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

Wang, Meiping; Zhu, Bin; Li, Jiang; Ye, Wen; Du, Bin; Li, Wen; Liu, Guangxu; Li, Wei; Wen, Jing; Yan, He; Xi, Xiuming

doi:10.21203/rs.2.20792/v1

Cited by 5 publications

(4 citation statements)

References 23 publications

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“…One must also consider that there is an accompanying sodium load as albumin formulations typically have a sodium concentration similar to that of normal saline (as detailed in Table 2). This is a particularly relevant concern given that worse outcomes are found in both critically ill patients and patients on maintenance HD with more fluid overload (29)(30)(31)(32). The basis for intravenous albumin use in the setting of KRT (including maintenance HD) is generally extrapolated from the results of studies in critical care but, as further discussed below, is not backed by high-quality trials designed specifically to assess its effect on KRT-related outcomes.…”

Section: Albumin Usage For Intradialytic Hypotensionmentioning

confidence: 99%

Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy

Hryciw

Joannidis

Hiremath

et al. 2021

CJASN

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Among its many functions, owing to its oversized effect on colloid oncotic pressure, intravascular albumin helps preserve the effective circulatory volume. Hypoalbuminemia is common in hospitalized patients and is found especially frequently in patients who require KRT either for AKI or as maintenance hemodialysis. In such patients, hypoalbuminemia is strongly associated with morbidity, intradialytic hypotension, and mortality. Intravenous albumin may be administered in an effort to prevent or treat hypotension or to augment fluid removal, but this practice is controversial. Theoretically, intravenous albumin administration might prevent or treat hypotension by promoting plasma refilling in response to ultrafiltration. However, clinical trials have demonstrated that albumin administration is not nearly as effective a volume expander as might be assumed according to its oncotic properties. Although intravenous albumin is generally considered to be safe, it is also very expensive. In addition, there are potential risks to using it to prevent or treat intradialytic hypotension. Some recent studies have suggested that hyperoncotic albumin solutions may precipitate or worsen AKI in patients with sepsis or shock; however, the overall evidence supporting this effect is weak. In this review, we explore the theoretical benefits and risks of using intravenous albumin to mitigate intradialytic hypotension and/or enhance ultrafiltration and summarize the current evidence relating to this practice. This includes studies relevant to its use in patients on maintenance hemodialysis and critically ill patients with AKI who require KRT in the intensive care unit. Despite evidence of its frequent use and high costs, at present, there are minimal data that support the routine use of intravenous albumin during KRT. As such, adequately powered trials to evaluate the efficacy of intravenous albumin in this setting are clearly needed.

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Section: Albumin Usage For Intradialytic Hypotensionmentioning

confidence: 99%

Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy

Hryciw

Joannidis

Hiremath

et al. 2021

CJASN

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“…A higher cumulative uid balance was an important factor associated with 28-day mortality following AKI. 22 In support of a conservative approach, the results of the pilot Conservative Versus Liberal Approach to Fluid Therapy of Septic Shock in Intensive Care (CLASSIC) trial showed that AKI occurred less often in patients with septic shock who were randomly assigned to a restrictive uid strategy. 23 Our results showed that uid strategy did not affect mortality nor length of ICU stay.…”

Section: Discussionmentioning

confidence: 99%

Dynamic testing based versus restrictive based fluid administration following early fluid resuscitation in septic shock patients, a pilot study

