From the Guidelines
Worsening creatinine in end-stage renal disease (ESRD) is typically referred to as acute kidney injury (AKI) or progression of renal failure, with the KDIGO guidelines providing a framework for its detection and staging, as outlined in Table 1 1.
Definition and Detection
The initial diagnosis of AKI is based on a patient meeting any of the criteria for stage 1, which includes a rise of >26 mmol/l or 0.3 mg/dl within 48 h, or a 50–99% creatinine rise from baseline within 7 days 1.
Staging and Management
Staging is carried out retrospectively when the episode is complete, and patients are classified according to the highest possible stage where the criterion is met, either by creatinine rise or by urine output 1.
- The management of worsening creatinine in ESRD involves optimizing dialysis prescription, addressing any reversible causes, and adjusting medications that are cleared by the kidneys.
- Regular monitoring of creatinine levels, along with other markers like blood urea nitrogen (BUN), electrolytes, and urine output (if present), helps guide treatment decisions in ESRD patients.
Clinical Implications
The KDIGO guidelines emphasize the importance of using a definition, such as KDIGO for adults, in routine clinical practice, despite some controversies and unresolved issues with the definition of AKI and acute-on-chronic kidney disease (ACKD) 1.
- Large studies have shown that small rises in creatinine are independently associated with increased mortality, highlighting the need for prompt detection and management of AKI in ESRD patients 1.
From the Research
Worsening Creatinine in ESRD
- Worsening creatinine in End-Stage Renal Disease (ESRD) can be referred to as a progression of kidney disease, with increasing creatinine levels indicating a decline in kidney function 2, 3.
- The Risk, Injury, Failure, Loss and ESRD (RIFLE) classification is used to define acute kidney injury (AKI), with "Loss" and "ESRD" being the last two stages of the classification 4.
- A study found that progression to "ESRD" was associated with higher baseline creatinine levels, with an odds ratio of 1.19 per every increase in creatinine of 0.1 mg/dl 4.
- The development of "Loss" and "ESRD" in critically ill patients is a significant concern, with almost 50% of patients developing some form of AKI, and 4.9% progressing to "ESRD" 4.
- Maladaptive repair after AKI is strongly associated with the development of chronic kidney disease (CKD) and long-term consequences, including worsening creatinine levels 5.
Key Factors
- Severity of AKI, age, and comorbidities are clinical factors that contribute to the progression of AKI to CKD/ESRD 5.
- The identification of AKI-to-CKD biomarkers could improve the early identification of AKI patients with higher risk for CKD progression, including worsening creatinine levels 5.
- Controlling blood pressure in patients receiving dialysis improves mortality, and volume control through adequate dialysis and sodium restriction can help optimize hypertension treatment in these patients 2.