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      Both Positive and Negative Fluid Balance May Be Associated with Reduced Long-term Survival in the Critically Ill

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          Abstract

          Objective

          Among critically ill patients with acute kidney injury, exposure to positive fluid balance (FB), compared with negative FB, has been associated with mortality and impaired renal recovery. However, its unclear whether positive and negative FB are associated with poor outcome compared to patients with even fluid balance (euvolemia). In this study, we examined the association between exposure to positive or negative FB, compared with even FB, on one-year mortality and renal recovery.

          Design

          Retrospective cohort study.

          Setting

          Eight medical-surgical ICUs at the University of Pittsburgh Medical Center, Pittsburgh, PA.

          Patients

          Critically ill patients admitted between July 2000 through October 2008.

          Interventions

          None

          Measurements & Main Results

          Among 18,084 patients, FB was categorized as negative (<0%); even (0 % – < 5%); or positive (≥5%). Following propensity matching, positive FB, compared with even or negative FB, was associated with increased mortality (30.3% vs. 21.1% vs. 22%, respectively, P<0.001). Using Gray’s model, negative compared with even FB, was associated with lower short-term mortality (adjusted hazard ratio range [AHR], 0.81, 95%CI, 0.68–0.96) but higher long-term mortality (AHR range, 1.16–1.22, P=0.004). Conversely, positive FB, was associated with higher mortality throughout one-year (AHR range, 1.30–1.92, P<0.001), which was attenuated in those who received RRT (Positive FB*RRT interaction AHR range, 0.43–0.89, P<0.001). Of patients receiving RRT, neither positive (adjusted odds ratio [AOR], 95% CI, 0.98, 0.68–1.4) nor negative (AOR, 0.81, 95% CI, 0.43–1.55) FB was associated with renal recovery.

          Conclusions

          Among critically ill patients, exposure to positive or negative FB, compared with even FB, was associated with higher one-year mortality. This mortality risk associated with positive FB, however, was attenuated by use of RRT. We found no association between FB and renal recovery.

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          A positive fluid balance is associated with a worse outcome in patients with acute renal failure

          Didier Payen, Anne-Cornélie JM de Pont, Yasser Sakr … (2008)
          Introduction Despite significant improvements in intensive care medicine, the prognosis of acute renal failure (ARF) remains poor, with mortality ranging from 40% to 65%. The aim of the present observational study was to analyze the influence of patient characteristics and fluid balance on the outcome of ARF in intensive care unit (ICU) patients. Methods The data were extracted from the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, a multicenter observational cohort study to which 198 ICUs from 24 European countries contributed. All adult patients admitted to a participating ICU between 1 and 15 May 2002, except those admitted for uncomplicated postoperative surveillance, were eligible for the study. For the purposes of this substudy, patients were divided into two groups according to whether they had ARF. The groups were compared with respect to patient characteristics, fluid balance, and outcome. Results Of the 3,147 patients included in the SOAP study, 1,120 (36%) had ARF at some point during their ICU stay. Sixty-day mortality rates were 36% in patients with ARF and 16% in patients without ARF (P < 0.01). Oliguric patients and patients treated with renal replacement therapy (RRT) had higher 60-day mortality rates than patients without oliguria or the need for RRT (41% versus 33% and 52% versus 32%, respectively; P < 0.01). Independent risk factors for 60-day mortality in the patients with ARF were age, Simplified Acute Physiology Score II (SAPS II), heart failure, liver cirrhosis, medical admission, mean fluid balance, and need for mechanical ventilation. Among patients treated with RRT, length of stay and mortality were lower when RRT was started early in the course of the ICU stay. Conclusion In this large European multicenter study, a positive fluid balance was an important factor associated with increased 60-day mortality. Outcome among patients treated with RRT was better when RRT was started early in the course of the ICU stay.
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            Classifying AKI by Urine Output versus Serum Creatinine Level.