Abdelbaky,

Ahmed,

Toema

et al. 2023

Preprint

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Background Efforts have been targeting early reversal of a hemodynamically unstable patient in septic shock. The classic rationale for fluid resuscitation in septic shock is to restore intravascular volume deficit with resultant augmentation of cardiac output. Latest surviving sepsis campaign guidelines recommended an initial fluid bolus with subsequent fluid administration, guided by dynamic testing. AIM OF WORK We aimed to test if restrictive fluid protocol was comparable to dynamic-based testing for fluid responsiveness protocol. METHODS This was a prospective cohort study, recruiting septic shock patients, conducted in Critical Care Department, Cairo University. All patients were initially resuscitated. Patients were randomized (1:1 ratio) to restrictive group (fluid administration with predetermined rate of 1 ml/kg/hour), and dynamic-based testing group (fluid administration according to dynamic measures, following passive leg raising method). Positive response was considered when cardiac output increased by 10%. Results Our study recruited 80 patients (39 males) with age of 57.3±18.8 years old. It was noted that clinical severity scores were higher in the restrictive group, with no significant difference in 3 hours lactate. Fluid strategy did not affect mortality. Logistic regression showed no significant difference regarding adjusted mortality, between those who showed acceptable fluid response according to dynamic testing and those who received a restrictive protocol (Hazard’s risk 0.913, P 0.903, CI 95% 0.212 – 3.935). Fluid strategy did not affect need for dialysis, nor mechanical ventilation, nor length of ICU stay. CONCLUSION Restrictive fluid strategy, following initial fluid resuscitation was comparable to dynamic testing-based strategy, in terms of mortality, need for ventilation, need for dialysis and ICU length of stay

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“…shown that positive cumulative fluid balance is associated with mortality and other poor outcomes, especially in patients with AKI [28,29].…”

Section: Real-world Use Of [Timp-2]*[igfbp7]mentioning

confidence: 99%

Real-World Use of AKI Biomarkers: A Quality Improvement Project Using Urinary Tissue Inhibitor Metalloprotease-2 and Insulin-Like Growth Factor Binding Protein 7 ([TIMP-2]*[IGFBP7])

La¹,

Gunning²,

Trevino³

et al. 2023

Am J Nephrol

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Introduction. Novel urinary biomarkers, including Tissue Inhibitor Metallo-protease-2 and Insulin-like Growth Factor Binding Protein 7 ([TIMP-2]*[IGFBP7]), have been developed to identify patients at risk for acute kidney injury (AKI). We investigated the “real world” clinical utility of [TIMP-2]*[IGFBP7] in preventing AKI. Methods. We performed a prospective single-center quality improvement study of intensive care unit (ICU) patients at risk for severe (KDIGO stage 2 or 3) AKI. In the prospective cohort, ICU providers were allowed to order [TIMP-2]*[IGFBP7] for patients at their discretion, then offered AKI practice recommendations based on the result. Outcomes were compared to a historical cohort in which biomarker values were not reported to clinical teams. Results. There was no difference in 7-day progression to severe AKI between the prospective (n=116) and historical cohorts (n=63) when [TIMP-2]*[IGFBP7] ≥0.3 (24(28%) vs 8(21%), p=0.38) despite more stage 1 AKI at time of biomarker measurement in the prospective cohort (58(67%) vs 9(23%), p<0.001). In the prospective cohort, patients with higher [TIMP-2]*[IGFBP7] values were more likely to receive a nephrology consult. Early consultation (within 24 hours of biomarker measurement, n=20) had a nonsignificant trends towards net negative volume balance (-1787mL(6716mL) vs +4974mL(15540mL)) and more diuretic use (19(95%) vs 8(80%)), and was associated with less severe AKI (9(45%) vs 10(100%), p=0.004) and inpatient dialysis (2(10%) vs 7(70%), p=0.002) compared to delayed consultation (n=10). Discussion/Conclusions. Despite the prospective cohort having more preexisting stage 1 AKI, there were equal rates of progression to severe AKI in the prospective and historical cohorts. In the setting of [TIMP-2]*[IGFBP7] reporting, there were more nephrology consults in response to elevated biomarker levels. Early nephrology consultation resulted in improved volume balance and favorable outcomes compared to delayed consultation.

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

Cited by 5 publications

References 23 publications

Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy

Intravenous Albumin for Mitigating Hypotension and Augmenting Ultrafiltration during Kidney Replacement Therapy

Dynamic testing based versus restrictive based fluid administration following early fluid resuscitation in septic shock patients, a pilot study

Real-World Use of AKI Biomarkers: A Quality Improvement Project Using Urinary Tissue Inhibitor Metalloprotease-2 and Insulin-Like Growth Factor Binding Protein 7 ([TIMP-2]*[IGFBP7])

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