fluids & aki

•Fluids & AKI

Fluids are GOOD

Volume overload is BAD

UGLY Fluids cause AKI

N Engl J Med 2004

•EGDT: fluids are good & prevent AKI

Lin et al, Shock 2006

Prowle et al Crit Care Med 2012

RF in non AKIRRT: 9 Anuria: 3CrCl>60 mL/min: 2

Phase-contrast MRI10 septic AKI patients11 normal volunteers

•Renal Plasma Flow and GFR

Prowle et al. Renal Failure 2010

Systematic reviewHuman studies22 articles250 patients

•RBF decreased in sepsis and early AKI?

Langenberg et al. Kidney Int 2006

7 SheepE. Coli infusion

•EGDT and AKI

Prowle et al. Crit Care 2012

•Fluids & AKI

Fluids are GOOD

Volume overload is BAD

UGLY Fluids cause AKI

•Fluid bolus? The FEAST trial

Maitland et al. NEJM 2011

N = 3141 childrenSevere infection

Conservative Liberal P

7 d volume balance (mL)

-136 mL ± 491 +6992 ± 502 <0.001

Death at 60 days 25.5% 28.4% 0.30Ventilator free days 14.6 ± 0.5 12.1 ± 0.5 <0.001ICU free days:

Day 1-7 0.9 ± 0.1 0.6 ± 0.1 <0.001Day 1-28 13.4 ± 0.4 11.2 ± 0.4 <0.001

Wiedemann, N Engl J Med 2006

PRCTN = 1000

•Fluid-Management in ARDS

Wiedemann et al. N Engl J Med 2006

•Venous pressure & ↘ renal bloodflow

Winton, J Physiol 1931

•AKI & CVP, CI, systolic BP, & PCWP

Mullens et al. JACC 2009

CVP CI

PCWPSBP

•AKI & CVP, CI, systolic BP, & PCWP

Mullens et al. JACC 2009

CVP CI

PCWPSBP

•Volume and outcome in AKI-RRT

Bouchard et al. KI 2009, Payen et al. Crit Care 2008, Grams et al. CJASN 2011, Vaara et al. Crit Care 2012

•Negative FB during CRRT is good

Bellomo et al. Crit Care Med 2012

•Negative FB during CRRT is good

Bellomo et al. Crit Care Med 2012

•Fluids & AKI

•Summary Recent PRCT’s HESStudy N Surviv

al AKI Other side effects

Magder, CABG10% HES 250/0,5

262 Less Better HD

FIRST, trauma6% HES 130/0,4

67 P42 B

LessSame

Better lactate ↘More blood

CRYSTMAS severe sepsis6% HES 130/0,4

196 Same

6S severe sepsis6% HES 130/0,42

798 Worse More

More blood

CHEST ICU6% HES 130/0,4

7000

Same More

Liver, pruritus, blood products

Magder et al Crit Care Med 2010, James et al. J Trauma 2011, Guidet et al. Crit Care 2012, Perner et al. NEJM 2012, Myburgh et al. NEJM 2012

•AKI after gelatin

Schabinski et al. Intensive Care Med 2009

ObservationalN = 1383 HESN = 1528 GEL

MVR adjusted Risk for AKI after >33mL/kg GEL: OR 1.99 (1.05-3.79)HES: OR 1.85 (1.01 – 3.41)

•PRCT’s on albumin

n Survival AKI Bleeding/coagulation

SAFE 6997 Same More PC

SAFE TBI 460 Worse More PC

FEAST sepsis 3141 Worse

SAFE severe sepsis 1218 No diff (trend)

No diff No diff

CRYSTMAS severe sepsis

196 No diff No diff

EARSS severe sepsis 792 No diff No diff ALBIOS severe sepsis

1818 No diff No diff No diff

•Saline vs. Plasmalyte ®?

Shaw et al. Ann Surg 2012

Saline = More complications and use of resources:❖ Major infection❖ Dialysis❖ Blood transfusions❖ Electrolyte disturbances

N = 30,994 vs. 926Major abd surgery

•Chloride liberal/restrictive fluid therapy

AKI stage 2-3

Yunos et al. JAMA 2012

•Take home messages

Fluids and AKI: just enough!✓Not too little✓Not too much

Fluids and AKI: beware for the ugly.

•Thank you for your attention!

Eric.hoste@ugent.be

•Fluids & AKI

To pee or not to pee: Fluids & AKI

Eric Hoste MD, PhDGhent University

Hospital

•CHEST: HES 130/0.4 vs. Saline

Myburgh et al. NEJM 2012

HES Saline

•CHEST: HES 130/0.4 vs. Saline

Myburgh et al. NEJM 2012

HES Saline

Perner et al. NEJM 2012