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Lia&#241;o et al&#46; suggested that AKI should be coined as <span class="elsevierStyleItalic">alteraci&#243;n renal aguda </span>&#40;ARA&#41; in Spanish&#46;<span class="elsevierStyleSup">4 </span>Since Lassnig&#8217;s study on patients undergoing cardiac surgery&#44; it is known that even slight increases &#40;0&#46;3mg&#47;dl&#41; in serum creatinine &#40;SCr&#41; with respect to baseline have an impact on postoperative morbidity and mortality&#46;<span class="elsevierStyleSup">5&#44;6 </span>These results have been confirmed in hospitalised patients&#46;<span class="elsevierStyleSup">7 </span></p><p class="elsevierStylePara">In 2004&#44; the Acute Dialysis Quality Initiative &#40;ADQI&#41; proposed the use of the RIFLE system &#40;Risk&#44; Injury&#44; Failure&#44; Loss and End stage renal disease&#41; with 3 diagnostic &#40;R&#44; I and F&#41; and 2 prognostic &#40;L and E&#41; categories&#46; The diagnosis is made based on SCr increases compared to baseline&#44; decreases in the glomerular filtration rate &#40;GFR&#41;&#44; or absolute decreases in diuresis&#46;<span class="elsevierStyleSup">2 </span>Patients are diagnosed and classified using the criteria that placed them in the most severe stage&#46; These criteria were reviewed in 2007 and modified by the Acute Kidney Injury Network &#40;AKIN&#41;&#44; this latter classification being recognised as the current one&#46;<span class="elsevierStyleSup">3 </span>However&#44; and perhaps for non-scientific reasons&#44;<span class="elsevierStyleSup">8 </span>the RIFLE classification is very popular&#46; The number of publications exceeds 150&#44; and a fairly recent systematic review included 24 studies covering more than 70 000 patients&#46;<span class="elsevierStyleSup">9 </span>Among the problems associated with this classification is the diagnosis and classification of patients whose baseline serum creatinine is unknown&#46; This occurs quite often in patients with an altered SCr value who are admitted to critical care units for acute problems &#40;e&#46;g&#46;&#44; septic shock&#44; acute coronary syndrome and heart failure&#41;&#46; The ADQI recommendation is to assume that patients with a previously unknown renal function&#44; with no known kidney disease&#44; have a GFR of 75-100ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#44; and then to back-calculate the SCr value using the simplified MDRD equation&#46;<span class="elsevierStyleSup">10 </span>This method has been used in several epidemiological studies despite its lack of validation&#46;<span class="elsevierStyleSup">11&#44;12 </span></p><p class="elsevierStylePara">The aim of this study is twofold&#58; <span class="elsevierStyleItalic">1&#41; </span>To assess the agreement between estimated baseline SCr &#40;est SCr&#41; against the known baseline SCr in patients undergoing cardiac surgery&#44; and <span class="elsevierStyleItalic">2&#41; </span>To analyse the impact of differences in baseline SCr on AKI frequency and severity for those episodes observed in cardiac surgery&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">MATERIAL AND METHODS </span></p><p class="elsevierStylePara">Perioperative data from cardiac surgery patients operated on in our hospital were compiled prospectively in a database kept by the Anaesthesiology Department&#46; We used data from patients operated on between 2002 and 2007&#46; All patients older than 14 years who underwent major cardiac surgery with or without extracorporeal circulation were included&#46; Patients were excluded if they were on dialysis prior to surgery&#44; were kidney transplant recipients&#44; had died within 24 hours of surgery or if they underwent second major surgery during the same hospitalisation period&#46; </p><p class="elsevierStylePara">The measured baseline SCr &#40;act SCr&#41; was considered as the last SCr measurement before surgery&#44; usually within 24 hours for patients undergoing elective surgery&#46; The kinetic Jaffe method was used&#46; The GFR was estimated from the simplified MDRD formula using four variables &#40;SCr&#44; age&#44; sex and race&#41;&#46; To calculate baseline serum creatinine &#40;est SCr&#41; from this equation&#44; considering a GFR of 75ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2 </span>&#40;the lower normal limit&#41;&#44; the ADQI recommendations were followed by using the following formula&#58; </p><p class="elsevierStylePara">Estimated SCr&#61;&#40;75&#47;&#91;186x&#40;age<span