RIFLE Criteria Accurately Identifies Renal Dysfunction and Renal Failure in Elderly Patients with Upper Amer A.

Alkhatib, MD, GastrointestinalShihab, Angela Lam, PharmD, Fuad MD, 4/21/12 and to edit Adler, Study ClickDouglas Master subtitle style Hemorrhage: AG.PilotMD, FACG, FASGE

Background: The incidence of acute kidney injury (AKI) as a complication of acute upper gastrointestinal bleeding (AUGIB) is not known. Recently, RIFLE criteria were used widely in the medical research to identify patients with different degrees of renal insufficiency.

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Objectives:

Our purpose is to determine the incidence, clinical presentations, endoscopic findings and outcomes of AKI in the elderly presenting with AUGIB using RIFLE criteria.

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Acute kidney injury (AKI) is characterized by acute decline in renal function, with manifestations ranging from minimal elevation of serum creatinine concentration to anuric renal failure. The incidence of acute kidney injury (AKI) in unsegregated patients with acute upper gastrointestinal bleeding (AUGIB) varies in the published literature from 1% to 11.4%.

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Methods

We retrospectively analyzed the records of all patients greater than or equal to 60 years of age with a diagnosis of acute upper gastrointestinal bleeding over a twenty month period starting from January 2006 and ending in August 2007. Glomerular filtration rate (GFR) was calculated in all patients using the Modification of Diet in Renal Disease (MDRD) formula using the patients baseline serum creatinine level.
4/21/12 The study was conducted in Spokane,

Renal function was categorized based on either the change of serum creatinine from baseline or the change in the estimated GFR using the Modification of Diet 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 on the change of serum creatinine
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Risk (R) designates an increase in the serum creatinine by 1.5-fold or a decrease in estimated GFR by more than 25% or a urine output less than 0.5 mL/kg/hr for 6 hours. Injury (I) includes patients whose serum creatinine doubles, or in whom the estimated GFR declines by more than 50%, or if urine output is less than 0.5 mL/kg/hr for 12 hours.
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Failure (F) includes patients who have developed any of the following criteria:

1- Threefold increase in serum creatinine 2- Increase in serum creatinine by 0.5 mg/dL (or more) in patients with a baseline 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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Statistical Analysis

Categorical variables were analyzed using the Chi-square test. The Student ttest was used to compare continuous variables.

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Results

A total of 113 patients (mean age 76.4 years, 52 men, and 61 women) were included. All patients studied were Caucasians and were representative of the local population in the Spokane, WA area. Average estimated GFR for all patients on presentation to the emergency room was 54.1 mL/min/ 1.73 m2, while average baseline GFR for all4/21/12 patients

There was a significant difference between patients who did and did not develop renal injury with regards to place of residency. Patients who were nursing home residents were more likely to develop acute renal injury with AUGIB than those who were not (38% vs. 14%, P 0.004). Medication profiles between the two groups were similar without significant differences. 4/21/12

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Shock and myocardial infarction were more common in patients with acute renal injury when compared to those without (25% and 9% vs. 2% and 0%, P 0.0003 and 0.02 respectively). Patients with acute renal injury on admission as defined by RIFLE tended to have longer lengths of stay (5.0 days vs. 2.37 days, P 0.005) and their hospitalization costs were higher ($20,230 vs. $11,779, P 0.02) than 4/21/12

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Discussion

The incidence of AUGIB in the elderly is higher than in younger patients, and the mean age of patients with AUGIB has increased over the last two decades. Thomopoulos et al compared the demographic features of adults with AUGIB between 1986 and 2001. These authors found an increase in the percentage of patients older than 60 years presenting with AUGIB4/21/12 46.1% from

We expect that as the US population ages, there will be an increase in the number of elderly patients presenting with AUGIB. In 2006, The US census bureau estimated that there were more than 50 million Americans who were 60 years old or older, accounting for approximately 16.9% of the total population. It is expected that the proportion of elderly patients in the US will increase from 1:8 4/21/12

The data from this initial pilot study suggests that elderly patients presenting with AUGIB complicated with acute renal injury as defined by the RIFLE criteria tend to be residents of nursing homes, have a higher chance of presenting with weakness and altered mental status, a higher serum creatinine on admission, less incidence of gastric ulcers/gastritis, and are more likely to have an unrevealing upper endoscopic 4/21/12 examination, a lengthier and costlier

Nursing home patients tend to have a higher incidence of acute renal dysfunction. This may explain the higher incidence of acute renal injury in the nursing home patients compared to others in our study. Nursing home patients may have delayed detection of melena or other symptoms of bleeding, which could lead to hypovolemia and, in turn, some degree of renal dysfunction. 4/21/12 A change in

Our study showed lengthier hospital stays of patients with AUGIB complicated with AKI compared to those who did not develop acute renal injury. This finding is consistent with the literature finding that reported lengthier and costlier hospital stays 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 4/21/12

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