Hospital Harm - Acute Kidney Injury

The measure assesses the number of inpatient hospitalizations for patients age 18 and older who have an acute kidney injury (stage 2 or greater) that occurred during the encounter. Acute kidney injury (AKI) stage 2 or greater is defined as a substantial increase in serum creatinine value, or by the initiation of kidney dialysis (continuous renal replacement therapy (CRRT), hemodialysis or peritoneal dialysis).

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LOINC(R) copyright 2004-2023 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2023 International Health Terminology Standards Development Organisation. ICD-10 copyright 2023 World Health Organization. All Rights Reserved.

This performance measure is not a clinical guideline and does not establish a standard of medical care, and has not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED "AS IS" WITHOUT WARRANTY OF ANY KIND. 

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Sex and Age.

First vital signs since the encounter start:
- Heart Rate
- Respiratory Rate
- Systolic Blood Pressure
- Temperature. 

The estimated glomerular filtration rate (eGFR) which is calculated using the index serum creatinine, patient sex, and age-based formula.

Patient sex collected for risk adjustment and to calculate the eGFR is determined by the
AdministrativeGender codes 'F' (female) and 'M' (male). These codes make up the "ONC Administrative
Sex" value set and are also used to derive the supplemental data element of patient sex for the measure.

All encounter diagnoses along with their present on admission (POA) indicators are being collected for the development of baseline risk adjustment model with initial focus on any encounter diagnoses captured for:
- Cancer (leukemia, lymphoma, or metastatic cancer)
- Diabetes
- Heart failure
- Hypertension
- Obesity

Encounter length of stay.

Please see the Hospital Harm - Acute Kidney Injury Risk Adjustment Methodology Report on the eCQM-specific page on the eCQI Resource Center website: https://ecqi.healthit.gov/

None

This measure focuses on stage 2 or greater acute kidney injury as an outcome in the hospital inpatient setting. The incidence of AKI in general hospitalized patients is 10%–20%, and among critically ill patients, the incidence of AKI has been reported as high as 45–50%; in cardiac surgery patients it ranges from 30%-50% (Thongprayoon et al., 2020). Less severe acute kidney injury and acute kidney injury requiring dialysis affect approximately 2,000 to 3,000 and 200 to 300 per million population per year, respectively. Acute kidney injury may result in the need for dialysis, and is associated with an increased risk of mortality (Schwager et al., 2023; Wilson et al., 2013). 

While not all instances of acute kidney injury are avoidable and may be due to natural progression of underlying illness or a complication of a necessary treatment such as chemotherapy, a proportion of acute kidney injury cases are preventable and treatable. The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest careful management of hemodynamic status, fluids, and vasoactive medications for the prevention of acute kidney injury (KDIGO, 2012). Several studies identified through systematic literature searches developed or evaluated the effectiveness of acute kidney injury electronic alert systems (Schwager et al., 2023; Selby et al., 2012; Ahmed et al., 2015; Porter et al., 2014; Wilson et al., 2014; Kirkendall et al., 2014; Cho et al., 2012). These studies used data elements for defining acute kidney injury that were already present and populated in the electronic health record (EHR). For acute kidney injury diagnosis, all except two were limited to using serum creatinine levels, suggesting that this is the most reliable and consistently available electronic data element for defining acute kidney injury.

Serum creatinine is an accepted proxy for acute kidney disease (Ostermann et al., 2020; KDIGO, 2012). It is cited by many guidelines for defining and monitoring acute kidney injury (Lameire et al., 2021; Ostermann et al., 2020; Lopes & Jorge, 2013; KDIGO, 2012). eGFR equations that incorporate creatinine and cystatin C but omit race are more accurate and lead to smaller differences between Black participants and non-Black participants than new equations without race with either creatinine or cystatin C alone (Inker et al., 2021).  As a result, a new race-neutral eGFR equation that that measures serum creatinine or cystatin C incorporate age, sex, and race to estimate measured GFR has been developed and is recommended by the Task Force from the National Kidney Foundation and American Society of Nephrology (Inker et al., 2021; Diao et al., 2021; Delgado et al., 2021; Delgado et al., 2022).  It was recommended by the Task Force to use within the measure a Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine equation refit without the race variable. This functionality has been available to all laboratories in the United States (Delgado et al., 2021; Delgado et al., 2022), and has acceptable performance characteristics and potential consequences that do not disproportionately affect any one group of individuals.

