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White KC, Nasser A, Gatton ML, Laupland KB. Current management of fluid balance in critically ill patients with acute kidney injury: A scoping review. CRIT CARE RESUSC 2023; 25:126-135. [PMID: 37876369 PMCID: PMC10581269 DOI: 10.1016/j.ccrj.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The overall objective of this scoping review is to assess the extent of the literature related to the fluid management of critically ill patients with acute kidney injury (AKI). Introduction AKI is common in critically ill patients where fluid therapy is a mainstay of treatment. An association between fluid balance (FB) and adverse patient-centred outcomes in critically ill patients with AKI regardless of severity has been demonstrated. The evidence for the prospective intervention of FB and its impact on outcomes is unknown. Inclusion criteria All studies investigating FB in patients with AKI admitted to an intensive care unit were included. Literature not related to FB in the critically ill patient with AKI population was excluded. Methods We searched MEDLINE, EMBASE, and CINAHL from January 1st, 2012, onwards. We included primary research studies, experimental and observational, recruiting adult participants admitted to an intensive care unit who had an AKI. We extracted data on study and patient characteristics, as well as FB, renal-based outcomes, and patient-centred outcomes. Two reviewers independently screened citations for eligible studies and performed data extraction. Results Of the 13,767 studies reviewed, 22 met the inclusion criteria. Two studies examined manipulation of fluid input, 18 studies assessed enhancing fluid removal, and two studies applied a restrictive fluid protocol. Sixteen studies examined patients receiving renal replacement therapy, five studies included non-renal replacement therapy patients, and one study included both. Current evidence is broad with varied approaches to managing fluid input and fluid removal. The studies did not demonstrate a consensus approach for any aspect of the fluid management of critically ill patients. There was a limited application of a restrictive fluid protocol with no conclusions possible. Conclusions The current body of evidence for the management of FB in critically ill patients with AKI is limited in nature. The current quality of evidence is unable to guide current clinical practice. The key outcome of this review is to highlight areas for future research.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Ahmad Nasser
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Michelle L. Gatton
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B. Laupland
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Abstract
Acute kidney injury (AKI) and chronic kidney disease are common interconnected syndromes that represent a public health problem. Acute kidney disease (AKD) is defined as the post-AKI status of acute or subacute kidney damage/dysfunction manifested by persistence of AKI beyond 7 to 90 days after the initial AKI diagnosis. Limited clinical data exist regarding AKD epidemiology but its incidence is observed in ∼25% of AKI survivors. Useful risk-stratification tools to predict risk of AKD and its prognosis are needed. Interventions on fluid management, nephrotoxic exposure, and follow-up care hold promise to ameliorate the burden of AKD and its complications.
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Affiliation(s)
- Javier A Neyra
- Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, 800 Rose Street, MN668, Lexington, KY 40536, USA.
| | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA
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Sang L, Chen S, Nong L, Xu Y, Liang W, Zheng H, Zhou L, Sun H, He J, Liu X, Li Y. The Prevalence, Risk Factors, and Prognosis of Acute Kidney Injury After Lung Transplantation: A Single-Center Cohort Study in China. Transplant Proc 2020; 53:686-691. [PMID: 33334610 DOI: 10.1016/j.transproceed.2020.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 10/16/2020] [Accepted: 10/30/2020] [Indexed: 01/01/2023]
Abstract
PURPOSE The aim of this study is to evaluate the incidence, risk factors, and prognosis of acute kidney injury (AKI) after lung transplantation (LTx). METHODS Records of patients who underwent LTx in a single center were retrospectively reviewed. The prevalence of post-transplant AKI, the use of continuous renal replacement therapy (CRRT), and the risk factors for AKI were investigated. The effects of AKI and CRRT on short-term outcomes and long-term survival were measured. RESULTS This study included 148 patients, 67 of which developed postoperative AKI. Of these, 31 patients underwent CRRT; the percentage of cases with no AKI was 6.2%, and the percentage of cases with stage 1, 2, and 3 who used CRRT was 0%, 10%, and 86.2%, respectively. Patients with AKI had significantly higher intensive care unit mortality and in-hospital mortality. The 1-year post-LTx survival rate of patients with AKI was 47.8%, significantly lower than those without AKI (74.1%). There was no difference in 1-year survival rate of those with stage 1 and stage 2 AKI, but patients with stage 3 AKI showed the worst survival. Patients who underwent CRRT had an inferior survival outcome (9.7% vs 76.1%, P < .05). We found that higher acute physiologic assessment and chronic health evaluation (APACHE) II scores (odds ratio [OR] 1.082, P = .009) and higher intraoperative fluid balance (OR 1.001, P = .012) were independent risk factors, and female sex (OR 2.539) and pulmonary hypertension (OR 2.869) were potential risk factors for post-LTx AKI. A prediction model integration of the above factors showed a good concordance with actual risks and had a concordance index (C-index) of 0.76 (95% confidence interval [CI], 0.66-0.87). CONCLUSION Severe AKI requiring CRRT had a negative impact on the short-term and long-term outcomes of patients.
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Affiliation(s)
- Ling Sang
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Sibei Chen
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Lingbo Nong
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Yonghao Xu
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Wenhua Liang
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Haichong Zheng
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Liang Zhou
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Huadong Sun
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Xiaoqing Liu
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China.
| | - Yimin Li
- The First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou, China.
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Ramesh GH, Uma JC, Farhath S. Fluid resuscitation in trauma: what are the best strategies and fluids? Int J Emerg Med 2019; 12:38. [PMID: 31801458 PMCID: PMC6894336 DOI: 10.1186/s12245-019-0253-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/29/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Traumatic injuries pose a global health problem and account for about 10% global burden of disease. Among injured patients, the major cause of potentially preventable death is uncontrolled post-traumatic hemorrhage. MAIN BODY This review discusses the role of prehospital trauma care in low-resource/remote settings, goals, principles and evolving strategies of fluid resuscitation, ideal resuscitation fluid, and post-resuscitation fluid management. Management of fluid resuscitation in few special groups is also discussed. CONCLUSIONS Prehospital trauma care systems reduce mortality in low-resource/remote settings. Delayed resuscitation seems a better option when transport time to definitive care is shorter whereas goal-directed resuscitation with low-volume crystalloid seems a better option if transport time is longer. Few general recommendations regarding the choice of fluid are provided. Adhering to evidence-based clinical practice guidelines and local modifications based on patient population, available resources, and expertise will improve patient outcomes.
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Affiliation(s)
- G H Ramesh
- Emergency Department BMC & RI. Victoria Hospital, City Market, Bengaluru, Karnataka, 560002, India
| | - J C Uma
- K.C.G Hospital 89, 5th Cross Rd, Behind Police Station, Malleshwaram, Bengaluru, Karnataka, 560003, India
| | - Sheerin Farhath
- Columbia Asia Hospital Yeshwanthpur 26/4, Brigade Gateway Malleshwaram West Beside Metro Cash and Carry West, Yeswanthpur, Bengaluru, Karnataka, 560055, India.
