Association between the early change of fluid overload during continuous renal replacement therapy and mortality in critically ill patients with acute kidney injury_West China Medical Journal

Authors：

LU Juan , WU Buyun , XING Changying ,  MAO Huijuan

Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing, Jiangsu 210029, P. R. China;

Corresponding author：

MAO Huijuan, Email: huijuanmao@126.com

Keywords：

Continuous renal replacement therapy; acute kidney injury; fluid balance; fluid overload; prognosis

DOI：

10.7507/1002-0179.202405239

Video：

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Objective To assess the relationship between the change in fluid overload at 48 h after initiation of continuous renal replacement therapy (CRRT) and 28-day mortality in critically ill patients with acute kidney injury (AKI). Methods A retrospective cohort study was performed using data from the MIMIC-IV database from 2008 to 2019. Patients who received CRRT for AKI for more than 24 h within 14 d of admission to the intensive care unit were included. The exposure variable was the proportion of change of fluid overload (ΔFO%, defined as the difference between body weight normalized fluid input and output) at 48 h after CRRT initiation, and the endpoint was 28-day mortality. Generalized additive linear regression models and logistic regression models were used to determine the relationship between the exposure and endpoint. Results A total of 911 patients were included in the study, with a median (lower quartile, upper quartile) ΔFO% of −3.27% (−6.03%, 0.01%) and a 28-day mortality of 40.1%. Generalized additive linear regression model showed that the ΔFO% at 48 h after CRRT initiation was associated with a J-shaped curve with 28-day mortality. After adjusting for other variables, as compared with the second quartile of ΔFO% group, the first quartile group [odds ratio (OR)=1.23, 95% confidence interval (CI) (0.81, 1.87), P=0.338] was not associated with higher risk of 28-day mortality, while the third quartile group [OR=1.54, 95%CI (1.01, 2.35), P=0.046] and the fourth quartile group [OR=2.05, 95%CI (1.32, 3.18), P=0.001] were significantly associated with higher risk of 28-day mortality. There was no significant relationship between ΔFO% groups and 28-day mortality in the first 24-hour after CRRT initiation (P>0.05), but there was a linear relationship between ΔFO% and 28-day mortality in the second 24-hour after CRRT initiation, the larger the ΔFO%, the higher the mortality rate [OR=1.10, 95%CI (1.04 1.16), P<0.001 for per 1% increase]. Conclusion In critically ill patients with AKI, the ΔFO% greater than −3.27% within 48 h after CRRT initiation is independently associated with an increased risk of 28-day mortality, and the goals of CRRT fluid management may be dynamical.

Citation： LU Juan, WU Buyun, XING Changying, MAO Huijuan. Association between the early change of fluid overload during continuous renal replacement therapy and mortality in critically ill patients with acute kidney injury. West China Medical Journal, 2024, 39(7): 1048-1055. doi: 10.7507/1002-0179.202405239 Copy

1.	Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med, 2015, 41(8): 1411-1423.
2.	Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol, 2018, 14(10): 607-625.
3.	Noble RA, Lucas BJ, Selby NM. Long-term outcomes in patients with acute kidney injury. Clin J Am Soc Nephrol, 2020, 15(3): 423-429.
4.	KDIGO AKI Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl, 2012, 2(1): 1-138.
5.	Mottes TA, Goldstein SL, Basu RK. Process based quality improvement using a continuous renal replacement therapy dashboard. BMC Nephrol, 2019, 20(1): 17.
6.	Bell M, SWING, Granath F, et al. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med, 2007, 33(5): 773-780.
7.	Schneider AG, Bellomo R, Bagshaw SM, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med, 2013, 39(6): 987-997.
8.	Ronco C, Ricci Z. Renal replacement therapies: physiological review. Intensive Care Med, 2008, 34(12): 2139-2146.
9.	Raimundo M, Crichton S, Martin JR, et al. Increased fluid administration after early acute kidney injury is associated with less renal recovery. Shock, 2015, 44(5): 431-437.
10.	Zhang L, Chen Z, Diao Y, et al. 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(4): 860.e7-860.e13.
11.	Zhang J, Crichton S, Dixon A, et al. Cumulative fluid accumulation is associated with the development of acute kidney injury and non-recovery of renal function: a retrospective analysis. Crit Care, 2019, 23(1): 392.
12.	Messmer AS, Zingg C, Müller M, et al. Fluid overload and mortality in adult critical care patients: a systematic review and meta-analysis of observational studies. Crit Care Med, 2020, 48(12): 1862-1870.
13.	Fang J, Wang M, Gong S, et al. Increased 28-day mortality due to fluid overload prior to continuous renal replacement in sepsis associated acute kidney injury. Ther Apher Dial, 2022, 26(2): 288-296.
14.	RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. An observational study fluid balance and patient outcomes in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy trial. Crit Care Med, 2012, 40(6): 1753-1760.
15.	Neyra JA, Lambert J, Ortiz-Soriano V, et al. Assessment of prescribed vs. achieved fluid balance during continuous renal replacement therapy and mortality outcome. PLoS One, 2022, 17(8): e0272913.
16.	孙治平, 孙伏喜, 牛常明, 等. 连续性肾脏替代治疗及其液体负平衡可改善脓毒性急性肾损伤患者的肾功能和预后. 中华危重病急救医学, 2015, 27(5): 321-326.
17.	Johnson A, Bulgarelli L, Pollard T, et al. MIMIC-IV (version 1.0). PhysioNet, 2021.
18.	Vincent JL, De Backer D. Circulatory shock. N Engl J Med, 2013, 369(18): 1726-1734.
19.	Woodward CW, Lambert J, Ortiz-Soriano V, et al. 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(9): e753-e760.
20.	Jhee JH, Lee HA, Kim S, et al. The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy. Crit Care, 2019, 23(1): 329.
21.	Naorungroj T, Neto AS, Zwakman-Hessels L, et al. Hourly fluid balance in patients receiving continuous renal replacement therapy. Blood Purif, 2020, 49(1/2): 93-101.
22.	沈忆宁, 邬步云, 毛慧娟. 聚焦危重症患者连续性肾脏替代治疗的容量管理. 中华医学杂志, 2024, 104(6): 461-464.
23.	Wu B, Shen Y, Peng Y, et al. The association of an early net ultrafiltration rate and 28-day mortality in patients receiving continuous kidney replacement therapy. Front Med (Lausanne). 2021, 8(1): 766557.
24.	Murugan R, Bellomo R, Palevsky PM, et al. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol, 2021, 17(4): 262-276.

1. Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med, 2015, 41(8): 1411-1423.
2. Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol, 2018, 14(10): 607-625.
3. Noble RA, Lucas BJ, Selby NM. Long-term outcomes in patients with acute kidney injury. Clin J Am Soc Nephrol, 2020, 15(3): 423-429.
4. KDIGO AKI Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl, 2012, 2(1): 1-138.
5. Mottes TA, Goldstein SL, Basu RK. Process based quality improvement using a continuous renal replacement therapy dashboard. BMC Nephrol, 2019, 20(1): 17.
6. Bell M, SWING, Granath F, et al. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med, 2007, 33(5): 773-780.
7. Schneider AG, Bellomo R, Bagshaw SM, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med, 2013, 39(6): 987-997.
8. Ronco C, Ricci Z. Renal replacement therapies: physiological review. Intensive Care Med, 2008, 34(12): 2139-2146.
9. Raimundo M, Crichton S, Martin JR, et al. Increased fluid administration after early acute kidney injury is associated with less renal recovery. Shock, 2015, 44(5): 431-437.
10. Zhang L, Chen Z, Diao Y, et al. 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(4): 860.e7-860.e13.
11. Zhang J, Crichton S, Dixon A, et al. Cumulative fluid accumulation is associated with the development of acute kidney injury and non-recovery of renal function: a retrospective analysis. Crit Care, 2019, 23(1): 392.
12. Messmer AS, Zingg C, Müller M, et al. Fluid overload and mortality in adult critical care patients: a systematic review and meta-analysis of observational studies. Crit Care Med, 2020, 48(12): 1862-1870.
13. Fang J, Wang M, Gong S, et al. Increased 28-day mortality due to fluid overload prior to continuous renal replacement in sepsis associated acute kidney injury. Ther Apher Dial, 2022, 26(2): 288-296.
14. RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. An observational study fluid balance and patient outcomes in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy trial. Crit Care Med, 2012, 40(6): 1753-1760.
15. Neyra JA, Lambert J, Ortiz-Soriano V, et al. Assessment of prescribed vs. achieved fluid balance during continuous renal replacement therapy and mortality outcome. PLoS One, 2022, 17(8): e0272913.
16. 孙治平, 孙伏喜, 牛常明, 等. 连续性肾脏替代治疗及其液体负平衡可改善脓毒性急性肾损伤患者的肾功能和预后. 中华危重病急救医学, 2015, 27(5): 321-326.
17. Johnson A, Bulgarelli L, Pollard T, et al. MIMIC-IV (version 1.0). PhysioNet, 2021.
18. Vincent JL, De Backer D. Circulatory shock. N Engl J Med, 2013, 369(18): 1726-1734.
19. Woodward CW, Lambert J, Ortiz-Soriano V, et al. 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(9): e753-e760.
20. Jhee JH, Lee HA, Kim S, et al. The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy. Crit Care, 2019, 23(1): 329.
21. Naorungroj T, Neto AS, Zwakman-Hessels L, et al. Hourly fluid balance in patients receiving continuous renal replacement therapy. Blood Purif, 2020, 49(1/2): 93-101.
22. 沈忆宁, 邬步云, 毛慧娟. 聚焦危重症患者连续性肾脏替代治疗的容量管理. 中华医学杂志, 2024, 104(6): 461-464.
23. Wu B, Shen Y, Peng Y, et al. The association of an early net ultrafiltration rate and 28-day mortality in patients receiving continuous kidney replacement therapy. Front Med (Lausanne). 2021, 8(1): 766557.
24. Murugan R, Bellomo R, Palevsky PM, et al. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol, 2021, 17(4): 262-276.

West China Medical Journal

Association between the early change of fluid overload during continuous renal replacement therapy and mortality in critically ill patients with acute kidney injury

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