class="elsevierStyleSup">-0&#44;203</span>&#41;x&#40;0&#46;742 for women&#41;x&#40;1&#46;21 for black people&#41;&#93;&#41;<span class="elsevierStyleSup">-0&#44;887 </span></p><p class="elsevierStylePara">Patients were assigned the highest stage by the RIFLE classification from SCr determinations during the first week after surgery&#46; The criterion based on percentage GFR decreases was not used&#44; due to its lack of linearity and consistency when compared with increases in SCr&#46;<span class="elsevierStyleSup">13 </span>The diuresis criterion was also not used due to lack of data&#46; </p><p class="elsevierStylePara">The agreement between act SCr and est SCr was assessed by the intraclass correlation coefficient<span class="elsevierStyleSup">14 </span>and Bland and Altman plot&#46;<span class="elsevierStyleSup">15 </span>The bias&#44; the overall mean of the differences between act SCr and est SCr&#44; was also calculated&#59; as well as precision&#44; defined as the bias standard deviation&#46; The estimated error was calculated as the percentage of patients diagnosed with AKI using est SCr &#40;estAKI&#41; with respect to those diagnosed from act SCr &#40;actAKI&#41;&#44; using the formula below&#58; </p><p class="elsevierStylePara">&#40;estAKI &#8211; actAKI&#41;&#47;actAKI </p><p class="elsevierStylePara">A positive value showed an overestimation while a negative one implied underestimation&#46; An initial analysis of the global sample and a second analysis&#44; excluding patients with stage 3 or higher chronic kidney disease &#40;CKD&#41; according to the National Kidney Foundation K&#47;DOQI classification&#44; were performed&#46;<span class="elsevierStyleSup">16 </span>The mean and standard deviation or median and interquartile range&#44; depending on the distribution of the quantitative variables studied&#44; were used as measures of central tendency and dispersion&#46; A statistical analysis of the data and plots was performed using SPSS version 18&#46;0&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RESULTS </span></p><p class="elsevierStylePara">A total 2167 operations were performed on 2131 patients during the study period&#46; Those patients excluded were&#58; 31 patients &#40;32 surgeries&#41; for undergoing preoperative dialysis or being kidney transplant recipients&#59; 27 who died soon after surgery &#40;&#60;24 hours&#41;&#59; and 5 for having a second surgery during the same hospitalisation period&#46; The final sample consisted of 2103 operations on 2067 patients&#44; and the main features are shown in Table 1&#46; </p><p class="elsevierStylePara">Table 2 shows the number and percentage of patients who reached each RIFLE stage during the first week after surgery&#44; according to the type of baseline SCr used&#44; either actual or estimated&#59; the correlation between both&#59; and the bias and precision&#46; The global overestimation rate was 104&#37; &#40;29&#46;1&#37; vs 14&#46;6&#37;&#41;&#46; The diagnosis of AKI whith est SCr showed a false positive rate of 14&#46;8&#37;&#46; After excluding patients with a GFR&#60;60ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#44; the correlation was better&#46; The overestimation decreased to 2&#46;4&#37; with a false positive rate of 0&#46;28&#37;&#46; </p><p class="elsevierStylePara">Figure 1 shows the correlation between est SCr and act SCr via Bland and Altman plots&#46; The point cloud arrangement indicates that the degree of agreement decreases when the baseline SCr increases&#46; Graphically&#44; there is greater agreement between both creatinine values after excluding patients with any CKD stage prior to surgery &#40;Figure 2&#41;&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">This study shows that the recommendation to calculate baseline SCr from the MDRD-4 equation assuming a GFR of 75ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2 </span>overestimates the incidence of AKI in patients undergoing cardiac surgery&#46; A similar conclusion was reached by several authors using more heterogeneous cohorts than ours&#46; In the BEST Kidney study&#44; Bagshaw<span class="elsevierStyleSup">17 </span>found an overestimation of 42&#37; using the same formula to calculate baseline SCr from a prospective study of over 1300 patients from 54 intensive care units &#40;ICUs&#41; in 23 countries&#46; In a cohort study of almost 5000 patients hospitalised during a year&#44; Siew<span class="elsevierStyleSup">18 </span>compared 3 different