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Zhang J, Crichton S, Dixon A, Seylanova N, Peng ZY, Ostermann M. Cumulative fluid accumulation is associated with the development of acute kidney injury and non-recovery of renal function: a retrospective analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:392. [PMID: 31796077 PMCID: PMC6891953 DOI: 10.1186/s13054-019-2673-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 11/13/2019] [Indexed: 12/18/2022]
Abstract
Background Acute kidney injury (AKI) is common in patients in the intensive care unit (ICU) and may be present on admission or develop during ICU stay. Our objectives were (a) to identify factors independently associated with the development of new AKI during early stay in the ICU and (b) to determine the risk factors for non-recovery of AKI. Methods We retrospectively analysed prospectively collected data of patients admitted to a multi-disciplinary ICU in a single tertiary care centre in the UK between January 2014 and December 2016. We identified all patients without AKI or end-stage renal failure on admission to the ICU and compared the outcome and characteristics of patients who developed AKI according to KDIGO criteria after 24 h in the ICU with those who did not develop AKI in the first 7 days in the ICU. Multivariable logistic regression was applied to identify factors associated with the development of new AKI during the 24–72-h period after admission. Among the patients with new AKI, we identified those with full, partial or no renal recovery and assessed factors associated with non-recovery. Results Among 2525 patients without AKI on admission, the incidence of early ICU-acquired AKI was 33.2% (AKI I 41.2%, AKI II 35%, AKI III 23.4%). Body mass index, Sequential Organ Failure Assessment score on admission, chronic kidney disease (CKD) and cumulative fluid balance (FB) were independently associated with the new development of AKI. By day 7, 69% had fully recovered renal function, 8% had partial recovery and 23% had no renal recovery. Hospital mortality was significantly higher in those without renal recovery. Mechanical ventilation, diuretic use, AKI stage III, CKD, net FB on first day of AKI and cumulative FB 48 h later were independently associated with non-recovery with cumulative fluid balance having a U-shape association. Conclusions Early development of AKI in the ICU is common and mortality is highest in patients who do not recover renal function. Extreme negative and positive FB were strong risk factors for AKI non-recovery.
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Affiliation(s)
- Jing Zhang
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.,Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Alison Dixon
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Nina Seylanova
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.,Sechenov Biomedical Science and Technology Park, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Zhiyong Y Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
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Fluid Overload Associates With Major Adverse Kidney Events in Critically Ill Patients With Acute Kidney Injury Requiring Continuous Renal Replacement Therapy. Crit Care Med 2019; 47:e753-e760. [DOI: 10.1097/ccm.0000000000003862] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Giglio M, Dalfino L, Puntillo F, Brienza N. Hemodynamic goal-directed therapy and postoperative kidney injury: an updated meta-analysis with trial sequential analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:232. [PMID: 31242941 PMCID: PMC6593609 DOI: 10.1186/s13054-019-2516-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/13/2019] [Indexed: 12/18/2022]
Abstract
Background Perioperative goal-directed therapy (GDT) reduces the risk of renal injury. However, several questions remain unanswered, such as target, kind of patients and surgery, and role of fluids and inotropes. We therefore update a previous analysis, including all studies published in the meanwhile, to clarify the clinical impact of this strategy on acute kidney injury. Main body Randomized controlled trials enrolling adult patients undergoing major surgery were considered. GDT was defined as perioperative monitoring and manipulation of hemodynamic parameters to reach normal or supranormal values by fluids alone or with inotropes. Trials comparing the effects of GDT and standard hemodynamic therapy were considered. Primary outcome was acute kidney injury, whichever definition was used. Meta-analytic techniques (analysis software RevMan, version 5.3) were used to combine studies, using random-effect odds ratios (OR) and 95% confidence intervals (CI). Trial sequential analyses were performed including all trials and considering only low risk of bias trials. Sixty-five trials with an overall sample of 9308 patients were included. OR for the development of renal injury was 0.64 (95% CI, 0.62–0.87; p = 0.0003), with no statistical heterogeneity. Trial sequential analyses and sensitivity analysis including studies with low risk of bias confirmed the main results. A significant decrease in renal injury rate was observed in studies that adopted cardiac output and oxygen delivery as hemodynamic target and that used both fluids and inotropes. The postoperative kidney injury rate was significantly lower in trials enrolling “high-risk” patients and major abdominal and orthopedic surgery. Short conclusion The present meta-analysis suggests that targeting GDT to perioperative systemic oxygen delivery, by means of fluids and inotropes, can be the best way to improve renal perfusion and oxygenation in high-risk patients undergoing major abdominal and orthopedic surgery. Electronic supplementary material The online version of this article (10.1186/s13054-019-2516-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mariateresa Giglio
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy.
