Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study

Suvi T Vaara, Anna-Maija Korhonen, Kirsi-Maija Kaukonen, Sara Nisula, Outi Inkinen, Sanna Hoppu, Jouko J Laurila, Leena Mildh, Matti Reinikainen, Vesa Lund, Ilkka Parviainen, Ville Pettilä, FINNAKI Study Group, Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, Sinikka Tolmunen, Ulla Rantalainen, Marja Miettinen, Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa Kauppinen, Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara, Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen, Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman, Tero Varpula, Päivi Porkka, Mirka Sivula, Mira Rahkonen, Anne Tsurkka, Taina Nieminen, Niina Pirttinen, Ari Alaspää, Ville Salanto, Hanna Juntunen, Teija Sanisalo, Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång, Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija Vaskelainen, Meri Poukkanen, Sirpa Suominen, Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi, Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane Roiko, Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana Kallinen, Tero Ala-Kokko, Jouko Laurila, Sinikka Sälkiö, Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu Johansson, Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne Toropainen, Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo Varila, Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu Laine, Suvi T Vaara, Anna-Maija Korhonen, Kirsi-Maija Kaukonen, Sara Nisula, Outi Inkinen, Sanna Hoppu, Jouko J Laurila, Leena Mildh, Matti Reinikainen, Vesa Lund, Ilkka Parviainen, Ville Pettilä, FINNAKI Study Group, Raili Laru-Sompa, Anni Pulkkinen, Minna Saarelainen, Mikko Reilama, Sinikka Tolmunen, Ulla Rantalainen, Marja Miettinen, Markku Suvela, Katrine Pesola, Pekka Saastamoinen, Sirpa Kauppinen, Ville Pettilä, Kirsi-Maija Kaukonen, Anna-Maija Korhonen, Sara Nisula, Suvi Vaara, Raili Suojaranta-Ylinen, Leena Mildh, Mikko Haapio, Laura Nurminen, Sari Sutinen, Leena Pettilä, Helinä Laitinen, Heidi Syrjä, Kirsi Henttonen, Elina Lappi, Hillevi Boman, Tero Varpula, Päivi Porkka, Mirka Sivula, Mira Rahkonen, Anne Tsurkka, Taina Nieminen, Niina Pirttinen, Ari Alaspää, Ville Salanto, Hanna Juntunen, Teija Sanisalo, Ilkka Parviainen, Ari Uusaro, Esko Ruokonen, Stepani Bendel, Niina Rissanen, Maarit Lång, Sari Rahikainen, Saija Rissanen, Merja Ahonen, Elina Halonen, Eija Vaskelainen, Meri Poukkanen, Sirpa Suominen, Jorma Heikkinen, Timo Lavander, Kirsi Heinonen, Anne-Mari Juopperi, Tadeusz Kaminski, Fiia Gäddnäs, Tuija Kuusela, Jane Roiko, Sari Karlsson, Matti Reinikainen, Tero Surakka, Helena Jyrkönen, Tanja Eiserbeck, Jaana Kallinen, Tero Ala-Kokko, Jouko Laurila, Sinikka Sälkiö, Vesa Lund, Päivi Tuominen, Pauliina Perkola, Riikka Tuominen, Marika Hietaranta, Satu Johansson, Seppo Hovilehto, Anne Kirsi, Pekka Tiainen, Tuija Myllärinen, Pirjo Leino, Anne Toropainen, Anne Kuitunen, Jyrki Tenhunen, Ilona Leppänen, Markus Levoranta, Sanna Hoppu, Jukka Sauranen, Atte Kukkurainen, Samuli Kortelainen, Simo Varila, Outi Inkinen, Niina Koivuviita, Jutta Kotamäki, Anu Laine

Abstract

Introduction: Positive fluid balance has been associated with an increased risk for mortality in critically ill patients with acute kidney injury with or without renal replacement therapy (RRT). Data on fluid accumulation prior to RRT initiation and mortality are limited. We aimed to study the association between fluid accumulation at RRT initiation and 90-day mortality.

Methods: We conducted a prospective, multicenter, observational cohort study in 17 Finnish intensive care units (ICUs) during a five-month period. We collected data on patient characteristics, RRT timing, and parameters at RRT initiation. We studied the association of parameters at RRT initiation, including fluid overload (defined as cumulative fluid accumulation > 10% of baseline weight) with 90-day mortality.

Results: We included 296 RRT-treated critically ill patients. Of 283 patients with complete data on fluid balance, 76 (26.9%) patients had fluid overload. The median (interquartile range) time from ICU admission to RRT initiation was 14 (3.3 to 41.5) hours. The 90-day mortality rate of the whole cohort was 116 of 296 (39.2%; 95% confidence interval 38.6 to 39.8%). The crude 90-day mortality of patients with or without fluid overload was 45 of 76 (59.2%) vs. 65 of 207 (31.4%), P < 0.001. In logistic regression, fluid overload was associated with an increased risk for 90-day mortality (odds ratio 2.6) after adjusting for disease severity, time of RRT initiation, initial RRT modality, and sepsis. Of the 168 survivors with data on RRT use at 90 days, 34 (18.9%, 95% CI 13.2 to 24.6%) were still dependent on RRT.

