J Korean Med Sci.  2016 Aug;31(8):1337-1344. 10.3346/jkms.2016.31.8.1337.

Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients

• Han MJ
• Park KH
• Shin JH
• Kim SH

• KMID: 2373765
• DOI: http://doi.org/10.3346/jkms.2016.31.8.1337

Abstract

Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.

Keyword

Continuous Renal Replacement Therapy; Critically Ill Patients; Daily Fluid Balance; Organ Failure

MeSH Terms

Acute Kidney Injury/*diagnosis/mortality/therapy
Aged
Critical Illness/*mortality
Female
Humans
Intensive Care Units
Male
Middle Aged
Organ Dysfunction Scores
*Renal Replacement Therapy
Retrospective Studies
Risk Factors
Survival Rate
Water-Electrolyte Balance/*physiology

Figure

• 

  Fig. 1 Time to CRRT according to daily fluid balance in critically ill patients. The time to start CRRT was shortened from group 1 to group 3 (P = 0.001). On day 5, the rate of CRRT implementation was 54.2%, 63.0%, and 95.7% in group 1, 2, and 3, respectively. Group 1 included patients with a fluid balance of < 1.5 L/day; group 2 included patients with a fluid balance of 1.5–3.0 L/day; and group 3 included patients with a fluid balance of ≥ 3.0 L/day. CRRT, continuous renal replacement therapy.

• 

  Fig. 2 The comparisons of the prevalence of organ failure between ICU admission and CRRT initiation. (A) Changes of the prevalence of respiratory failure did not statistically differ. But it was slightly decreased from 21.6% to 5.4% in group 1, but was increased from 12.5% to 34.4% in group 3 (P = 0.085 and 0.075, respectively). (B) Cardiovascular failure became prevalent at CRRT initiation in groups 2 and 3, compared with those at ICU admission (from 29.0% to 64.5% and from 43.8% to 81.3%, P = 0.010 and 0.004, in group 2 and 3, respectively). (C) The nervous failure also increased from 18.8% to 56.3% in group 3 (P = 0.004). (D) The prevalence of liver failure did not change between ICU admission and CRRT initiation (from 6.3% to 9.4%, P = 1.000 in group 3). (E) Although a slight increase in coagulation failure from 3.1% to 15.6% was seen in group 3, this was not statistically significant (P = 0.196). Group 1 included patients with a fluid balance of < 1.5 L/day; group 2 included patients with a fluid balance of 1.5–3.0 L/day; and group 3 included patients with a fluid balance of ≥ 3.0 L/day. CRRT, continuous renal replacement therapy; ICU, intensive care unit.

• 

  Fig. 3 Twenty-eight-day survival rate according to daily fluid balance prior to CRRT in critically ill patients. The cumulative survival rates differed between the groups (P = 0.013). The 28-day survival rates were 41.0% in group 1, 31.6% in group 2, and 18.8% in group 3. Group 1 included patients with a fluid balance of < 1.5 L/day; group 2 included patients with a fluid balance of 1.5–3.0 L/day; and group 3 included patients with a fluid balance of ≥ 3.0 L/day. CRRT, continuous renal replacement therapy.

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