| | - Lidia Dalfino
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
| | - Filomena Puntillo
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
| | - Nicola Brienza
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
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8
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de Lange N, Schol P, Lancé M, Woiski M, Langenveld J, Rijnders R, Smits L, Wassen M, Henskens Y, Scheepers H. Restrictive Versus Massive Fluid Resuscitation Strategy (REFILL study), influence on blood loss and hemostatic parameters in obstetric hemorrhage: study protocol for a randomized controlled trial. Trials 2018; 19:166. [PMID: 29510717 PMCID: PMC5838856 DOI: 10.1186/s13063-018-2512-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 01/30/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Postpartum hemorrhage (PPH) is associated with maternal morbidity and mortality and has an increasing incidence in high-resource countries, despite dissemination of guidelines, introduction of skills training, and correction for risk factors. Current guidelines advise the administration, as fluid resuscitation, of almost twice the amount of blood lost. This advice is not evidence-based and could potentially harm patients. METHODS All women attending the outpatient clinic who are eligible will be informed of the study; oral and written informed consent will be obtained. Where there is more than 500 ml blood loss and ongoing bleeding, patients will be randomized to care as usual, fluid resuscitation with 1.5-2 times the amount of blood loss or fluid resuscitation with 0.75-1.0 times the blood loss. Blood loss will be assessed by weighing all draping. A blood sample, for determining hemoglobin concentration, hematocrit, thrombocyte concentration, and conventional coagulation parameters will be taken at the start of the study, after 60 min, and 12-18 h after delivery. In a subgroup of women, additional thromboelastometric parameters will be obtained. DISCUSSION Our hypothesis is that massive fluid administration might lead to a progression of bleeding due to secondary coagulation disorders. In non-pregnant individuals with massive blood loss, restrictive fluid management has been shown to prevent a progression to dilution coagulopathy. These data, however, cannot be extrapolated to women in labor. Our objective is to compare both resuscitation protocols in women with early, mild PPH (blood loss 500-750 ml) and ongoing bleeding, taking as primary outcome measure the progression to severe PPH (blood loss > 1000 ml). TRIAL REGISTRATION Netherlands Trial Register, NTR 3789 . Registered on 11 January 2013.
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Affiliation(s)
- Natascha de Lange
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, P.O. 11120, 9700 CC Groningen, the Netherlands
| | - Pim Schol
- Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Marcus Lancé
- Department of Anesthesiology and Pain Treatment, Department of Intensive Care, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Mallory Woiski
- Department of Obstetrics and Gynecology, Radboud University Medical Centre, P.O. 9101, 6500 HB Nijmegen, the Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Robbert Rijnders
- Department of Obstetrics and Gynecology, Jeroen Bosch Hospital, P.O. 90153, 5200 ME ‘s-Hertogenbosch, the Netherlands
| | - Luc Smits
- Department of Epidemiology, Caphri School for Public Health and Primary Care, P.O. 616, 6200 MD Maastricht, the Netherlands
| | - Martine Wassen
- Department of Obstetrics and Gynecology, Zuyderland, P.O. 5500, 6130 MB Sittard-Geleen, the Netherlands
| | - Yvonne Henskens
- Central Diagnostics Laboratory, Maastricht University Medical Centre, P.O. 5500, 6202 AZ Maastricht, the Netherlands
| | - Hubertina Scheepers
- GROW: School for Oncology and Developmental Biology and Department of Obstetrics and Gynecology, Maastricht University Medical Centre, P.O. 616, 6200 MD Maastricht, the Netherlands
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Langston C. Managing Fluid and Electrolyte Disorders in Kidney Disease. Vet Clin North Am Small Anim Pract 2017; 47:471-490. [DOI: 10.1016/j.cvsm.2016.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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10
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Further Clarification of Postoperative Anemia and Its Effects on the Kidney. Anesth Analg 2016; 123:e20. [PMID: 27575563 DOI: 10.1213/ane.0000000000001538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Influence of volume administration on Doppler-based renal resistive index, renal hemodynamics and renal function in medical intensive care unit patients with septic-induced acute kidney injury: a pilot study. Int Urol Nephrol 2016; 48:1327-1334. [DOI: 10.1007/s11255-016-1312-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/02/2016] [Indexed: 01/20/2023]
