Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease*

Abstract

Objective Incident acute kidney injury (AKI) and prevalent chronic kidney disease (CKD) are commonly encountered in septic patients. We examined the differential effect of AKI and CKD on the association between cumulative fluid balance (CFB) and hospital mortality in critically ill septic patients. Design Retrospective cohort study. Setting Urban academic medical center ICU. Patients ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 h of ICU admission. Patients with estimated glomerular filtration rate <15 mL/min/1.73m2 or receiving chronic dialysis were excluded. Interventions None. Measurements and Main Results 2632 patients, 1211 with CKD, were followed until hospital death or discharge. AKI occurred in 1525 (57.9%), of whom 679 (44.5%) had CKD. Hospital mortality occurred in 603 (22.9%) patients. Every 1 L increase in CFB at 72 h of ICU admission was independently associated with hospital mortality in all patients, adjusted odds ratio (aOR) 1.06, 95% CI (1.04–1.08), p <0.001, and in each AKI/CKD subgroup: aOR 1.06 (1.03–1.09) for AKI+/CKD+; 1.09 (1.05–1.13) for AKI−/CKD+; 1.05 (1.03–1.08) for AKI+/CKD−; and 1.07 (1.02–1.11) for AKI−/CKD−. There was a significant interaction between AKI and CKD on CFB, p =0.005, such that different CFB cut-offs with the best prognostic accuracy for hospital mortality were identified: 5.9 L for AKI+/CKD+; 3.8 L for AKI−/CKD+; 4.3 L for AKI+/CKD−; and 1.5 L for AKI−/CKD−. The addition of CFB to the admission SOFA score had increased prognostic utility for hospital mortality when compared to SOFA alone, particularly in patients with AKI. Conclusions Higher CFB at 72 h of ICU admission was independently associated with hospital mortality regardless of AKI or CKD presence. We characterized CFB cut-offs associated with hospital mortality based on AKI/CKD status, underpinning the heterogeneity of fluid regulation in sepsis and kidney disease.

Proceedings of Réanimation 2017, the French Intensive Care Society International Congress

“…The most frequent reasons for maintaining carbapenems as DT were: Antibiotic susceptibility tests (38% of cases), severity level (33% of cases) immunosuppression (8% of cases). The Median length of ICU stay after infection was respectively 12 (6-27) and 11 (7)(8)(9)(10)(11)(12)(13)(14)(15)(16) days for carbapenems and alternatives DT (p = 0.1). The D28 mortality was 24% for patients with carbapenems DT and 24% for patients with alternatives DT (p = 0.02).…”

“…The overall in-ICU mortality rate was 15%. 21 (22%) patients developed ICU-acquired infections after a median of 8 [7][8][9][10][11][12][13] between between D1 and D3, between D1 and D5 and between D1 and D7 were also similar between patients with and without ICUacquired infections (Fig. 12).…”

“…Results During the study period 146 patients with ESBL-PE infection met eligibility criteria with respectively a median age and SAPS II score of 63 (51-74) and 50 (38-70). The median SOFA Score at first day of antibiotic therapy and ICU admission were 7 (4-11) and 7 (5)(6)(7)(8)(9)(10)(11) respectively. The most frequent site of infection were respiratory tract (45%), urinary tract (20%) and abdominal (17%).…”

“…Treatment At diagnosis of ketoacidosis, 11 patients received sodium bicarbonate, in which 7 received hypertonic sodium bicarbonate; 9 of them had either a pH < 7.0, EKG signs of hyperkalemia or hyperkalemia >5.0. Patients received a median of 3000 mL of NaCl 0.9% in the first 24 h. Initial insulin bolus of 10 UI [8][9][10] has been injected in 24% of patients. This was slightly correlated to hyperglycemia (Spearman test, p = 0.035) but not to pH or kalemia.…”

“…All patients were male, victims of poly trauma following an accident of traffic. In admission, SAPSII was 31 and SOFA was 4 [2][3][4][5][6][7][8]. We have noted the presence of a serious head injury in 15 patients, extended open skull fractures of the venous sinus in 9 patients.…”