oh |n e|eeot|on o the berum creot|n|ne
b|omorker. Reno| o||ure con be obhmptomot|c but |b
oten obboc|oted f|th non-bpec|nc bhmptomb o ot|Vue,
hemotur|o, fonk po|n, dhbpneo, edemo, hhpertenb|on,
noubeo, conub|on, o decreobe |n ur|ne output, or obnormo|
ur|no|hb|b , ebpec|o||h fhen obboc|oted f|th burV|co| or
med|co| co-morb|d|t|eb. ^ ur|no|hb|b egom|ned |mmed|ote|h
oter eo|d|nV moh demonbtrote Vronu|or cobtb, reno| tubu|or
ep|the||o| ce||b, prote|nur|o, or red b|ood ce||b. Nephro|oV|btb
f||| ||ke|h eeo|uote the ur|ne bomp|e under the m|crobcope,
check ur|ne bpec|nc Vroe|th, ur|ne e|ectro|hteb ond other tebtb
to determ|ne the coube o the ^Rf or ocute k|dneh |njurh |^Kll.
Pat|entswhopresentw|thAKl|ntheoutpat|entsett|ng
mobt common|h hoee ^Kl becondorh to druV tog|c|th, eo|ume
dep|et|on, or bepb|b. 0n on |n-pot|ent bob|b ^Kl |b oten
o rebu|t o mu|t|p|e r|bk octorb ond co-morb|d|t|eb.
Chere ore three brood coteVor|eb o ^Kl) pre-reno|, reno| ond
pobt-reno|. Rod|o|oV|btb common|h odm|n|bter hhdrot|on f|th
or f|thout b|corbonote or N-oceth|chbte|ne to m|n|m|ie reno|
underperus|onandr|skocontrast-|nducednephropathy.
Che mobt common pobt-reno| coubeb o ^Kl ore k|dneh btoneb,
mobt common|h eeo|uoted f|th reno| u|trobonoVrophh.
0nce the c||n|c|on ru|eb out pre-reno| ond pobt-reno| coube,
|ntr|nb|c reno| d|beobe |b mobt oten obcr|bed to ^CN. ^CN
|b mobt oten coubed bh reno| hhpoperub|on ond reno|
|bchem|o but |ntr|nb|c ond egtr|nb|c nephrotog|nb bhou|d
a|sobecons|dered.
Diagnostic criteria for acute kidney injury
Che ormot|on o the ^cute K|dneh lnjurh Netfork |^KlNl
hob rebu|ted |n o nef conbenbub denn|t|on o ^Kl. L|kef|be,
nomenc|oture hob chonVed to c|or|h the ronVe o reno|
dhbunct|on obboc|oted f|th reno| |njurh, not o|| o fh|ch
rebu|tb |n k|dneh o||ure. Chereore, the preerred term|no|oVh
|b nof ^cute K|dneh lnjurh |^Kll f|th ^Rf |nd|cot|ee o beeere
reno| dhbunct|on thot moh |eod to reno| rep|ocement
therapyorresu|t|nendstagerena|d|sease.
Thenewd|agnost|ccr|ter|aorAKlbaseduponAKlN|s
chorocter|ied bh on obrupt |f|th|n 48 hourbl reduct|on |n
k|dneh unct|on denned ob on obbo|ute |ncreobe |n berum
creot|n|ne o more thon or equo| to 0.3 mV/d| | 26.4 mo|/|l,
Stage I Stage II Stage V Stage III Stage IV
130 120 110 100 90 80 70 60 50 40 30 20 15 10 0
CKD risk factors/damage
with preserved Glomerular
Filtration Rate (GFR)
Mild
kidney function
Moderate
kidney function
Severe
kidney function
Kidney failure
end-stage renal
disease (ESRD)
Kidney Function
(GFR) ml/min/1.73m
2
SEVERITY
100%
80%
60%
40%
20%
0%
3.3%
89%
3.0% 4.3% 0.2% 01%
P
r
e
v
a
l
e
n
c
e

o
f

C
K
D

(
U
S
A
)
Renal Status
Prevalence of CKD (USA)
Normal Stage I Stage II Stage III Stage IV Stage V
Figure 1
73 ^ CL 7eo|thcore lR pub||cot|on - ^utumn 2008
0T T 0 P l C T L C N l C A L l NN0 vAT l 0 N
Lr|c $cott Contor, l0, |b heod o med|co|
S proebb|ono| bere|ceb ot CL 7eo|thcore,
led|co| 0|oVnobt|cb.