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12
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Ma PL, Peng XX, Du B, Hu XL, Gong YC, Wang Y, Xi XM. Sources of Heterogeneity in Trials Reporting Hydroxyethyl Starch 130/0.4 or 0.42 Associated Excess Mortality in Septic Patients: A Systematic Review and Meta-regression. Chin Med J (Engl) 2016; 128:2374-82. [PMID: 26315087 PMCID: PMC4733795 DOI: 10.4103/0366-6999.163387] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background: This meta-analysis was to determine the association of the cumulative dose of 130/0.4 or 0.42 (hydroxyethyl starch [HES] 130/0.4*) or delta daily fluid balance (i.e., daily fluid balance in HES group over or below control group) with the heterogeneity of risk ratio (RR) for mortality in randomized control trials (RCTs). Methods: Three databases (PubMed, EMBASE, Cochrane) were searched to identify prospective RCTs reporting mortality in adult patients with sepsis to compare HES130/0.4* with crystalloids or albumin. Meta-analysis was performed using random effects. Sensitivity and meta-regression analyses were used to examine the heterogeneity sources of RR for mortality. Results: A total number of 4408 patients from 11 RCTs were included. The pooled RR showed no significant difference for overall mortality in patients with administration of HES130/0.4* compared with treatment of control fluids (RR: 1.02, 95% confidence interval: 0.90–1.17; P = 0.73). Heterogeneity was moderate across recruited trials (I2 = 34%, P = 0.13). But, a significant variation was demonstrated in subgroup with crystalloids as control fluids (I2= 42%, P < 0.1). Sensitivity analysis revealed that trials with high risk of bias did not significantly impact the pooled estimates for mortality. Meta-regression analysis also did not determine a dose-effect relationship of HES130/0.4* with mortality (P = 0.298), but suggested daily delta fluid balance being likely associated with mortality in septic patients receiving HES130/130/0.4* (P = 0.079). Conclusions: Inappropriate daily positive fluid balance was likely an important source of heterogeneity in these trials reporting HES130/0.4* associated with excess mortality in septic patients.
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Affiliation(s)
- Peng-Lin Ma
- Department of Critical Care Medicine, 309th Hospital of Chinese People's Liberation Army, Beijing 100091, China
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Honore PM, Jacobs R, Hendrickx I, Bagshaw SM, Joannes-Boyau O, Boer W, De Waele E, Van Gorp V, Spapen HD. Prevention and treatment of sepsis-induced acute kidney injury: an update. Ann Intensive Care 2015; 5:51. [PMID: 26690796 PMCID: PMC4686459 DOI: 10.1186/s13613-015-0095-3] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Sepsis-induced acute kidney injury (SAKI) remains an important challenge in critical care medicine. We reviewed current available evidence on prevention and treatment of SAKI with focus on some recent advances and developments. Prevention of SAKI starts with early and ample fluid resuscitation preferentially with crystalloid solutions. Balanced crystalloids have no proven superior benefit. Renal function can be evaluated by measuring lactate clearance rate, renal Doppler, or central venous oxygenation monitoring. Assuring sufficiently high central venous oxygenation most optimally prevents SAKI, especially in the post-operative setting, whereas lactate clearance better assesses mortality risk when SAKI is present. Although the adverse effects of an excessive “kidney afterload” are increasingly recognized, there is actually no consensus regarding an optimal central venous pressure. Noradrenaline is the vasopressor of choice for preventing SAKI. Intra-abdominal hypertension, a potent trigger of AKI in post-operative and trauma patients, should not be neglected in sepsis. Early renal replacement therapy (RRT) is recommended in fluid-overloaded patients’ refractory to diuretics but compelling evidence about its usefulness is still lacking. Continuous RRT (CRRT) is advocated, though not sustained by convincing data, as the preferred modality in hemodynamically unstable SAKI. Diuretics should be avoided in the absence of hypervolemia. Antimicrobial dosing during CRRT needs to be thoroughly reconsidered to assure adequate infection control.