The KDIGO offers clinical practice guidelines for preventing and managing acute kidney injury:

FLUIDS
3.1.1: In the absence of hemorrhagic shock, we suggest using isotonic crystalloids rather than colloids (albumin or starches) as initial management for expansion of intravascular volume in patients at risk for acute kidney injury or with acute kidney injury. (Level 2, grade B)

VASOPRESSORS
3.1.2: We recommend the use of vasopressors in conjunction with fluids in patients with vasomotor shock with, or at risk for, acute kidney injury. (Level 1, grade C)

PROTOCOLIZED HEMODYNAMIC MANAGEMENT
3.1.3: We suggest using protocol-based management of hemodynamic and oxygenation parameters to prevent development or worsening of acute kidney injury in high-risk patients in the perioperative setting (2C) or in patients with septic shock. (Level 2, grade C)

In April 2019, KDIGO held a follow-up conference (Ostermann et al., 2020). The effectiveness of the 2012 KDIGO recommendations in preventing AKI was also noted to have been confirmed in small single-center randomized controlled trials (RCTs), such as the Prevention of AKI (PrevAKI) and the Biomarker Guided Intervention for Prevention of AKI (BigpAK) studies (Meersch et al., 2017; Göcze et al., 2018). In addition, results of RCTs have provided new data relevant to several facets of preventing and managing AKI, including early resuscitation, fluid therapy, prevention of contrast-associated AKI, and timing of acute renal replacement therapy (RRT) (Kellum et al., 2016; Nijssen et al., 2017; Self et al., 2018; Zarbock et al, 2016; Gaudry et al., 2016; Barbar et al., 2018).

A lower measure score indicates higher quality

Reference Type: CITATION

Reference Text: 'Ahmed, A., Vairavan, S., Akhoundi, A., Wilson, G., Chiofolo, C., Chbat, N., & Kashani, K. (2015). Development and validation of electronic surveillance tool for acute kidney injury: A retrospective analysis. J Crit Care, 30(5), 988-993. doi: 10.1016/j.jcrc.2015.05.007'

Reference Type: CITATION

Reference Text: 'Barbar, S.D., Clere-Jehl, R., Bourredjem, A., Hernu, R., Montin,i F., Bruyère, R., Lebert, C., Bohé, J., Badie, J., Erald,i J.P., Rigaud, J.P., Levy, B., Siam,i S., Louis, G., Bouadma, L., Constantin, J.M., Mercier, E., Klouche, K., du Cheyron, D., ... Quenot, J.P. (2018). IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018 Oct 11;379(15):1431-1442. doi: 10.1056/NEJMoa1803213. PMID: 30304656'

Reference Type: CITATION

Reference Text: 'Cho, A., Lee, J.E., Yoon, J.Y., Jang, H.R., Huh, W., Kim, Y.G., & Oh, H.Y. (2012). Effect of an electronic alert on risk of contrast-induced acute kidney injury in hospitalized patients undergoing computed tomography. American Journal of Kidney Diseases, 60(1), 74-81. doi: 10.1053/j.ajkd.2012.02.331. Epub 2012 Apr 11. PMID: 22497793'

Reference Type: CITATION

Reference Text: 'Delgado, C., Baweja, M., Crews, D.C., Eneanya, N.D., Gadegbeku, C.A., Inker, L.A., Mendu, M L., Miller, W.G., Moxey-Mims, M.M., Roberts, G.V., St Peter, W.L., Warfield, C., & Powe, N.R. (2021). A unifying approach for GFR estimation: Recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. Journal of the American Society of Nephrology: JASN, 32(12), 2994–3015. doi: 10.1681/ASN.2021070988. Epub 2021 Dec 1. PMID: 34556489; PMCID: PMC8638402'

Reference Type: CITATION

Reference Text: 'Delgado, C., Baweja, M., Crews, D.C., Eneanya, N.D., Gadegbeku, C.A., Inker, L.A., Mendu, M.L., Miller, W.G., Moxey-Mims, M.M., Roberts, G.V., St Peter, W.L., Warfield, C., & Powe, N.R. (2022). A unifying approach for GFR estimation: Recommendations of the NKF-ASN task force on reassessing the inclusion of race in diagnosing kidney disease. American journal of kidney diseases: The official journal of the National Kidney Foundation, 79(2), 268–288.e1. doi: 10.1053/j.ajkd.2021.08.003. Epub 2021 Sep 23. PMID: 34563581'