Conclusions: Patients with fluid overload at RRT initiation had twice as high crude 90-day mortality compared to those without. Fluid overload was associated with increased risk for 90-day mortality even after adjustments.

Figures

Figure 1
Figure 1
Study flow chart with 90-day mortality rates. *ICU, intensive care unit; RRT, renal replacement therapy.
Figure 2
Figure 2
Kaplan-Meier unadjusted survival curves for 90-day survival in patients with or without fluid overload. *Number of patients with fluid overload 76 and without fluid overload 207.
Figure 3
Figure 3
Ninety-day mortality according to the percentage of fluid accumulation prior to renal replacement therapy initiation. *Comparison across groups P < 0.001.

References

    1. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;16:813–818. doi: 10.1001/jama.294.7.813.
    1. Bagshaw SM, Laupland KB, Doig CJ, Mortis G, Fick GH, Mucenski M, Godinez-Luna T, Svenson LW, Rosenal T. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care. 2005;16:R700–9. doi: 10.1186/cc3879.
    1. Vaara ST, Pettilä V, Reinikainen M, Kaukonen KM. for the Finnish Intensive Care Consortium. Population-based incidence, mortality and quality of life in critically ill patients treated with renal replacement therapy: a nationwide retrospective cohort study in Finnish intensive care units. Crit Care. 2012;16:R13. doi: 10.1186/cc11158.
    1. Piccinni P, Cruz DN, Gramaticopolo S, Garzotto F, Dal Santo M, Aneloni G, Rocco M, Alessandri E, Giunta F, Michetti V, Iannuzzi M, Belluomo Anello C, Brienza N, Carlini M, Pelaia P, Gabbanelli V, Ronco C. Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT) Minerva Anestesiol. 2011;16:1072–1083.
    1. Bell M, Swing, Granath F, Schon S, Ekbom A, Martling CR. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med. 2007;16:773–780. doi: 10.1007/s00134-007-0590-6.
    1. The RENAL replacement study investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;16:1627–1638.
    1. Lin YF, Ko WJ, Chu TS, Chen YS, Wu VC, Chen YM, Wu MS, Chen YW, Tsai CW, Shiao CC, Li WY, Hu FC, Tsai PR, Tsai TJ, Wu KD. NSARF Study Group. The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy. Am J Surg. 2009;16:325–332. doi: 10.1016/j.amjsurg.2008.10.021.
    1. Saudan P, Niederberger M, De Seigneux S, Romand J, Pugin J, Perneger T, Martin PY. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int. 2006;16:1312–1317. doi: 10.1038/sj.ki.5001705.
    1. Prescott GJ, Metcalfe W, Baharani J, Khan IH, Simpson K, Smith WC, MacLeod AM. A prospective national study of acute renal failure treated with RRT: incidence, aetiology and outcomes. Nephrol Dial Transplant. 2007;16:2513–2519. doi: 10.1093/ndt/gfm264.
    1. Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis. 2008;16:272–284. doi: 10.1053/j.ajkd.2008.02.371.
    1. Karvellas CJ, Farhat MR, Sajjad I, Mogensen SS, Leung AA, Wald R, Bagshaw SM. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis. Crit Care. 2011;16:R72. doi: 10.1186/cc10061.
    1. Ostermann M, Dickie H, Barrett NA. Renal replacement therapy in critically ill patients with acute kidney injury - when to start. Nephrol Dial Transplant. 2012;16:2242–2248. doi: 10.1093/ndt/gfr707.
    1. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;16:1–138.
    1. Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, Bunchman TE, Baker C, Mottes T, McAfee N, Barnett J, Morrison G, Rogers K, Fortenberry JD. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int. 2005;16:653–658. doi: 10.1111/j.1523-1755.2005.67121.x.
    1. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL. Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis. 2010;16:316–325. doi: 10.1053/j.ajkd.2009.10.048.
    1. Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL. Sepsis Occurrence in Acutely Ill Patients (SOAP) investigators. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care. 2008;16:R74. doi: 10.1186/cc6916.
    1. The RENAL replacement study investigators. Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lee J, Lo S, McArthur C, McGuiness S, Norton R, Myburgh J, Scheinkestel C, Su S. 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;16:1753–1760.
    1. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int. 2009;16:422–427. doi: 10.1038/ki.2009.159.
    1. Heung M, Wolfgram DF, Kommareddi M, Hu Y, Song PX, Ojo AO. Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury. Nephrol Dial Transplant. 2012;16:956–961. doi: 10.1093/ndt/gfr470.
