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      Weight-Based Assessment of Fluid Overload in Patients with Acute Kidney Injury

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          Abstract

          Introduction: Acute kidney injury (AKI) with fluid overload is associated with poor outcomes. While percentage fluid overload (PFO) using intake/output charts (PFO<sub>i/o</sub>) has been validated as a marker of overload, accurate PFO<sub>i/o</sub> measurements may not be possible in a general ward. We propose an alternative weight-based PFO calculation: PFO<sub>w</sub> = [(maximum weight − baseline weight) ÷ baseline weight] × 100%. Methods: This is a prospective, observational pilot study on general ward inpatients with AKI who were referred for nephrology consult. PFO<sub>w</sub> was compared with PFO<sub>i/o</sub>, and both were evaluated for associations with dialysis requirement, AKI stage 2 or 3, and 90-day mortality. Results: Fifty-eight patients with a median age of 67.5 years (interquartile range 18.0) were recruited. Of which, 33 (56.9%) were males and 41 (70.7%) had preexisting CKD 3 or higher. We found no correlation between PFO<sub>i/o</sub> and PFO<sub>w</sub> ( R<sup>2</sup> = 0.015, p = 0.531). A higher PFO<sub>w</sub> was observed in AKI stage 2 or 3 ( p = 0.005) and in patients requiring dialysis ( p = 0.001). On multivariate analysis, each percentage increase in PFO<sub>w</sub> was associated with increased odds of AKI stage 2 or 3 (odds ratio 1.37 [95% CI 1.05–1.78], p = 0.020) and dialysis need (odds ratio 1.69 [95% CI 1.20–2.39], p = 0.003). Twenty-nine patients had complete quantitative data to calculate PFO<sub>i/o</sub>. Multivariate analysis of these 29 patients showed that PFO<sub>w</sub> correlated with AKI stage 2 or 3 and dialysis requirement, while PFO<sub>i/o</sub> had no correlation with these events. The area under the curve receiver operating characteristics of PFO<sub>w</sub> was 0.706 for AKI stage 2 or 3 and 0.819 for AKI requiring dialysis. The optimal PFO<sub>w</sub> cutoff was determined at ≥1%. Three deaths occurred within 90 days, and all had PFO<sub>w</sub> ≥ 1%, although the log-rank test did not achieve statistical significance ( p = 0.050). Conclusion: The proposed PFO<sub>w</sub> is a potential prognostic indicator for general ward patients with AKI. PFO<sub>w</sub> ≥ 1% is associated with poor renal outcomes.

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          Most cited references 19

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          Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients

          Introduction Serum creatinine concentration (sCr) is the marker used for diagnosing and staging acute kidney injury (AKI) in the RIFLE and AKIN classification systems, but is influenced by several factors including its volume of distribution. We evaluated the effect of fluid accumulation on sCr to estimate severity of AKI. Methods In 253 patients recruited from a prospective observational study of critically-ill patients with AKI, we calculated cumulative fluid balance and computed a fluid-adjusted sCr concentration reflecting the effect of volume of distribution during the development phase of AKI. The time to reach a relative 50% increase from the reference sCr using the crude and adjusted sCr was compared. We defined late recognition to estimate severity of AKI when this time interval to reach 50% relative increase between the crude and adjusted sCr exceeded 24 hours. Results The median cumulative fluid balance increased from 2.7 liters on day 2 to 6.5 liters on day 7. The difference between adjusted and crude sCr was significantly higher at each time point and progressively increased from a median difference of 0.09 mg/dL to 0.65 mg/dL after six days. Sixty-four (25%) patients met criteria for a late recognition to estimate severity progression of AKI. This group of patients had a lower urine output and a higher daily and cumulative fluid balance during the development phase of AKI. They were more likely to need dialysis but showed no difference in mortality compared to patients who did not meet the criteria for late recognition of severity progression. Conclusions In critically-ill patients, the dilution of sCr by fluid accumulation may lead to underestimation of the severity of AKI and increases the time required to identify a 50% relative increase in sCr. A simple formula to correct sCr for fluid balance can improve staging of AKI and provide a better parameter for earlier recognition of severity progression.
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            Kidney disease: improving global outcomes (KDIGO) acute kidney injury work group KDIGO clinical practice guideline for acute kidney injury

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              Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy.

              In pediatric intensive care unit (PICU) patients, fluid overload (FO) at initiation of continuous renal replacement therapy (CRRT) has been reported to be an independent risk factor for mortality. Previous studies have calculated FO based on daily fluid balance during ICU admission, which is labor intensive and error prone. We hypothesized that a weight-based definition of FO at CRRT initiation would correlate with the fluid balance method and prove predictive of outcome. This is a retrospective single-center review of PICU patients requiring CRRT from July 2006 through February 2010 (n = 113). We compared the degree of FO at CRRT initiation using the standard fluid balance method versus methods based on patient weight changes assessed by both univariate and multivariate analyses. The degree of fluid overload at CRRT initiation was significantly greater in nonsurvivors, irrespective of which method was used. The univariate odds ratio for PICU mortality per 1% increase in FO was 1.056 [95% confidence interval (CI) 1.025, 1.087] by the fluid balance method, 1.044 (95% CI 1.019, 1.069) by the weight-based method using PICU admission weight, and 1.045 (95% CI 1.022, 1.07) by the weight-based method using hospital admission weight. On multivariate analyses, all three methods approached significance in predicting PICU survival. Our findings suggest that weight-based definitions of FO are useful in defining FO at CRRT initiation and are associated with increased mortality in a broad PICU patient population. This study provides evidence for a more practical weight-based definition of FO that can be used at the bedside.
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                Author and article information

                Journal
                NEF
                Nephron
                10.1159/issn.1660-8151
                Nephron
                S. Karger AG
                1660-8151
                2235-3186
                2020
                June 2020
                13 May 2020
                : 144
                : 6
                : 281-289
                Affiliations
                aDepartment of Renal Medicine, Changi General Hospital, Singapore, Singapore
                bAnaesthetics and Critical Care, Borders General Hospital, Melrose, United Kingdom
                Author notes
                *Dr. Chang Yin Chionh, Department of Renal Medicine, Changi General Hospital, 2 Simei Street 3, Singapore 529889 (Singapore), kidneyinjury@gmail.com
                Article
                506398 Nephron 2020;144:281–289
                10.1159/000506398
                32403114
                © 2020 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 5, Tables: 5, Pages: 9
                Categories
                Clinical Practice: Research Article

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