Reference Type: CITATION

Reference Text: 'Diao, J.A., Inker, L.A., Levey, A.S., Tighiouart, H., Powe, N.R., & Manrai, A.K. (2021). In search of a better equation - Performance and equity in estimates of kidney function. N Engl J Med. 2021 Feb 4;384(5):396-399. doi: 10.1056/NEJMp2028243. Epub 2021 Jan 6. PMID: 33406354; PMCID: PMC8084706'

Reference Type: CITATION

Reference Text: 'Gaudry, S., Hajage, D., Schortgen, F., Martin-Lefevre, L., Pons, B., Boulet, E., Boyer, A., Chevrel, G., Lerolle, N., Carpentier, D., de Prost, N., Lautrette, A., Bretagnol, A., Mayaux, J., Nseir, S., Megarbane, B., Thirion, M., Forel, J.M., Maize,l J., ... Dreyfuss, D. (2016). Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016 Jul 14;375(2):122-33. doi: 10.1056/NEJMoa1603017. Epub 2016 May 15. PMID: 27181456'

Reference Type: CITATION

Reference Text: 'Göcze, I., Jauch, D., Götz, M., Kennedy, P., Jung, B., Zeman, F., Gnewuch, C., Graf, B. M., Gnann, W., Banas, B., Bein, T., Schlitt, H. J., & Bergler, T. (2018). Biomarker-guided Intervention to Prevent Acute Kidney Injury After Major Surgery: The Prospective Randomized BigpAK Study. Annals of surgery, 267(6), 1013–1020. doi: 10.1097/SLA.0000000000002485. PMID: 28857811'

Reference Type: CITATION

Reference Text: 'Inker, L.A., Eneanya, N.D., Coresh, J., Tighiouart, H., Wang, D., Sang, Y., Crews, D.C., Doria, A., Estrella, M.M., Froissart, M., Grams, M.E., Greene, T., Grubb, A., Gudnason, V., Gutiérrez, O.M., Kalil, R., Karger, A.B., Mauer, M., Navis, G., ... Levey, A.S.(2021). Chronic Kidney Disease Epidemiology Collaboration. New creatinine- and cystatin c-based equations to estimate GFR without race. N Engl J Med. 2021 Nov 4;385(19):1737-1749. doi: 10.1056/NEJMoa2102953. Epub 2021 Sep 23. PMID: 34554658; PMCID: PMC8822996'

Reference Type: CITATION

Reference Text: 'Kellum, J.A., Chawla, L.S., Keener, C., Singbartl, K., Palevsky, P.M., Pike, F.L., Yealy, D.M., Huang, D.T., Angus, D.C., & ProCESS and ProGReSS-AKI Investigators. (2016). The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock. American journal of respiratory and critical care medicine, 193(3), 281–287. doi: 10.1164/rccm.201505-0995OC. PMID: 26398704; PMCID: PMC4803059'

Reference Type: CITATION

Reference Text: 'Kidney Disease: Improving Global Outcomes (KDIGO). (2012). KDIGO 2012 Clinical practice guideline for acute kidney injury. Kidney International, Suppl. 2, 1–141. doi:10.1038/kisup.2012.2'

Reference Type: CITATION

Reference Text: 'Kirkendall, E.S., Spires, W.L., Mottes, T.A., Schaffzin, J.K., Barclay, C., & Goldstein, S.L. (2014). Development and performance of electronic acute kidney injury triggers to identify pediatric patients at risk for nephrotoxic medication-associated harm. Applied Clinical Informatics, 5(2), 313-333. doi: 10.4338/ACI-2013-12-RA-0102. PMID: 25024752; PMCID: PMC4081739'

Reference Type: CITATION

Reference Text: 'Lameire, N.H., Levin, A., Kellum, J.A., Cheung, M., Jadoul, M., Winkelmayer, W.C., Stevens, P.E., & Conference Participants. (2021). Harmonizing acute and chronic kidney disease definition and classification: report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney International, 100(3), 516–526. https://doi.org/10.1016/j.kint.2021.06.028'