methods to estimate the baseline serum creatinine with values obtained from pre-admission renal function for diagnosing AKI&#46; The methods were SCr calculated from MDRD with a GFR of 75ml&#47;min&#44; the minimum SCr value during admission and the SCr value on admission&#46; The first 2 methods overestimated the incidence by almost 50&#37;&#44; while the use of SCr on admission underestimated the diagnosis by 46&#37;&#46; More recently&#44; Z&#225;vada<span class="elsevierStyleSup">19 </span>found similar results when comparing 3 different methods&#44; including the one recommended by ADQI&#44; in non-selected patients from 3 different hospital ICUs&#46; Finally&#44; after prospectively analysing 224 patients from 2 general ICUs used as controls in the EARLYRAF study&#44; Pickering and Endre<span class="elsevierStyleSup">20 </span>found an overall overestimation of 35&#46;7&#37; with an assumed GFR of 75ml&#47;min&#44; which increased to 92&#46;8&#37; when a baseline GFR of 100ml&#47;min was considered&#46; Unlike our cohort study&#44; only 23&#37; of the patients underwent cardiac surgery&#44; and the rest had thoracic surgery&#44; vascular surgery&#44; sepsis&#44; trauma or cardiac arrest&#46; Our study was the first to focus on postoperative cardiac surgery patients&#44; therefore it is not possible to make direct comparisons with other studies&#46; </p><p class="elsevierStylePara">Both the prevalence of CKD or preoperative renal dysfunction and the incidence of AKI have a clear impact on the percentage of overestimation&#46; To some extent&#44; the first may be influenced by age &#40;generally higher in surgical patients&#41; and other cardiovascular risk factors &#40;particularly hypertension and diabetes&#41;&#44; which were significantly present in our sample&#46; It is worth noting that the best definition of preoperative renal dysfunction for patients undergoing cardiac surgery was established by Wijeysundera&#44;<span class="elsevierStyleSup">21 </span>as creatinine clearance &#40;CrCl&#41; lower than 60ml&#47;min&#46; The odds ratio for developing severe AKI &#40;with a need for RRT&#41; in a random sample of 2000 patients operated on over a period of 16 months was 5 &#40;confidence interval &#91;CI&#93; 95&#37;&#59; 2-12&#46;6&#41; when presenting this degree of renal dysfunction&#46; The prevalence of preoperative renal dysfunction in this sample was 27&#37;&#46; The prevalence of moderate or severe CKD &#40;GFR&#60;60ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#41; in the Pickering study cited above was 28&#37;&#44; while that of Bagshaw was 46&#37;&#44; which left our study between them &#40;33&#46;1&#37;&#41;&#46; Excluding these patients the overestimation decreased in all 3 studies&#46; This effect is easily explained&#44; as a significant number of cases where the patient is given a GFR above the real one are excluded&#46; Another concept worth mentioning&#44; which was also described by Wijeysundera&#44; is that of occult renal insufficiency&#46;<span class="elsevierStyleSup">22 </span>This is defined as preoperative renal function with a CrCl&#60;60ml&#47;min&#44; but with a preoperative baseline SCr&#60;1&#46;13mg&#47;dl&#46; In a cohort of over 10 000 patients undergoing cardiac surgery&#44; the prevalence of occult renal failure was 9&#37;&#44; and was very similar to our sample &#40;8&#46;5&#37;&#41;&#46; This concept stresses the importance of estimating GFR or CrCl in addition to baseline SCr in a preoperative analytical evaluation&#46; </p><p class="elsevierStylePara">The risk factors for AKI in the context of cardiac surgery have been extensively studied&#44; with several grading systems established to calculate RRT preoperative risk&#46;<span class="elsevierStyleSup">23-25 </span>Preoperative renal function appears constantly among the factors considered&#46; The incidence of AKI was 14&#46;2&#37; in our sample&#44; lower than both the Pickering &#40;31&#46;2&#37;&#41; and BEST &#40;44&#46;9&#37;&#41; studies&#46; Since the number of diagnosed cases is the denominator in the overestimation calculation&#44; the smaller this number is&#44; the higher the overestimation&#46; Together with the different prevalence of CKD&#44; this situation may explain our findings&#46; </p><p class="elsevierStylePara">We believe that the main limitation of this study is the use of baseline SCr taken as part of the preoperative evaluation&#58; this value need not necessarily reflect the subject&#8217;s SCr at baseline&#46; A