Dr. Eric Scott Cantor
References:
. ^|| C, Khon l, $|mpbon F, et o|. lnc|dence ond 0utcomeb |n
^cute K|dneh lnjurh ) ^ Comprehenb|ee lopu|ot|on-1obed
$tudh. J ^m $oc Nephro|2007, 8)2(2-2(8.
2. L|ono, fernondo, lobcuo|, Ju||o, lodr|d ^cute Reno| fo||ure
$tudh Croup. Lp|dem|o|oVh o ocute reno| o||ure) ^ probpect|ee,
mu|t|center, commun|th-bobed btudh. K|dneh lnternot|ono|
((6, 50)8-88.
3. Gue JL, 0on|e|b f, $tor R^, et o|. lnc|dence ond lorto||th o
^cute Reno| fo||ure |n led|core 1enenc|or|eb, ((2 to 200.
J ^m $oc Nephro| 2006, 7)35-42.
4. lehto RL, Ke||um J^, $hoh $E, lo||tor|b 1^, Ronco C, Fornock
0C, et o|. ^cute K|dneh lnjurh Netfork) report o on |n|t|ot|ee to
|mproee outcomeb |n ocute k|dneh |njurh. Cr|t|co| Core 2007,
)R3do|)0.86/cc573.
5. lr|nce lR, IhonV 7, lorr|b l, et o|. lnc|dence o NephroVen|c
$hbtem|c f|brob|b ot Cfo LorVe led|co| Centerb. Rod|o|oVh
2008, 248) 807-86.
CfR = C|omeru|or f||trot|on Rote
**ARf=AcuteRena|fa||ure
$ource) 1e||omo R, Ronco C, Ke||um J^, lehto RL, lo|eebkh l, ^0l
forkVroup. ^cute reno| o||ure - denn|t|on, outcome meobureb,
on|mo| mode|b, fu|d theroph ond |normot|on techno|oVh needb)
theSecondlnternat|ona|ConsensusConerenceotheAcute
0|o|hb|b uo||th ln|t|ot|ee |^0ll Croup. Cr|t|co| Core 2004, 8)R-
04-R22. ^eo||ob|e ot http)//ccorum.com/content/8/4/R204
GFR Criteria* Urine Output Criteria
High
Sensitivity
High
Specificity
Risk
lncreasedSCreatxl.5or
CfRdecrease>25%
lncreasedSCreatx2or
CfRdecrease>50%
lncreasedSCreatx3
CfRdecrease75%
0RSCreat>4mg/d|
Acuter|se>0.5mg/d|
Pers|stentARf**=comp|ete|oss
ok|dneyunct|on>4weeks
LndStageK|dneyD|sease
|>3monthsl
U0<0.5m|/kg/h
x6hr
U0<0.5m|/kg/h
xl2hr
U0<0.3m|/kg/h
x24houror
Anur|axl2hrs
0
|
|
g
u
r
|
a
Injury
Failure
Loss
ESKD
o percentoVe |ncreobe |n berum creot|n|ne o more thon or equo| to 50% |.5-o|d
rom bobe||nel, or o reduct|on |n ur|ne output |documented o||Vur|o o |ebb thon
0.5 m|/kV per hour or more thon b|g hourbl.
4
^ nef Vrod|nV bhbtem bobed upon
the ocronhm RlfLL |R|bk, lnjurh, fo||ure, Lobb, ond Lnd btoVel hob been denned bh
chonVeb |n berum creot|n|ne ond ur|ne output, fh|ch d|e|deb ^Kl |nto three |eee|b
o beeer|th. $toV|nV con be obbebbed oeer one feek ob onh obnormo||t|eb ore
thp|co||h bubto|ned or more thon 24 hourb.