            John A. Kellum, Florentina E Sileanu, Raghavan Murugan … (2015)
            Severity of AKI is determined by the magnitude of increase in serum creatinine level or decrease in urine output. However, patients manifesting both oliguria and azotemia and those in which these impairments are persistent are more likely to have worse disease. Thus, we investigated the relationship of AKI severity and duration across creatinine and urine output domains with the risk for RRT and likelihood of renal recovery and survival using a large, academic medical center database of critically ill patients. We analyzed electronic records from 32,045 patients treated between 2000 and 2008, of which 23,866 (74.5%) developed AKI. We classified patients by levels of serum creatinine and/or urine output according to Kidney Disease Improving Global Outcomes staging criteria for AKI. In-hospital mortality and RRT rates increased from 4.3% and 0%, respectively, for no AKI to 51.1% and 55.3%, respectively, when serum creatinine level and urine output both indicated stage 3 AKI. Both short- and long-term outcomes were worse when patients had any stage of AKI defined by both criteria. Duration of AKI was also a significant predictor of long-term outcomes irrespective of severity. We conclude that short- and long-term risk of death or RRT is greatest when patients meet both the serum creatinine level and urine output criteria for AKI and when these abnormalities persist.
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              Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study

              Suvi Vaara, Anna-Maija Korhonen, Kirsi-Maija Kaukonen … (2012)
              Introduction Positive fluid balance has been associated with an increased risk for mortality in critically ill patients with acute kidney injury with or without renal replacement therapy (RRT). Data on fluid accumulation prior to RRT initiation and mortality are limited. We aimed to study the association between fluid accumulation at RRT initiation and 90-day mortality. Methods We conducted a prospective, multicenter, observational cohort study in 17 Finnish intensive care units (ICUs) during a five-month period. We collected data on patient characteristics, RRT timing, and parameters at RRT initiation. We studied the association of parameters at RRT initiation, including fluid overload (defined as cumulative fluid accumulation > 10% of baseline weight) with 90-day mortality. Results We included 296 RRT-treated critically ill patients. Of 283 patients with complete data on fluid balance, 76 (26.9%) patients had fluid overload. The median (interquartile range) time from ICU admission to RRT initiation was 14 (3.3 to 41.5) hours. The 90-day mortality rate of the whole cohort was 116 of 296 (39.2%; 95% confidence interval 38.6 to 39.8%). The crude 90-day mortality of patients with or without fluid overload was 45 of 76 (59.2%) vs. 65 of 207 (31.4%), P < 0.001. In logistic regression, fluid overload was associated with an increased risk for 90-day mortality (odds ratio 2.6) after adjusting for disease severity, time of RRT initiation, initial RRT modality, and sepsis. Of the 168 survivors with data on RRT use at 90 days, 34 (18.9%, 95% CI 13.2 to 24.6%) were still dependent on RRT. Conclusions Patients with fluid overload at RRT initiation had twice as high crude 90-day mortality compared to those without. Fluid overload was associated with increased risk for 90-day mortality even after adjustments.
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                Author and article information

                Journal
                Journal ID (nlm-journal-id): 0355501
                Journal ID (pubmed-jr-id): 3206
                Journal ID (nlm-ta): Crit Care Med
                Journal ID (iso-abbrev): Crit. Care Med.
                Title: Critical care medicine
                ISSN (Print): 0090-3493
                ISSN (Electronic): 1530-0293
                Publication date Nihms-submitted: 10 February 2017
                Publication date (Print): August 2017
                Publication date PMC-release: 01 August 2018
                Volume: 45
                Issue: 8
                Pages: e749-e757
                Affiliations
                [1 ]The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
                [2 ]The Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
                [3 ]The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
                [4 ]Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
                Author notes
                Corresponding Author: Raghavan Murugan, MD, MS, Associate Professor of Critical Care Medicine, and, Clinical & Translational Science, 642A Scaife Hall, University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA 15261, muruganr@ 123456upmc.edu , Telephone: 412-647-1263
                Article
                Accession ID: PMC5511076 Pmcid ID: PMC5511076 Pmc-uid ID: 5511076 Manuscript ID: nihpa849964
                DOI: 10.1097/CCM.0000000000002372
                PMC ID: 5511076
                PubMed ID: 28437375
                SO-VID: 6f89575b-3609-4949-b6ef-c243bf8b2891
                History
                Categories
                Subject: Article

                Keywords: acute kidney injury,renal replacement therapy,dialysis,fluid balance,renal recovery,mortality
                Data availability:
                Keywords: acute kidney injury, renal replacement therapy, dialysis, fluid balance, renal recovery, mortality

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