RIFLE Criteria Accurately Identifies Renal

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RIFLE Criteria Accurately

Identifies RenalDysfunction and Renal Failurein Elderly

Patients with UpperGastrointestinal

Hemorrhage: A Pilot Study

Amer A. Alkhatib, MD, Angela Lam,PharmD, Fuad Shihab, MD,

and Douglas G. Adler, MD, FACG, FASGE


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Background: The incidence of acutekidney injury (AKI) as a complicationof acute upper gastrointestinal bleeding

(AUGIB) is not known. Recently, RIFLEcriteria were used widely in the medicalresearch to identify patients with differentdegrees of renal insufficiency.


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Objectives:

Our purpose is to determine theincidence, clinical presentations,

endoscopic findings and outcomes of AKIin the elderly presenting with AUGIBusing RIFLE criteria.


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Acute kidney injury (AKI) is characterized by acutedecline in renal function, with manifestationsranging from minimal elevation of serum creatinineconcentration to anuric renal failure.

The incidence of acute kidney injury (AKI) inunsegregated patients with acute uppergastrointestinal bleeding (AUGIB) varies in thepublished literature from 1% to 11.4%.


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Methods

We retrospectively analyzed the recordsof all patients greater than or equal to 60years of age with a diagnosis of acuteupper gastrointestinal bleeding over a

twenty month period starting fromJanuary 2006 and ending in August 2007.

Glomerular filtration rate (GFR) wascalculated in all patients using theModification of Diet in Renal Disease(MDRD) formula using the patientsbaseline serum creatinine level.

The study was conducted in Spokane,


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Renal function was categorized based oneither the change of serum creatininefrom baseline or the change in the

estimated GFR using the Modification ofDiet in Renal Disease (MDRD) formula,

The RIFLE score defines acute kidney

injury (AKI) with three levels of severity:risk (R), injury (I) and failure (F) based onthe change of serum creatinine


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Risk (R) designates an increase in theserum creatinine by 1.5-fold or adecrease in estimated GFR by more than

25% or a urine output less than 0.5mL/kg/hr for 6 hours.

Injury (I) includes patients whose serumcreatinine doubles, or in whom theestimated GFR declines by more than50%, or if urine output is less than 0.5mL/kg/hr for 12 hours.


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Failure (F) includes patients who havedeveloped any of the following criteria:

1- Threefold increase in serum creatinine

2- Increase in serum creatinine by 0.5mg/dL (or more) in patients with abaseline serum creatinine of 4 or more

3- Decrease in estimated GFR by 75%

4- Urine output 0.3 mL/kg/hr for 24 hours

5- Anuria for 12 hours.5


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Results

A total of 113 patients (mean age 76.4years, 52 men, and 61 women) were

included. All patients studied wereCaucasians and were representative ofthe local population in the Spokane, WAarea.

Average estimated GFR for all patientson presentation to the emergency roomwas 54.1 mL/min/ 1.73 m2, while

average baseline GFR for all patients


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There was a significant differencebetween patients who did and did notdevelop renal injury with regards to

place of residency. Patients who were nursing home

residents were more likely to developacute renal injury with AUGIB than thosewho were not (38% vs. 14%, P 0.004).Medication profiles between the twogroups were similar without significant

differences.


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Shock and myocardial infarction weremore common in patients with acuterenal injury when compared to those

without (25% and 9% vs. 2% and 0%, P0.0003 and 0.02 respectively).

Patients with acute renal injury onadmission as defined by RIFLE tended tohave longer lengths of stay (5.0 days vs.2.37 days, P 0.005) and theirhospitalization costs were higher

($20,230 vs. $11,779, P 0.02) than


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Discussion

The incidence of AUGIB in the elderly ishigher than in younger patients, and the

mean age of patients with AUGIB hasincreased over the last two decades.

Thomopoulos et al compared the

demographic features of adults withAUGIB between 1986 and 2001. Theseauthors found an increase in thepercentage of patients older than 60

years presenting with AUGIB from 46.1%


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We expect that as the US populationages, there will be an increase in thenumber of elderly patients presenting

with AUGIB. In 2006, The US census bureau

estimated that there were more than 50million Americans who were 60 years oldor older, accounting for approximately16.9% of the total population. It isexpected that the proportion of elderly

patients in the US will increase from 1:8


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The data from this initial pilot studysuggests that elderly patients presentingwith AUGIB complicated with acute renal

injury as defined by the RIFLE criteriatend to be residents of nursing homes,have a higher chance of presenting withweakness and altered mental status, a

higher serum creatinine on admission,less incidence of gastric ulcers/gastritis,and are more likely to have anunrevealing upper endoscopicexamination, a lengthier and costlier


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Nursing home patients tend to have ahigher incidence of acute renaldysfunction. This may explain the higher

incidence of acute renal injury in thenursing home patients compared toothers in our study.

Nursing home patients may havedelayed detection of melena or othersymptoms of bleeding, which could leadto hypovolemia and, in turn, some

degree of renal dysfunction. A change in


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Our study showed lengthier hospitalstays of patients with AUGIB complicatedwith AKI compared to those who did not

develop acute renal injury. This finding isconsistent with the literature finding thatreported lengthier and costlier hospitalstays in patients with AKI in a different

clinical setting. Our study demonstrates a higher risk of

myocardial infarction and shock in

patients with AKI with AUGIB, and is


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References

1. Molitoris BA, Levin A, Warnock DG, et al;Acute Kidney Injury Network

working group. Improving outcomes ofacute kidney injury: report

of an initiative. Nat Clin Pract Nephrol2007;3:439442.

2. del Olmo JA, Pena A, Serra MA, et al.Predictors of morbidity and

mortality after the first episode of uppergastrointestinal bleeding in liver

cirrhosis. He atol 2000;32:19 24.


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14. http://www.census.gov/apsd/wepeople/w

15. Alkhatib AA, Abubakr SM, Elkhatib FA. Anestimate of hospitalization

cost for elderly patients with acute uppergastrointestinal bleeding in the

USA. Dig Dis Sci 2009;53:695.

16. Nygaard HA, Naik M, Ruths S, et al. Clinicimportant renal impairment

in various groups of old persons. Scand J PriCare 2004;

22:152156.


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RIFLE Criteria Accurately Identifies Renal