Cho||enVeb to rop|d d|oVnob|b remo|n ob berum creot|n|ne |b o b|omorker o reno|
unct|on not |njurh. Lbt|mot|on o CRf obbumeb o bteodh or equ|||br|um btote, fh|ch
|s|ncons|stentw|ththerap|dchanges|nrena|unct|onthatoccur|nAKl.Creat|n|ne
|ncreobeb b|of|h re|ot|ee to the chonVe |n reno| unct|on. lt moh toke 48 to 72 hourb
to obberee on e|eeot|on |n berum creot|n|ne oter on ocute |nbu|t to the k|dneh.
$erum creot|n|ne |eee| |b bobed upon product|on, fh|ch eor|eb f|th mubc|e mobb,
eo|ume o d|btr|but|on, ond tubu|or becret|on, fh|ch con |n turn eorh bobed upon
oVe, beg, roce, fe|Vht, d|et, druVb, ond mubc|e metobo||bm.
Looking ahead
^ number o nef b|omorkerb under |neebt|Vot|on bhof prom|be |n the|r ob|||th to
|ncreobe benb|t|e|th, bpec|nc|th, ond c|or|ncot|on o et|o|oVh, proVnob|b, ond t|me
benb|t|e|th or detect|on o ^Kl ob compored to the h|btor|co| ube o berum creot|n|ne.
lonh o thebe nef b|omorkerb ore re|eobed |n rebponbe to tubu|or |njurh, o meobure
o onotom|c potho|oVh rother thon unct|on. Chebe |nc|ude ur|norh Vommo Vutomh|
tronbpept|dobe |CCCl, N-oceth| V|ucobom|ndobe |N^Cl, o|pho ond omeVo V|utoth|one
$-tronberobe, netroph|| Ve|ot|nobe obboc|oted ||pco||n |NC^Ll, k|dneh |njurh mo|ecu|e
|Kll-l, ond chbtot|n C. ln bome c|rcumbtonceb, thebe ur|norh enihmeb con detect
^Kl rom 2 hourb to our dohb eor||er thon o r|be |n berum creot|n|ne. ^|thouVh thebe
morkerb ore current|h be|nV ubed on on egper|mento| bob|b, theh ore egpected to
|mpoct the proct|ce o c||n|co| med|c|ne |n the not too d|btont uture.
Unt|| thebe nef b|omorkerb ore c||n|co||h oeo||ob|e, rod|o|oV|btb con be reobbured
bytheknow|edgethatthe|nc|denceoAKlonanoutpat|entbas|s|srare.AKl|s
common|h but not o|fohb obboc|oted f|th bhmptomb or chonVe |n ur|ne output,
on obnormo| ur|no|hb|b ond berum creot|n|ne. Coneerbe|h, |n-pot|entb bhou|d be
conb|dered ot h|Vher r|bk or ^Kl ond concom|tont|h N$f. Cheh bhou|d rout|ne|h
hoee the|r b|ood tebted or berum creot|n|ne, f|th o compor|bon mode to the|r
bobe||ne, beore odm|n|btrot|on o onh C1Cl. for thobe on chron|c hemod|o|hb|b,
|t |b recommended thot theh rece|ee hemod|o|hb|b ob boon ob pobb|b|e oter
odm|n|btrot|on o o C1Cl ond certo|n|h f|th|n 24 hourb. Codo||n|um |b d|o|hbob|e
buthasnotbeenproventodecreasethe|nc|denceorsever|tyoNSf.
lr|nce et o| |n the $eptember 2008 ed|t|on o Rod|o|oVh btudh ound no cobeb
o N$f oter 74,24 pot|ent egpobureb to C1Cl, fhen rece|e|nV btondord dobe,
evenw|thoutpre-screen|ngopat|ents.
5
Reasonab|escreen|ngand|dent|cat|on
o pot|entb ot h|Vhebt r|bk or N$f, bobed upon f0^ c|obb |obe||nV ond ^CR
recommendot|onb, bhou|d m|n|m|ie the r|bk o N$f moe|nV orford.
Figure 2