Outcomes from a cohort of patients with acute kidney injury subjected to continuous venovenous hemodiafiltration: The role of negative fluid balance

Abstract

BackgroundSeveral factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT.ResultsThis was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55–76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and SOFA score at ICU admission was 61 (50–74) and 10 (7–12), respectively. The dialysis dose delivered was 33.2 (28.9–38.7) ml/kg/h. The median time between ICU admission and CVVHDF initiation was 2 (1–4) days. The median cumulative fluid balance during the CVVHDF period was -1838 (-5735 +2993) ml. The mortality rate up to90 days was 58%. The independent mortality risk factors in propensity score model were: chronic obstructive pulmonary disease (OR = 3.44[1.14–10.4; p = 0.028]), hematologic malignancy (OR = 5.14[1.66–15.95; p = 0.005]), oliguria (OR = 2.36[1.15–4.9; p = 0.02]), positive daily fluid balance during CVVHDF (OR = 4.55[2.75–13.1; p<0.001]), and total SOFA score on first dialysis day (OR = 1.27[1.12–1.45; p<0.001]).ConclusionsDialysis-related factors may influence the outcomes. In our cohort, positive daily fluid balance during CRRT was associated with lower survival. Multicenter, randomized studies are needed to assess fluid balance as a primary outcome to define the best strategy in this patient population.

Shiga Toxin-Associated Hemolytic Uremic Syndrome: Specificities of Adult Patients and Implications for Critical Care Management

“…This action is currently evaluated in a prospective trial (NCT03275792). In critically ill adult patients in general [ 212 , 213 ], and in those under renal replacement therapy specifically [ 214 , 215 ], fluid balance has been shown to influence survival. Altogether, these results call for increased alertness regarding fluid resuscitation in critically ill adults with STEC-HUS.…”

The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy

“…However, there is no consensus on the optimal fluid management for such patients [8–12]. Several recent studies revealed that an increase of cumulative fluid balance (CFB) was significantly associated with an increase in mortality risk in critically ill patients [13–17], while Balakumar et al showed that both positive and negative fluid balance were associated with higher mortality rates compared with even fluid balance [18]. Furthermore, Silversides et al reported that active removal of fluid using RRT in critically ill patients was associated with less survival benefit compared with standard care [19–21].…”

Mortality predictors in acute kidney injury patients who underwent continuous venovenous hemodiafiltration: A retrospective, single-center study

“…In our study, mortality was significantly higher in patients with lactic acidosis (p<0.001, chi-square test). In a study evaluating patients who underwent CVVHDF, Santos et al emphasized that reduced urine output was an independent predictor of mortality [13]. Other studies with similar results also showed this effect was not associated with creatinine level [14].…”