Reference Type: CITATION

Reference Text: 'Lopes, J. A., & Jorge, S. (2013). The RIFLE and AKIN classifications for acute kidney injury: A critical and comprehensive review. Clinical Kidney Journal, 6(1), 8-14. doi: 10.1093/ckj/sfs160. Epub 2012 Jan 1. PMID: 27818745; PMCID: PMC5094385'

Reference Type: CITATION

Reference Text: 'Meersch, M., Schmidt, C., Hoffmeier, A., Van Aken, H., Wempe, C., Gerss, J., & Zarbock, A. (2017). Prevention of cardiac surgery-associated AKI by implementing the KDIGO guidelines in high risk patients identified by biomarkers: the PrevAKI randomized controlled trial. Intensive care medicine, 43(11), 1551–1561. doi: 10.1007/s00134-016-4670-3. Epub 2017 Jan 21. Erratum in: Intensive Care Med. 2017 Mar 7;: PMID: 28110412; PMCID: PMC5633630'

Reference Type: CITATION

Reference Text: 'Nijssen, E.C., Rennenberg, R J., Nelemans, P.J., Essers, B.A., Janssen, M.M., Vermeeren, M.A., Ommen, V.V., & Wildberger, J.E. (2017). Prophylactic hydration to protect renal function from intravascular iodinated contrast material in patients at high risk of contrast-induced nephropathy (AMACING): a prospective, randomised, phase 3, controlled, open-label, non-inferiority trial. Lancet (London, England), 389(10076), 1312–1322. doi: 10.1016/S0140-6736(17)30057-0. Epub 2017 Feb 21. PMID: 28233565'

Reference Type: CITATION

Reference Text: 'Ostermann, M., Bellomo, R., Burdmann, E.A., Doi, K., Endre, Z.H., Goldstein, S.L., Kane-Gill, S.L., Liu, K.D., Prowle, J.R., Shaw, A.D., Srisawat, N., Cheung, M., Jadoul, M., Winkelmayer, W.C., Kellum, J.A., & Conference Participants. (2020). Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference. Kidney international, 98(2), 294–309. doi: 10.1016/j.kint.2020.04.020. Epub 2020 Apr 26. PMID: 32709292; PMCID: PMC8481001'

Reference Type: CITATION

Reference Text: 'Porter, C.J., Juurlink, I., Bisset, L.H., Bavakunji, R., Mehta, R.L., & Devonald, M.A. (2014). A real-time electronic alert to improve detection of acute kidney injury in a large teaching hospital. Nephrol Dial Transplant, 29(10), 1888-1893. doi: 10.1093/ndt/gfu082'

Reference Type: CITATION

Reference Text: 'Schwager, E., Ghosh, E., Eshelman, L., Pasupathy, K.S., Barreto, E.F., & Kashani, K. (2023). Accurate and interpretable prediction of ICU-acquired AKI. Journal of critical care, 75, 154278. https://doi.org/10.1016/j.jcrc.2023.154278'

Reference Type: CITATION

Reference Text: 'Selby, N.M., Crowley, L., Fluck, R.J., McIntyre, C.W., Monaghan, J., Lawson, N., & Kolhe, N.V. (2012). Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. Clinical Journal of The American Society of Nephrology: CJASN, 7(4), 533-540. doi: 10.2215/CJN.08970911. Epub 2012 Feb 23. PMID: 22362062'

Reference Type: CITATION

Reference Text: 'Self, W.H., Semler, M.W., Wanderer, J.P., Wang, L., Byrne, D.W., Collins, S.P., Slovis, C.M., Lindsell, C.J., Ehrenfeld, J.M., Siew, E.D., Shaw, A.D., Bernard, G.R., Rice, T.W., & SALT-ED Investigators. (2018). Balanced crystalloids versus saline in noncritically ill adults. The New England journal of medicine, 378(9), 819–828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27. PMID: 29485926; PMCID: PMC5846618'

Reference Type: CITATION

Reference Text: 'Thongprayoon, C., Hansrivijit, P., Kovvuru, K., Kanduri, S.R., Torres-Ortiz, A., Acharya, P., Gonzalez-Suarez, M.L., Kaewput, W., Bathini, T., & Cheungpasitporn, W. (2020). Diagnostics, risk factors, treatment and outcomes of acute kidney injury in a new paradigm. Journal of clinical medicine, 9(4), 1104. https://doi.org/10.3390/jcm9041104'