    1. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;16:707–10. doi: 10.1007/BF01709751.
    1. Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA. 1993;16:2957–2963. doi: 10.1001/jama.1993.03510240069035.
    1. Clark WR, Turk JE, Kraus MA, Gao D. Dose determinants in continuous renal replacement therapy. Artificial organs. 2003;16:815–820. doi: 10.1046/j.1525-1594.2003.07288.x.
    1. Brierley J, Carcillo JA, Choong K, Cornell T, Decaen A, Deymann A, Doctor A, Davis A, Duff J, Dugas MA, Duncan A, Evans B, Feldman J, Felmet K, Fisher G, Frankel L, Jeffries H, Greenwald B, Gutierrez J, Hall M, Han YY, Hanson J, Hazelzet J, Hernan L, Kiff J, Kissoon N, Kon A, Irazuzta J, Lin J, Lorts A. et al.Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med. 2009;16:666–688. doi: 10.1097/CCM.0b013e31819323c6.
    1. Bone RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest. 1992;16:1644–1655. doi: 10.1378/chest.101.6.1644.
    1. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care. 2004;16:R204–12. doi: 10.1186/cc2872.
    1. Bagshaw SM, Brophy PD, Cruz D, Ronco C. Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury. Crit Care. 2008;16:169. doi: 10.1186/cc6948.
    1. Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, deBoisblanc B, Connors AF Jr, Hite RD, Harabin AL. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med. 2006;16:2564–2575.
    1. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol. 2011;16:966–973. doi: 10.2215/CJN.08781010.
    1. Bagshaw SM, Wald R, Barton J, Burns KE, Friedrich JO, House AA, James MT, Levin A, Moist L, Pannu N, Stollery DE, Walsh MW. Clinical factors associated with initiation of renal replacement therapy in critically ill patients with acute kidney injury-A prospective multicenter observational study. J Critical Care. 2012;16:268–275. doi: 10.1016/j.jcrc.2011.06.003.
    1. Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, Paganini EP, Chertow GM. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004;16:1613–1621. doi: 10.1111/j.1523-1755.2004.00927.x.
    1. Fulop T, Pathak MB, Schmidt DW, Lengvarszky Z, Juncos JP, Lebrun CJ, Brar H, Juncos LA. Volume-related weight gain and subsequent mortality in acute renal failure patients treated with continuous renal replacement therapy. ASAIO J. 2010;16:333–337.
    1. Dass B, Shimada M, Kambhampati G, Ejaz NI, Arif AA, Ejaz AA. Fluid balance as an early indicator of acute kidney injury in CV surgery. Clin Nephrol. 2012;16:438–444.
    1. Smith SH, Perner A. Higher vs. lower fluid volume for septic shock: clinical characteristics and outcome in unselected patients in a prospective, multicenter cohort. Crit Care. 2012;16:R76. doi: 10.1186/cc11333.
    1. Delannoy B, Floccard B, Thiolliere F, Kaaki M, Badet M, Rosselli S, Ber CE, Saez A, Flandreau G, Guerin C. Six-month outcome in acute kidney injury requiring renal replacement therapy in the ICU: a multicentre prospective study. Intensive Care Med. 2009;16:1907–1915. doi: 10.1007/s00134-009-1588-z.
    1. Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, Dhainaut JF. Hemodiafe Study Group. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006;16:379–385. doi: 10.1016/S0140-6736(06)69111-3.
    1. Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Aneman A, Madsen KR, Moller MH, Elkjaer JM, Poulsen LM, Bendtsen A, Winding R, Steensen M, Berezowicz P, Soe-Jensen P, Bestle M, Strand K, Wiis J, White JO, Thornberg KJ, Quist L, Nielsen J, Andersen LH, Holst LB, Thormar K, Kjaeldgaard AL, Fabritius ML, Mondrup F, Pott FC, Moller TP. et al.Hydroxyethyl starch 130/0.4 versus Ringer's acetate in severe sepsis. N Engl J Med. 2012;16:124–34. doi: 10.1056/NEJMoa1204242.
    1. Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-van Straaten H, Ronco C, Kellum JA. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (BEST kidney) investigators. Intensive Care Med. 2007;16:1563–1570. doi: 10.1007/s00134-007-0754-4.
    1. Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-van Straaten HM, Ronco C, Kellum JA. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Critical Care. 2009;16:129–140. doi: 10.1016/j.jcrc.2007.12.017.
    1. Palevsky PM, Zhang JH, O'Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;16:7–20.
    1. Maccariello E, Soares M, Valente C, Nogueira L, Valenca RV, Machado JE, Rocha E. RIFLE classification in patients with acute kidney injury in need of renal replacement therapy. Intensive Care Med. 2007;16:597–605. doi: 10.1007/s00134-007-0535-0.

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