significant number of patients admitted to the emergency department with symptoms of ischaemic heart disease or heart failure undergo cardiac surgery several days later&#44; once the patient has been stabilised&#46; However&#44; similar approaches have been used in the above studies&#46; Although the current recommendation is to use a SCr value obtained in the 3 months before admission&#44; there is no known best method for calculating baseline SCr when a baseline measurement is not available&#46; In the study by Pickering and Endre&#44;<span class="elsevierStyleSup">20 </span>the random assignment of SCr values from a lognormal distribution curve adjusted to the parameters of central tendency and dispersion of the source population was the method that most closely approximated to the actual incidence &#40;with an AKI underestimation of 2&#46;9&#37;&#41;&#46; Failing that&#44; and as a more practical method&#44; the authors recommend using the lowest SCr observed during the first 7 days of hospital stay &#40;an AKI overestimation of 5&#46;7&#37;&#41;&#46; This recommendation&#44; of course&#44; should only be done for an epidemiological analysis&#59; as such a delay in diagnosis is not acceptable from a healthcare point of view&#46; </p><p class="elsevierStylePara">A second limitation of this study is the use of SCr criterion only for AKI diagnosis&#44; excluding patients diagnosed from a decrease in diuresis&#46; This is a problem for all retrospective analyses using the RIFLE system&#44; which are the vast majority of those published&#46; This is because this parameter is rarely reflected in databases with sufficient detail to be applied &#40;i&#46;e&#46;&#44; on an hourly basis&#41;&#46; Therefore&#44; we did not give sensitivity and specificity values&#44; as all criteria must be used to make the diagnosis reliably and to classify those patients with the most severe stage&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSIONS </span></p><p class="elsevierStylePara">Using baseline creatinine calculated from the MDRD equation in the diagnosis of AKI overestimates the incidence in patients undergoing cardiac surgery&#46; This is common in populations with an increased prevalence of mild CKD&#44; with the intensity depending both on this factor and the incidence of AKI&#46; However&#44; this is acceptable in patients whose premorbid GFR is normal or nearly normal&#46; This observation must be considered&#44; especially in hospital-based epidemiological studies&#46; </p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><a href="grande&#47;11102&#95;16025&#95;25311&#95;en&#95;t111102i&#46;jpg" class="elsevierStyleCrossRefs"><img src="11102_16025_25311_en_t111102i.jpg" alt=" Main demographic variables&#44; comorbidity&#44; surgical variables&#44; postoperative variables and hospital stay in the studied cohort &#40;n&#61;2103&#41; "></img></a></p><p class="elsevierStylePara">Table 1&#46; Main demographic variables&#44; comorbidity&#44; surgical variables&#44; postoperative variables and hospital stay in the studied cohort &#40;n&#61;2103&#41; </p><p class="elsevierStylePara"><a href="grande&#47;11102&#95;16025&#95;25312&#95;en&#95;t111102i&#46;jpg" class="elsevierStyleCrossRefs"><img src="11102_16025_25312_en_t111102i.jpg" alt="Renal function stratified by RIFLE category "></img></a></p><p class="elsevierStylePara">Table 2&#46; Renal function stratified by RIFLE category </p><p class="elsevierStylePara"><a href="grande&#47;11102&#95;16025&#95;25313&#95;en&#95;f1&#95;11102i&#46;jpg" class="elsevierStyleCrossRefs"><img src="11102_16025_25313_en_f1_11102i.jpg" alt="Bland and Altman plot for the global cohort &#40;n&#61;2103&#41; showing the degree of agreement between both creatinine values "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Bland and Altman plot for the global cohort &#40;n&#61;2103&#41; showing the degree of agreement between both creatinine values </p><p class="elsevierStylePara"><a href="grande&#47;11102&#95;16025&#95;25314&#95;en&#95;f2&#95;11102i&#95;copy1&#46;jpg" class="elsevierStyleCrossRefs"><img src="11102_16025_25314_en_f2_11102i_copy1.jpg" alt="Bland and Altman plot after excluding patients with impaired renal function&#44; stage 3 CKD &#40;n&#61;1408&#41;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Bland and Altman plot after excluding patients with impaired renal function&#44; stage 3 CKD &#40;n&#61;1408&#41;</p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introducci&#243;n y objetivo&#58; </span>La