Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest

Introduction Fluid resuscitation in the critically ill often results in a positive fluid balance, potentially diluting the serum creatinine concentration and delaying diagnosis of acute kidney injury (AKI). Methods Dilution during AKI was quantified by combining creatinine and volume kinetics t...

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Main Authors:	Pickering, John W., Md Ralib, Azrina, Endre, Zoltan H.
Format:	Article
Language:	English
Published:	Critical Care Forum 2013
Subjects:	R Medicine (General)
Online Access:	http://irep.iium.edu.my/32042/ http://irep.iium.edu.my/32042/ http://irep.iium.edu.my/32042/1/Crit_Care_2013_Pickering-2.pdf

id	iium-32042
recordtype	eprints
spelling	iium-320422013-09-30T02:07:48Z http://irep.iium.edu.my/32042/ Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest Pickering, John W. Md Ralib, Azrina Endre, Zoltan H. R Medicine (General) Introduction Fluid resuscitation in the critically ill often results in a positive fluid balance, potentially diluting the serum creatinine concentration and delaying diagnosis of acute kidney injury (AKI). Methods Dilution during AKI was quantified by combining creatinine and volume kinetics to account for fluid type, and rates of fluid infusion and urine output. The model was refined using simulated patients receiving crystalloids or colloids under four glomerular filtration rate (GFR) change scenarios and then applied to a cohort of critically ill patients following cardiac arrest. Results The creatinine concentration decreased during six hours of fluid infusion at 1 litre-per-hour in simulated patients, irrespective of fluid type or extent of change in GFR (from 0% to 67% reduction). This delayed diagnosis of AKI by 2 to 9 hours. Crystalloids reduced creatinine concentration by 11 to 19% whereas colloids reduced concentration by 36 to 43%. The greatest reduction was at the end of the infusion period. Fluid dilution alone could not explain the rapid reduction of plasma creatinine concentration observed in 39 of 49 patients after cardiac arrest. Additional loss of creatinine production could account for those changes. AKI was suggested in six patients demonstrating little change in creatinine, since a 52 ± 13% reduction in GFR was required after accounting for fluid dilution and reduced creatinine production. Increased injury biomarkers within a few hours of cardiac arrest, including urinary cystatin C and plasma and urinary Neutrophil-Gelatinase-Associated-Lipocalin (biomarker-positive, creatinine-negative patients) also indicated AKI in these patients. Conclusions Creatinine and volume kinetics combined to quantify GFR loss, even in the absence of an increase in creatinine. The model improved disease severity estimation, and demonstrated that diagnostic delays due to dilution are minimally affected by fluid type. Creatinine sampling should be delayed at least one hour following a large fluid bolus to avoid dilution. Unchanged plasma creatinine post cardiac arrest signifies renal injury and loss of function. Critical Care Forum 2013-01-17 Article PeerReviewed application/pdf en http://irep.iium.edu.my/32042/1/Crit_Care_2013_Pickering-2.pdf Pickering, John W. and Md Ralib, Azrina and Endre, Zoltan H. (2013) Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest. Critical Cara, 17 (1). R7 (1)-R7 (18). ISSN 1466-609X http://ccforum.com/content/17/1/R7
repository_type	Digital Repository
institution_category	Local University
institution	International Islamic University Malaysia
building	IIUM Repository
collection	Online Access
language	English
topic	R Medicine (General)
spellingShingle	R Medicine (General) Pickering, John W. Md Ralib, Azrina Endre, Zoltan H. Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
description	Introduction Fluid resuscitation in the critically ill often results in a positive fluid balance, potentially diluting the serum creatinine concentration and delaying diagnosis of acute kidney injury (AKI). Methods Dilution during AKI was quantified by combining creatinine and volume kinetics to account for fluid type, and rates of fluid infusion and urine output. The model was refined using simulated patients receiving crystalloids or colloids under four glomerular filtration rate (GFR) change scenarios and then applied to a cohort of critically ill patients following cardiac arrest. Results The creatinine concentration decreased during six hours of fluid infusion at 1 litre-per-hour in simulated patients, irrespective of fluid type or extent of change in GFR (from 0% to 67% reduction). This delayed diagnosis of AKI by 2 to 9 hours. Crystalloids reduced creatinine concentration by 11 to 19% whereas colloids reduced concentration by 36 to 43%. The greatest reduction was at the end of the infusion period. Fluid dilution alone could not explain the rapid reduction of plasma creatinine concentration observed in 39 of 49 patients after cardiac arrest. Additional loss of creatinine production could account for those changes. AKI was suggested in six patients demonstrating little change in creatinine, since a 52 ± 13% reduction in GFR was required after accounting for fluid dilution and reduced creatinine production. Increased injury biomarkers within a few hours of cardiac arrest, including urinary cystatin C and plasma and urinary Neutrophil-Gelatinase-Associated-Lipocalin (biomarker-positive, creatinine-negative patients) also indicated AKI in these patients. Conclusions Creatinine and volume kinetics combined to quantify GFR loss, even in the absence of an increase in creatinine. The model improved disease severity estimation, and demonstrated that diagnostic delays due to dilution are minimally affected by fluid type. Creatinine sampling should be delayed at least one hour following a large fluid bolus to avoid dilution. Unchanged plasma creatinine post cardiac arrest signifies renal injury and loss of function.
format	Article
author	Pickering, John W. Md Ralib, Azrina Endre, Zoltan H.
author_facet	Pickering, John W. Md Ralib, Azrina Endre, Zoltan H.
author_sort	Pickering, John W.
title	Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
title_short	Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
title_full	Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
title_fullStr	Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
title_full_unstemmed	Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
title_sort	combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest
publisher	Critical Care Forum
publishDate	2013
url	http://irep.iium.edu.my/32042/ http://irep.iium.edu.my/32042/ http://irep.iium.edu.my/32042/1/Crit_Care_2013_Pickering-2.pdf
first_indexed	2023-09-18T20:46:14Z
last_indexed	2023-09-18T20:46:14Z
_version_	1777409693203824640

Combining creatinine and volume kinetics identifies missed cases of acute kidney injury following cardiac arrest

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