Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury

Heung, Michael; Wolfgram, Dawn; Kommareddi, Mallika; Hu, Youna; Song, Peter; Ojo, Akinlolu

doi:10.1093/ndt/gfr470

Cited by 180 publications

(130 citation statements)

References 37 publications

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“…Similar patterns of association with mortality have been reported in studies from South America (15) and Canada (14). Greater degrees of volume overload have been associated with a higher risk of adverse outcomes, including greater risk of 60-day mortality (24,25), longer duration of ventilator dependence (18,26), and slower recovery of renal function in those with AKI requiring RRT (19). Of note, although no randomized studies have been implemented to test if earlier initiation of RRT for volume control is beneficial (because volume removal by RRT may be offset by decreases in urine output), there is biologic plausibility to suggest that preservation of urine output may be a reasonable clinical management goal.…”

Section: Discussionsupporting

confidence: 62%

“…Patients with AKI who develop reduced urine output have substantially greater risk of death (13)(14)(15)(16), longer duration of dialysis dependence (16), and longer hospital stay (13) compared with those who do not. Reduced urine output in patients with AKI requiring RRT may indicate a greater severity of kidney injury with less likelihood of renal recovery (17), greater associated mortality (14), and predisposition to complications related to volume management (18,19). No study to our knowledge has tested whether more intensive RRT in AKI leads to a reduction in urine output, a potential surrogate marker of residual renal function.…”

Section: Introductionmentioning

confidence: 99%

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Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study

Causland

Asafu‐Adjei

Betensky

et al. 2016

CJASN

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Background and objectives Intensive RRT may have adverse effects that account for the absence of benefit observed in randomized trials of more intensive versus less intensive RRT. We wished to determine the association of more intensive RRT with changes in urine output as a marker of worsening residual renal function in critically ill patients with severe AKI.Design, setting, participants, & measurements The Acute Renal Failure Trial Network Study (n=1124) was a multicenter trial that randomized critically ill patients requiring initiation of RRT to more intensive (hemodialysis or sustained low-efficiency dialysis six times per week or continuous venovenous hemodiafiltration at 35 ml/kg per hour) versus less intensive (hemodialysis or sustained low-efficiency dialysis three times per week or continuous venovenous hemodiafiltration at 20 ml/kg per hour) RRT. Mixed linear regression models were fit to estimate the association of RRT intensity with change in daily urine output in survivors through day 7 (n=871); Cox regression models were fit to determine the association of RRT intensity with time to $50% decline in urine output in all patients through day 28.Results Mean age of participants was 60615 years old, 72% were men, and 30% were diabetic. In unadjusted models, among patients who survived $7 days, mean urine output was, on average, 31.7 ml/d higher (95% confidence interval, 8.2 to 55.2 ml/d) for the less intensive group compared with the more intensive group (P50.01). More intensive RRT was associated with 29% greater unadjusted risk of decline in urine output of $50% (hazard ratio, 1.29; 95% confidence interval, 1.10 to 1.51).Conclusions More intensive versus less intensive RRT is associated with a greater reduction in urine output during the first 7 days of therapy and a greater risk of developing a decline in urine output of $50% in critically ill patients with severe AKI.

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Section: Discussionsupporting

confidence: 62%

Section: Introductionmentioning

confidence: 99%

Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study

Causland

Asafu‐Adjei

Betensky

et al. 2016

CJASN

View full text Add to dashboard Cite

show abstract

“…[26] Fluid overload is also associated with a reduced likelihood of recovery of renal functions. [27] In the survivor group, fluid balance and mean CVP before PD was lower than in the non-survivors. Although there are large-scale retrospective reports on the timing of PD initiation, no criteria have been established from randomized-controlled trials, but rather based on historically held beliefs and practices of medical personnel worldwide.…”

Section: Discussionmentioning

confidence: 80%

Peritoneal dialysis in children undergoing congenital cardiac surgery under three years of age

Ayık¹

2017

Turk Gogus Kalp Dama

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“…Importantly, when Raimundo et al (23) looked at many of the hemodynamic parameters over 12-72 hours after AKI and adjusted for the initial hemodynamic measurements, the associations were no longer significant for all indices, except MAP. Not surprisingly, cumulative fluid balance, which has been previously shown to affect AKI outcomes (24,25), was associated with higher risk of AKI progression in 12-72 hours but not over the first 12 hours.…”

mentioning

confidence: 76%

The Golden Hours of AKI

Koyner¹

2015

Clinical Journal of the American Society of Nephrology

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Throughout various fields of scientific investigation, including neonatology and trauma medicine, the idea of the golden hour of treatment has long been debated (1-3). Defined as an interval most critical for successful emergency treatment and improved patient outcomes, the golden hour(s) is contingent on the delivery of early and frequently, protocol-driven care. Although advances in medicine have improved outcomes in these fields, the concept of the golden hour remains loosely applied and increasingly investigated in the setting of AKI. With recent advances in critical care nephrology, including consensus definitions, improved risk stratification, and biomarkers, intensivists and nephrologists are ideally positioned to investigate how best to improve patient outcomes and decrease the severity of renal damage in the golden hours of early AKI (4-6).In the past, AKI research has focused on the earlier identification of AKI before the rise in serum creatinine or drop in urine output (7,8). Recently, investigators have shifted their focus beyond simply replacing serum creatinine with a new gold standard and have sought to augment the information provided by serum creatinine and urine output, combining them with biochemical biomarkers, functional assessment of urine-making capacity, or both (9-11). Although these studies and others have shown that functional and damage biomarkers with physiologic links to the kidney are useful tools in predicting the risk of progression of early AKI, they were part of observational studies and require additional investigation.Additionally, an increasing number of controlled trials has shown efficacy when attempting to prevent severe AKI. Judicious intravenous fluid selection of nonhyperchloremic solutions (12) and remote ischemic preconditioning (13) showed renoprotective effects, which decreased the incidence of severe AKI (regardless of the need for RRT). Similarly, a meta-analysis investigating perioperative hemodynamic optimization, Brienza et al. (14) showed that trials targeting both supranormal and normal hemodynamic targets decreased the risk of postoperative AKI. However, not every controlled trial targeting hemodynamics parameters has shown a clinical benefit in preventing AKI. Two recent large-scale multicenter investigations of resuscitation protocols in the setting of severe sepsis and septic shock showed relatively low severe AKI event rates (2.8%-13.5%) and no difference in the duration of treatment in those requiring RRT (15,16). Although the ideal resuscitation strategy, intravenous fluid selection, and hemodynamic parameters to prevent the development of AKI continue to take shape, much less is known about how best to treat and optimize the patient just entering the golden hours that follow a new diagnosis of AKI.For those with newly diagnosed AKI, there is a dearth of proven interventions to prevent AKI progression. Data surrounding the use of automated, electronic medical record alerts for those with new-onset AKI seemed promising at first (17,18), but when pati...

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Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury

Abstract: In patients with AKI, a higher degree of fluid overload at RRT initiation predicts worse renal recovery at 1 year. Clinical trials are needed to determine whether interventions targeting fluid overload may improve patient and renal outcomes.

Cited by 180 publications

References 37 publications

Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study

Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study

Peritoneal dialysis in children undergoing congenital cardiac surgery under three years of age

The Golden Hours of AKI

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