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Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients

Etienne Macedo1, Josée Bouchard1, Sharon H Soroko1, Glenn M Chertow2, Jonathan Himmelfarb3, T Alp Ikizler4, Emil P Paganini5, Ravindra L Mehta1* and for the Program to Improve Care in Acute Renal Disease (PICARD) study

  • * Corresponding author: Ravindra L Mehta

  • † Equal contributors

Author Affiliations

1 Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego San Diego, 200 West Arbor Drive, MC 8342, San Diego, CA 92103, USA

2 Division of Nephrology, Department of Medicine, Stanford University School of Medicine, 780 Welch Road, Suite 106, Palo Alto, CA 94034, USA

3 Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, 908 Jefferson St, Seattle, WA 98104, USA

4 Division of Nephrology, Department of Medicine Vanderbilt University School of Medicine,638 Robinson Research Building, 2200 Pierce Avenue, Nashville, TN 37232-0146, USA

5 Division of Nephrology, Department of Medicine, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA

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Critical Care 2010, 14:R82  doi:10.1186/cc9004

Published: 6 May 2010



Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI.


In 253 patients recruited from a prospective observational study of critically-ill patients with AKI, we calculated cumulative fluid balance and computed a fluid-adjusted sCr concentration reflecting the effect of volume of distribution during the development phase of AKI. The time to reach a relative 50% increase from the reference sCr using the crude and adjusted sCr was compared. We defined late recognition to estimate severity of AKI when this time interval to reach 50% relative increase between the crude and adjusted sCr exceeded 24 hours.


The median cumulative fluid balance increased from 2.7 liters on day 2 to 6.5 liters on day 7. The difference between adjusted and crude sCr was significantly higher at each time point and progressively increased from a median difference of 0.09 mg/dL to 0.65 mg/dL after six days. Sixty-four (25%) patients met criteria for a late recognition to estimate severity progression of AKI. This group of patients had a lower urine output and a higher daily and cumulative fluid balance during the development phase of AKI. They were more likely to need dialysis but showed no difference in mortality compared to patients who did not meet the criteria for late recognition of severity progression.


In critically-ill patients, the dilution of sCr by fluid accumulation may lead to underestimation of the severity of AKI and increases the time required to identify a 50% relative increase in sCr. A simple formula to correct sCr for fluid balance can improve staging of AKI and provide a better parameter for earlier recognition of severity progression.