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Affiliation(s)
- Patrick M Honore
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Rita Jacobs
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Inne Hendrickx
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | - Olivier Joannes-Boyau
- Haut Leveque University Hospital of Bordeaux, University of Bordeaux 2, Pessac, France.
| | - Willem Boer
- Department of Anaesthesiology and Critical Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - Elisabeth De Waele
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Viola Van Gorp
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
| | - Herbert D Spapen
- Intensive Care Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Mehta RL. Challenges and pitfalls when implementing renal replacement therapy in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S9. [PMID: 26729322 PMCID: PMC4699092 DOI: 10.1186/cc14727] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Several new methods of renal replacement therapy (RRT) are now available for treating patients in the ICU setting. However, utilization of RRT in the ICU is subject to considerable variation and the need for RRT is associated with worse outcomes. Several factors influence the application of dialysis and reflect the interplay of patient and process of care elements that are dynamic in nature. Despite multiple studies evaluating RRT and its application, there are gaps in our knowledge that must be overcome to improve outcomes. This article discusses some of the important issues that require attention in delivering RRT in critically ill patients and provides a framework for the optimal use of RRT in the ICU.
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Moore E, Tobin A, Reid D, Santamaria J, Paul E, Bellomo R. The Impact of Fluid Balance on the Detection, Classification and Outcome of Acute Kidney Injury After Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1229-35. [DOI: 10.1053/j.jvca.2015.02.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Indexed: 12/20/2022]
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Zhang L, Chen Z, Diao Y, Yang Y, Fu P. Associations of fluid overload with mortality and kidney recovery in patients with acute kidney injury: A systematic review and meta-analysis. J Crit Care 2015; 30:860.e7-13. [PMID: 25979272 DOI: 10.1016/j.jcrc.2015.03.025] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 03/30/2015] [Accepted: 03/31/2015] [Indexed: 02/05/2023]
Abstract
PURPOSE Fluid resuscitation is commonly administered to maintain adequate renal perfusion in critically ill patients to prevent or even treat acute kidney injury (AKI). However, recent studies show that fluid overload is common and might be associated with poor outcomes in patients with AKI. Hence, the objective of this study was to assess the associations of fluid overload with mortality and kidney recovery in patients with AKI. MATERIALS AND METHODS We electronically searched original articles published in peer-reviewed journals from their inception to January 2015 in PubMed, EMBASE, the Cochrane Library databases, Google Scholar, and Chinese database (SinoMed). We additionally searched the reference lists of all retrieved articles. We performed a systematic review and meta-analysis of all eligible cohort or case-control studies of fluid overload in patients with AKI. The primary outcomes were mortality and kidney recovery. We pooled adjusted odds ratios (ORs) with 95% confidence intervals (95% CIs) by using Review Manager 5.2 (The Cochrane Collaboration, Oxford, UK). RESULTS A total of 5095 patients from 12 cohort studies published from 2008 to 2014 were included. A significant positive association was found between fluid overload and mortality in patients with AKI (OR, 2.23; 95% CI, 1.66-3.01), with similar findings in sepsis (OR, 2.27; 95% CI, 1.69-to 3.03) and nonsepsis subgroups (OR, 3.40; 95% CI, 2.50-4.63). There was also a significant association between mean fluid balance (continuous variables) and mortality (OR, 1.16; 95% CI, 1.07-1.27). Although there was a trend of lower rate of kidney recovery in the fluid overload group, there was no significant association between fluid overload and kidney recovery (OR, 0.66; 95% CI, 0.37-1.15), or dialysis dependence (OR, 0.72; 95% CI, 0.38-1.35). CONCLUSIONS Fluid overload is associated with an increased risk of mortality in patients with AKI. The evidence of the relationship between fluid overload and kidney recovery is insufficient.