definici&#243;n y clasificaci&#243;n actual de insuficiencia renal aguda se basa en criterios de consenso &#40;sistemas RIFLE y AKIN&#41;&#46; De los par&#225;metros recomendados &#40;creatinina&#44; tasa de filtraci&#243;n glomerular y diuresis&#41;&#44; la creatinina es el m&#225;s empleado&#46; En ausencia de valor basal conocido se recomienda su&#160;estimaci&#243;n a partir de la ecuaci&#243;n MDRD simplificada&#44; asumiendo en el c&#225;lculo&#160;una tasa de filtraci&#243;n de 75&#160;ml&#47;min&#47;1&#44;73 m<span class="elsevierStyleSup">2</span>&#46; El objetivo del presente trabajo fue evaluar la repercusi&#243;n diagn&#243;stica del empleo de la creatinina basal estimada frente al valor real medido&#160;en pacientes operados de cirug&#237;a card&#237;aca&#46; <span class="elsevierStyleBold">M&#233;todos&#58;</span> An&#225;lisis de pacientes operados de cirug&#237;a card&#237;aca mayor incluidos de forma prospectiva en una base de datos&#46; Para cada paciente se calcul&#243; el estadio RIFLE m&#225;ximo alcanzado usando la creatinina basal medida y la estimada&#46; Se analiz&#243; la repercusi&#243;n sobre el diagn&#243;stico mediante coeficientes de correlaci&#243;n intraclase&#44; an&#225;lisis de concordancia y gr&#225;ficas de Bland y Altman&#46; <span class="elsevierStyleBold">Resultados&#58;</span> La incidencia de insuficiencia renal aguda postoperatoria en 2&#46;103 casos operados entre 2002 y 2007 fue del 29&#44;1&#37; al utilizar la creatinina estimada &#40;14&#44;3&#37; con la medida&#41;&#46; Esto supone una sobrestimaci&#243;n del 104&#37;&#44; y la correlaci&#243;n intraclase es de 0&#44;12&#46; Excluyendo a los pacientes con insuficiencia renal cr&#243;nica conocida &#40;tasa de filtrado glomerular &#91;TFG&#93; &#60;60 ml&#47;min&#47;1&#44;73 m<span class="elsevierStyleSup">2</span>&#41;&#44; tanto la sobrestimaci&#243;n &#40;2&#44;4&#37;&#41; como la correlaci&#243;n &#40;0&#44;57&#41; mejoraron&#46; <span class="elsevierStyleBold">Conclusiones&#58;</span> El c&#225;lculo de la creatinina basal a partir de la ecuaci&#243;n MDRD sobrestima la incidencia de insuficiencia renal aguda tras la cirug&#237;a card&#237;aca&#44; y es un m&#233;todo inadecuado para su detecci&#243;n cuando el valor basal se desconoce&#46;<span class="elsevierStyleItalic"></span></p>"
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        "resumen" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction and objectives&#58; </span>The current definition and classification of acute kidney injury is based on consensus criteria &#40;RIFLE and AKIN systems&#41;&#46; Creatinine is the most commonly used of the recommended parameters &#40;creatinine&#44; glomerular filtration rate and diuresis&#41;&#46; If the baseline value is not known&#44; it can be calculated based on the simplified MDRD equation&#44; assuming a filtration rate of 75ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2 </span>for the calculation&#46; The aim of this study was to evaluate the diagnostic impact of using estimated baseline creatinine compared to the actual value measured in patients undergoing cardiac surgery&#46; <span class="elsevierStyleBold">Methods&#58; </span>Analysis of patients undergoing major cardiac surgery&#44; who were prospectively included in a database&#46; The maximum RIFLE stage reached was calculated for each patient using the measured and estimated baseline creatinine levels&#46; The impact on the diagnosis was analysed using intraclass correlation coefficients&#44; concordance analysis and Bland-Altman plots&#46; <span class="elsevierStyleBold">Results&#58; </span>The incidence of postoperative acute kidney injury in 2103 cases between 2002 and 2007 was 29&#46;1&#37;&#44; according to estimated creatinine &#40;14&#46;3&#37; with the measure&#41;&#46; This represents an overestimation of 104&#37;&#44; with an intraclass correlation of 0&#46;12&#46; By excluding patients with known chronic kidney disease &#40;glomerular filtration rate &#91;&#60;60ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#41;&#44; both the overestimation &#40;2&#46;4&#37;&#41; and the correlation &#40;0&#46;57&#41; improved&#46; <span class="elsevierStyleBold">Conclusions&#58; </span>The calculation of baseline creatinine using the MDRD equation overestimates the incidence of acute kidney injury after cardiac surgery&#44; and is an inadequate method for detection when the baseline value is unknown&#46; </p>"
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