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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

          <div class="section"> <a class="named-anchor" id="S1"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e169">Objective</h5> <p id="P1">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. </p> </div><div class="section"> <a class="named-anchor" id="S2"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e174">Design</h5> <p id="P2">Retrospective cohort study.</p> </div><div class="section"> <a class="named-anchor" id="S3"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e179">Setting</h5> <p id="P3">Eight medical-surgical ICUs at the University of Pittsburgh Medical Center, Pittsburgh, PA. </p> </div><div class="section"> <a class="named-anchor" id="S4"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e184">Patients</h5> <p id="P4">Critically ill patients admitted between July 2000 through October 2008.</p> </div><div class="section"> <a class="named-anchor" id="S5"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e189">Interventions</h5> <p id="P5">None</p> </div><div class="section"> <a class="named-anchor" id="S6"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e194">Measurements &amp; Main Results</h5> <p id="P6">Among 18,084 patients, FB was categorized as negative (&lt;0%); even (0 % – &lt; 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&lt;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&lt;0.001), which was attenuated in those who received RRT (Positive FB*RRT interaction AHR range, 0.43–0.89, P&lt;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. </p> </div><div class="section"> <a class="named-anchor" id="S7"> <!-- named anchor --> </a> <h5 class="section-title" id="d6339683e199">Conclusions</h5> <p id="P7">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. </p> </div>

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

          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.

            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 balance and acute kidney injury.

              Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.
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                Author and article information

                Journal
                Critical Care Medicine
                Critical Care Medicine
                Ovid Technologies (Wolters Kluwer Health)
                0090-3493
                2017
                August 2017
                : 45
                : 8
                : e749-e757
                Article
                10.1097/CCM.0000000000002372
                5511076
                28437375
                6f89575b-3609-4949-b6ef-c243bf8b2891
                © 2017

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