Cumulative positive fluid balance is a risk factor for acute kidney injury and requirement for renal replacement therapy after liver transplantation

The incidence of acute kidney injury (AKI) is commonly seen in critically ill children, the origins of which may be traced to a wide range of conditions such as inborn errors of metabolism, sepsis, congenital heart defects, bone marrow and organ transplantation, and to a lesser extent from multiple organ dysfunction syndrome (MODS) [1]. It is vital to provide a form of fluid and electrolyte clearance in these patients until native renal function improves. Nearly 3,600 critically ill children per year with acute kidney injury receive life-saving continuous renal replacement therapy (CRRT) in the United States. However, there is no CRRT device approved by the Food and Drug Administration for use in pediatric patients. Thus, clinicians unsafely adapt adult CRRT devices for use in the pediatric patients due to lack of safer alternatives. Complications observed with using adult adapted CRRT devices in children include hypotension, hemorrhage, thrombosis, temperature instability, inaccurate fluid balance between ultrafiltrate (UF) removed from and replacement fluid (RF) delivered to the patient, electrolyte disorders, and alteration of drug clearance. This research addresses this unmet clinical need through the design, mechanical and biological characterization of a pediatric specific Kidney Injury and Dysfunction Support (KIDS) CRRT device that provides high accuracy in fluid balance, reduces extracorporeal blood volume, and eliminates other problems associated with using adapted adult CRRT devices in children.

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

Critical Care ◽

10.1186/s13054-019-2633-0 ◽

2019 ◽

Vol 23 (1) ◽

Author(s):

Jong Hyun Jhee ◽

Hye Ah Lee ◽

Seonmi Kim ◽

Youn Kyung Kee ◽

Ji Eun Lee ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Replacement Therapy ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Fluid Balance ◽

Interactive Effect ◽

Kidney Injury ◽

Input And Output ◽

The Impact ◽

Cumulative Fluid Balance

Abstract Background The interactive effect of cumulative input and output on achieving optimal fluid balance has not been well elucidated in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). This study evaluated the interrelation of fluid components with mortality in patients with AKI requiring CRRT. Methods This is a retrospective observational study conducted with a total of 258 patients who were treated with CRRT due to AKI between 2016 and 2018 in the intensive care unit of Ewha Womans University Mokdong Hospital. The amounts of fluid input and output were assessed at 24-h and 72-h from the initiation of CRRT. The study endpoints were 7- and 28-day all-cause mortality. Results The mean patient age was 64.7 ± 15.8 years, and 165 (64.0%) patients were male. During the follow-up, 7- and 28-day mortalities were observed in 120 (46.5%) and 157 (60.9%) cases. The patients were stratified into two groups (28-day survivors vs. non-survivors), and the cumulative fluid balances (CFBs) at 24 h and 72 h were significantly higher in the 28-day non-survivors compared with the survivors. The increase in 24-h and 72-h CFB was significantly associated with an increase in 7- and 28-day mortality risks. To examine the interactive effect of cumulative input or output on the impact of CFB on mortality, we also stratified patients into three groups based on the tertile of 24-h and 72-h cumulative input or output. The increases in 24-h and 72-h CFBs were still significantly related to the increases in 7-day and 28-day mortality, irrespective of the cumulative input. However, we did not find significant associations between increase in 24-h and 72-h CFB and increase in mortality risk in the groups according to cumulative output tertile. Conclusions The impact of cumulative fluid balance on mortality might be more dependent on cumulative output. The physicians need to decrease the cumulative fluid balance of CRRT patients as much as possible and consider increasing patient removal.

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Faculty Opinions recommendation of Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.722094970.793513414 ◽

2016 ◽

Author(s):

Claudio Ronco ◽

Zaccaria Ricci

Keyword(s):

Acute Kidney Injury ◽

Risk Factor ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Independent Risk Factor ◽

Kidney Injury

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Early negative fluid balance is associated with lower mortality after cardiovascular surgery

Perfusion ◽

10.1177/0267659118780103 ◽

2018 ◽

Vol 33 (8) ◽

pp. 630-637 ◽

Cited By ~ 9

Author(s):

Chenglong Li ◽

Hong Wang ◽

Nan Liu ◽

Ming Jia ◽

Haitao Zhang ◽

...

Keyword(s):

Acute Kidney Injury ◽

Renal Replacement Therapy ◽

Critically Ill ◽

Fluid Balance ◽

Cardiovascular Surgery ◽

Postoperative Mortality ◽

Kidney Injury ◽

Positive Fluid Balance ◽

Negative Fluid Balance ◽

The Relationship

Background: Early fluid expansion could prevent postoperative organ hypoperfusion. However, excessive fluid resuscitation adversely influences multiple organ systems. This retrospective, observational study aimed to investigate the relationship between early negative fluid balance and postoperative mortality in critically ill adult patients following cardiovascular surgery. Methods: In total, 567 critically ill patients who had undergone cardiovascular surgery and whose intensive care unit length of stay (LOS) was more than 24 hours were enrolled. The baseline characteristics, daily fluid balance and cumulative fluid balance were obtained. Patients were followed until discharge or day 28. Multivariate logistic regressions adjusted by propensity score were used to analyze the relationship between early negative fluid balance and postoperative mortality. Results: Overall, postoperative mortality was 6.2% (35/567). Acute Physiology and Chronic Health Evaluation II on admission (odd ratios [OR] 1.110), acute kidney injury stage (OR 1.639) and renal replacement therapy received (OR 3.922) were the independent risk factors of postoperative mortality, whereas negative daily fluid balance at day 2 (OR 0.411) was the protective factor. Patients with a negative daily fluid balance at day 2 had lower postoperative mortality (3.4% vs. 12.2% in the positive fluid balance group), lower acute kidney injury (AKI) stage, were less likely to receive renal replacement therapy (RRT) and experienced shorter hospital LOS compared with those with a daily positive fluid balance. Conclusion: This retrospective, observational study indicates that early negative fluid balance is associated with lower postoperative mortality in critically ill patients following cardiovascular surgery. Further prospective, randomized trials are needed to prove the benefits from the restrictive fluid management strategy.

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