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Affiliation(s)
- Ling Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
| | - Zhiwen Chen
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
| | - Yongshu Diao
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China.
| | - Yingying Yang
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
| | - Ping Fu
- Division of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
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Abstract
PURPOSE OF REVIEW To describe the effect of ageing on kidney function and to summarize the benefits of advocated measures to prevent perioperative acute kidney injury (AKI) in elderly patients. RECENT FINDINGS Given a reduced renal reserve and the burden of comorbidities, the senescent kidney is susceptible to develop perioperative AKI and is less able to recover when injury occurs. Current evidence suggests that preoperative statin therapy, tight glycemic control or urine alkalinization with bicarbonate do not protect the kidneys from harm. The theoretical kidney protective effect of preoperative aspirin therapy or renal vasodilatation with atrial natriuretic peptide or fenoldopam is only supported by low-quality evidence that needs further evaluation. Although questions regarding the amount and timing of fluid resuscitation during surgery are seeking answers in ongoing multicenter studies, the harmful effect of hydroxyethyl starches (HES) and hyperchloremic solutions is now surrounded by strong evidence. SUMMARY The future increase in elderly patients being exposed to surgery calls for improved perioperative management to prevent collaterally increased AKI. Although pharmacological therapies aiming to protect the kidneys from harm are under evaluation, hemodynamic optimization and avoidance of nephrotoxic drugs, including HES and hyperchloremic solutions, are critical for the elderly perioperative patient.
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McCulloch MI. Acute Kidney Injury (AKI): Current Thoughts and Controversies in Pediatrics. CURRENT PEDIATRICS REPORTS 2015. [DOI: 10.1007/s40124-014-0073-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Effect of hydroxyethyl starch on postoperative kidney function in patients having noncardiac surgery. Anesthesiology 2014; 121:730-9. [PMID: 25054470 DOI: 10.1097/aln.0000000000000375] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Whether intraoperative use of hydroxyethyl starch impairs kidney function remains unknown. The authors thus tested the primary hypothesis that Hextend promotes renal injury in surgical patients. Secondarily, the authors evaluated the dose-outcome relationship, in-hospital and 90-day mortality, and whether the relationship between colloid use and acute kidney injury (AKI) depends on baseline risk for AKI. METHODS The authors evaluated the data of 44,176 adults without preexisting kidney failure who had inpatient noncardiac surgery from 2005 to 2012. Patients given a combination of colloid and crystalloid were propensity matched on morphometric, and baseline characteristics to patients given only crystalloid. The primary analysis was a proportional odds logistic regression with AKI as an ordinal outcome based on the Acute Kidney Injury Network classification. RESULTS The authors matched 14,680 patients receiving colloids with 14,680 patients receiving noncolloids for a total of 29,360 patients. After controlling for potential confounding variables, the odds of developing a more serious level of AKI with Hextend was 21% (6 to 38%) greater than with crystalloid only (P = 0.001). AKI risk increased as a function of colloid volume (P < 0.001). In contrast, the relationship between colloid use and AKI did not differ on baseline AKI risk (P = 0.84). There was no association between colloid use and risk of in-hospital (P = 0.81) or 90-day (P = 0.02) mortality. CONCLUSION Dose-dependent renal toxicity associated with Hextend in patients having noncardiac surgery is consistent with randomized trials in critical care patients.
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