Reference Type: CITATION

Reference Text: 'Wilson, F. P., Yang, W., & Feldman, H.I. (2013). Predictors of death and dialysis in severe AKI: The UPHS-AKI cohort. Clinical Journal of the American Society of Nephrology, 8(4), 527-537. doi: 10.2215/cjn.06450612'

Reference Type: CITATION

Reference Text: 'Wilson, F.P., Reese, P.P., Shashaty, M.G., Ellenberg, S.S., Gitelman, Y., Bansal, A.D., & Fuchs, B. (2014). A trial of in-hospital, electronic alerts for acute kidney injury: Design and rationale. Clinical Trials, 11(5), 521-529. doi: 10.1177/1740774514542619. Epub 2014 Jul 14. PMID: 25023200; PMCID: PMC4156885'

Reference Type: CITATION

Reference Text: 'Zarbock, A., Kellum, J.A., Schmidt, C., Van Aken, H., Wempe, C., Pavenstädt, H., Boanta, A., Gerß, J., & Meersch, M. (2016). Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN Randomized Clinical Trial. JAMA, 315(20), 2190–2199. doi: 10.1001/jama.2016.5828. PMID: 27209269'

Inpatient hospitalizations: Includes time in the emergency department and observation when the transition between these encounters (if they exist) and the inpatient encounter are within an hour or less of each other.

The numerator harm, AKI (stage 2 or greater), is defined as a substantial increase in serum creatinine value during the encounter, as evidenced by a subsequent increase in value at least 2 times higher than the lowest serum creatinine value, and the increased value is greater than the highest sex-specific normal value for serum creatinine. The following steps are performed to determine if this criterion for AKI is met:
- To identify AKI, evaluate if any serum creatinine value obtained between 48 hours after the start of the encounter and either 30 days after the start of the encounter or discharge, whichever is sooner, is at least 1.5 times higher than the lowest value obtained within the prior 7 days. If yes, then:
- Evaluate if the increased serum creatinine is greater than the highest sex-specific normal value for serum creatinine. If yes, then:
- To stage AKI, evaluate if any serum creatinine value obtained between 48 hours after the start of the encounter and either 30 days after the start of the encounter or discharge, whichever is sooner, is at least 2 times higher than the lowest prior value (at any prior time) during that encounter. If yes, then:
- Evaluate if the increased serum creatinine value is greater than the highest sex-specific normal value for serum creatinine. If yes, then a harm (AKI stage 2 or greater) has been identified.

The highest normal serum creatinine value for females is defined as 1.02 mg/dL.
The highest normal serum creatinine value for males is defined as 1.18 mg/dL.

The eGFR values are calculated using the CKD-EPI Creatinine Equation, recommended by the National Kidney Foundation (Delgado et al., 2022). This is a sex-specific, race-neutral formula.

The CKD-EPI Creatinine Equation used for females: 142 x [min((Serum Creatinine)/0.7,1)] raised to the power of (-0.241) x max [((Serum Creatinine)/0.7,1) raised to the power of (-1.200)] x [0.9938] raised to the power of Age x 1.012.

The CKD-EPI Creatinine Equation used for males: 142 x [min((Serum Creatinine)/0.9,1)] raised to the power of (-0.302) x max [((Serum Creatinine)/0.9,1) raised to the power of (-1.200)] x [0.9938] raised to the power of Age.

The "index" serum creatinine is defined as the lowest serum creatinine value within the first 24 hours of encounter start. If there are no serum creatinine values within the first 24 hours, then the index is the first serum creatinine value within the first 48 hours of the encounter start. This serum creatinine value is used to identify and exclude patients with AKI at the start of the encounter.

The "index" eGFR is calculated using the "index" serum creatinine, patient sex, and patient age based on the CKD-EPI Creatinine Equation.

"Initiation" of kidney dialysis (CRRT, hemodialysis and peritoneal) during hospitalization is defined as documentation that kidney dialysis (CRRT, hemodialysis or peritoneal) was started during the encounter.

In addition to clinical electronic health record data, this measure uses Present on Admission (POA) indicators (e.g., POA = U) as found in billing/claims system within the measure criteria.

