Acute Kidney Injury (AKI) acquired in the clinical setting has been under recognized in its scope, severity as well as its impact on patient long term (post-AKI) outcomes (Brown, BioMed Research International, 2016, Article ID 4278579). Improving the quality of the measures of AKI is an important step to both raising awareness to the prevalence of AKI and to helping clinicians, researchers, industry, government & entrepreneurs work towards improved patient care in both treating and reducing AKI. Earlier & more accurate diagnosis should help with identification of various causes as well as allow earlier, more successful intervention in order to provide improved quality of patient care. We do, however, see three specific areas for potential improvement.

A) Temporal relationship with Serum Creatinine rise vs. time of kidney insult: Regarding Question 1 & 2 (“Serum Creatinine > or = to 1.5 times baseline” & “How useful is the measure in assessing and improving quality of care for patients?”), we believe that monitoring of 1.5 times baseline of Serum Creatinine may not be ideal, but from a ease & expense perspective, is a step in the right direction. However, this currently defined “Numerator” is a measure that, based on current literature, is not typically present for over 24-48 hours after the injury event has occurred. So, continued efforts to utilize & track with “earlier warning” biomarkers such as NGAL, NAG, CysC and/or TIMP-2 with IGF8P7 which are predictive of AKI within 12 hours of the injury should be considered (and even possibly UDP-glucose, which has been called a “causal” biomarker, not just a result of “correlation”)? (Leow, WJPCHS 2018 Vol 9(I):79-90; Lannemyer, Anesthesiology 2017 126:205-13; and Hobson, Crit Care Clin. 2017 Apr;33(2):379-396; and Liberman, J Am Soc Nephrol 2016)

B) Heart Surgery, Pediatrics & Adults: An increasing body of literature show the prevalence & significance of Acute Kidney Injury post cardiac surgery, both for the pediatric & adult population. The range of incidences reported is 5-52% in pediatric patients, and up to 40% in adult patients (Leow, WJPCHS 2018 Vol 9(I) 79-90); Li, Crit Care Med. 2011 June 39(6): 1493–1499; Brown, Ann Thorac Surg. 2012 Feb 93(2): 570–576; Hobson, Ann Surg. 2015 Jun 261(6):1207-14). Given the prevalence across all age groups, especially post-cardiac surgery patients, we would like to see provisions to include the pediatric population as well as track who experiences AKI in the post-surgical (especially cardiac) setting.

C) Tracking ALL stages of AKI is important: Current ICD coding for AKI does not allow for delineation between stages of AKI as identified with either RIFLE, AKIN and KDIGO criteria. It would seem to be an improvement to expand the measure to identify and track incidence of all stages of AKI to offer more actionable granularity on the both severity and prevelence. We feel very strongly that even the “lowest” and earliest stages of kidney injury should be tracked which could potentially help in identifying root causes and aid in improving patient care. As the business guru Peter Drucker is claimed to have said: “If you can’t measure it, you can’t improve it”.