Fluid Overload Associates With Major Adverse Kidney Events in Critically Ill Patients With Acute Kidney Injury Requiring Continuous Renal Replacement Therapy

Abstract

Objectives: We examined the association between fluid overload and major adverse kidney events in critically ill patients requiring continuous renal replacement therapy for acute kidney injury. Design: Retrospective cohort study. Setting: ICU in a tertiary medical center. Patients: Four-hundred eighty-one critically ill adults requiring continuous renal replacement therapy for acute kidney injury. Interventions: None. Measurements and Main Results: Fluid overload was assessed as fluid balance from admission to continuous renal replacement therapy initiation, adjusted for body weight. Major adverse kidney events were defined as a composite of mortality, renal replacement therapy-dependence or inability to recover 50% of baseline estimated glomerular filtration rate (if not on renal replacement therapy) evaluated up to 90 days after discharge. Patients with fluid overload less than or equal to 10% were less likely to experience major adverse kidney events than those with fluid overload greater than 10% (71.6% vs 79.4%; p = 0.047). Multivariable logistic regression showed that fluid overload greater than 10% was associated with a 58% increased odds of major adverse kidney events (p = 0.046), even after adjusting for timing of continuous renal replacement therapy initiation. There was also a 2.7% increased odds of major adverse kidney events for every 1 day increase from ICU admission to continuous renal replacement therapy initiation (p = 0.024). Fluid overload greater than 10% was also found to be independently associated with an 82% increased odds of hospital mortality (p = 0.004) and 2.5 fewer ventilator-free days (p = 0.044), compared with fluid overload less than or equal to 10%. Conclusions: In critically ill patients with acute kidney injury requiring continuous renal replacement therapy, greater than 10% fluid overload was associated with higher risk of 90-day major adverse kidney events, including mortality and decreased renal recovery. Increased time between ICU admission and continuous renal replacement therapy initiation was also associated with decreased renal recovery. Fluid overload represents a potentially modifiable risk factor, independent of timing of continuous renal replacement therapy initiation, that should be further examined in interventional studies.

The dose - response association between fluid overload and hospital mortality in critically ill patients: a multicenter, prospective, observational cohort study

“…In other words, a "spot" or "range" for an optimal fluid balance may exist. This non-linear association has been reported in several studies [15,25,26]. This finding appears to be logical because a volume depletion causes hypovolemia and tissue or organ hypoperfusion, among other conditions.…”

“…However, all of those studies proposed a linear association between FO and outcomes, as a higher percentage of FO was related to an increased risk of adverse outcomes. This raised the question of whether there is an optimal volume plot or range of fluid balance for ICU patients and the dose-response association between FO and outcomes in critically ill patients is still limited [15].…”

The Prevalence, Risk Factors and Prognosis of Acute Kidney Injury after Lung Transplantation: A Single-center Cohort Study in China

“…However, the patients with more positive uid balance during surgery was also always accompanied by more intraoperative hemorrhage, these patients would receive more intraoperative transfusion and vasopressors; this condition of uncontrolled hemodynamic has been proved to have a great negative impact on the development of AKI (12). Furthermore, uid overload has been demonstrated to be associated with adverse kidney events in critically ill patients (15,16). The relationship between hypotension and AKI is well known (14,17), however, when patients with hypotension during surgery need uid resuscitation, we must manage the amount of uid more accurately to avoid overcorrection.…”

AKI—A Relevant Safety End Point?

“…MAKE has been used in a few randomized controlled trials in AKI 23,24 and is slowly making its way into observational literature as well. [25][26][27] However, additional work is still needed to evaluate the patientcenteredness of the doubling of Scr criterion, which is often the most common MAKE criterion met. Future work may identify better end points that incorporate cause and clinical context (eg, suspected hemodynamic vs parenchymal injury).…”