The POA Indicator is intended to differentiate conditions present at the time of admission from those conditions that develop during the inpatient admission.
- A POA Indicator of Y = yes (Diagnosis was present at time of inpatient admission)
- A POA Indicator of N = no (Diagnosis was not present at time of inpatient admission)
- A POA Indicator of W = clinically undetermined
- A POA Indicator of U = documentation insufficient to determine if the condition was present at the time of inpatient admission

Per CMS and the Agency for Healthcare Research and Quality (AHRQ) convention, POA indicators of Y and W are accepted indicators of a diagnosis present on admission. POA indicators of N and U are accepted indicators of a diagnosis that is not present on admission.

A patient characteristic of male or female sex is required as part of the initial population criteria, as sex is crucial to this measure. For example:
- The eGFR estimating equation that is used to identify AKI is sex-specific; and
- The reference ranges for the serum creatinine value are sex-specific, which matters because the serum creatinine must rise to a sex-specific abnormal value to be flagged as AKI.

Exclude encounters that do not have at least two serum creatine values within 48 hours of arrival. Two values are needed within this timeframe to determine if the patient has AKI or moderate-to-severe renal dysfunction on arrival.

For encounters that show no patients with identified harm of 2.0 increase in serum creatinine, query for initiation of renal dialysis during hospitalization, defined by the start of dialysis occurring during the encounter.
- If dialysis starts more than 48 hours after the start of the encounter, this meets numerator criteria.
- If dialysis starts 48 hours or less after the start of the encounter, this meets denominator exclusion criteria.

Encounters for patients with an increase in serum creatinine value of at least 0.3 mg/dL between the index serum creatinine and any subsequent serum creatinine taken within 48 hours of the encounter start are excluded. Due to the variability of decimal precision within programming languages and calculation tools, the value of >=0.3 is expressed in the logic as >0.299.

Note the measure is currently confined to using mg/dL as the unit of measurement for creatinine and mL/min as the unit of measurement for eGFR results.

When reporting the first body temperature for risk adjustment, values from either Celsius or Fahrenheit readings are acceptable to report but Celsius readings are preferred. Celsius readings conform to the Fast Healthcare Interoperability Resources (FHIR) standard which will assist with future FHIR implementations.

This eCQM is an episode-based measure. An episode is defined as each inpatient hospitalization or encounter that ends during the measurement period.

This version of the eCQM uses QDM version 5.6. Please refer to the eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

Inpatient hospitalizations that end during the measurement period for patients 18 years of age or older without an obstetrical or pregnancy related condition, with a length of stay of 48 hours or longer, and who had at least one serum creatinine value after 48 hours from the start of the hospitalization

Equals Initial Population

Inpatient hospitalizations for patients with an increase in serum creatinine value of at least 0.3 mg/dL
between the index serum creatinine and a subsequent serum creatinine taken within 48 hours of the encounter start.

Inpatient hospitalizations for patients with the index eGFR value of <60 mL/min within 48 hours of the encounter start.

Inpatient hospitalizations for patients who have less than two serum creatinine results within the first 48 hours of the encounter start.

Inpatient hospitalizations for patients who have kidney dialysis (CRRT, hemodialysis or peritoneal dialysis) initiated 48 hours or less after the encounter start, and who do not have evidence of a 2 times increase in serum creatinine.

Inpatient hospitalizations for patients with at least one specified diagnosis present on admission during the encounter that puts them at extremely high risk for AKI:
- Hemolytic Uremic Syndrome (HUS)
- Large Body Surface Area (BSA) Burns
- Traumatic Avulsion of Kidney
- Rapidly Progressive Nephritic Syndrome
- Thrombotic Thrombocytopenic Purpura
- Out of Hospital Cardiac Arrest (OHCA)

Inpatient hospitalizations for patients who have at least one specified procedure that starts during the encounter that puts them at extremely high risk for AKI:
- Extracorporeal membrane oxygenation (ECMO)
- Intra-Aortic Balloon Pump
- Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)
- Nephrectomy

Inpatient hospitalizations for patients who develop AKI (stage 2 or greater) during the encounter, as evidenced by:

A subsequent increase in serum creatinine value at least 2 times higher than the lowest serum creatinine value, and the increased value is greater than the highest sex-specific normal value for serum creatinine.

Or:

Kidney dialysis (CRRT, hemodialysis or peritoneal dialysis) initiated more than 48 hours after the start of the encounter. Evidence of a 2 times increase in serum creatinine is not required.

Only one harm is counted per encounter.

Not Applicable

None

For every patient evaluated by this measure also identify payer, race, ethnicity and sex