Relationship between fluid status and its management on acute renal failure (ARF) in intensive care unit (ICU) patients with sepsis: a prospective analysis.
BACKGROUND
Sepsis carries a high morbidity and mortality, further enhanced by acute renal failure (ARF). Although fluid loading can prevent ARF in dehydrated patients, this approach could be risky in septic patients, since it can deteriorate oxygenation. This study evaluates the relationship between fluid status and management and ARF development in septic patients.


METHODS
Patients admitted to the ICU between 1 January 2001 and 31 December 2001 were included if serum creatinine (Cr) was <2 mg% on admission, and if they developed sepsis. ARF was determined as a doubling of serum Cr, an increase of serum Cr >2 mg%, or oliguria <500 ml/24 hr.


RESULTS
257 out of 2442 patients, admitted to the intensive care unit (ICU), developed sepsis, 29 developed ARF, 13 needed a renal replacement. ARF vs. non-ARF patients were older (65.2 +/- 13.3 vs. 55.1 +/- 17.4, p=0.002), had a higher central venous pressure (CVP) at day 1 (9.6 +/- 4.3 vs. 5.2 +/- 3.6 mmHg, p<0.001), and at day 2 (7.1 +/- 5.1 vs. 5.1 +/- 4.0 mmHg, p=0.03), a higher colloid fluid loading for the first 3 days (2037 +/- 1681 vs. 1116 +/- 1220 mL, p<0.03), a higher serum Cr (1.25 +/- 0.39 vs. 0.96 +/- 0.33 mg/dL, p=0.009) and an increase vs. a decrease in serum Cr during the first 24 hr (+0.30 +/- 0.58 vs. -0.31 +/- 0.45 mg/dL, p=0.02), a lower diuresis (1347 +/- 649 vs. 1849 +/- 916 mL, p=0.005). There was no difference in APACHE II scores (19.2 +/- 7.2 vs. 17.2 +/- 6.6, p=0.1), or MAP (64.5 +/- 12.4 vs. 67.9 +/- 12.4, p=0.18). The fraction of inspired oxygen (FiO2) need in the ARF group increased from 40.4 +/- 11.5 to 65.6 +/- 24.2% from day 1 to day 2 (p=0.04), where it remained unchanged in the non-ARF group. The use of diuretics was higher in the ARF group (21/29 vs. 43/228, p=0.001).


CONCLUSIONS
Septic patients developing ARF have an elevated CVP at day 1 of sepsis, indicating cardiodepression or intrarenal causes for hypoperfusion. These patients develop ARF despite further fluid loading. Respiratory function deteriorated in patients with ARF. Persistent fluid challenges should be avoided if they do not lead to an improvement in renal function, or if oxygenation deteriorates.
Van Biesen
Wim
W
Renal Division, University Hospital, Ghent-Belgium. wim.vanbiesen@UGent.be
Yegenaga
Itir
I
Vanholder
Raymond
R
Verbeke
Francis
F
Hoste
Erik
E
Colardyn
Francis
F
Lameire
Norbert
N
D018806:APACHE; D058186:Acute Kidney Injury / Q000097:blood / Q000382:microbiology* / Q000503:physiopathology / Q000517:prevention & control*; D000368:Aged; D002496:Central Venous Pressure; D003404:Creatinine / Q000097:blood; D004231:Diuresis; D005440:Fluid Therapy; D006801:Humans; D001239:Inhalation; D007362:Intensive Care Units; D008875:Middle Aged; D009318:Natriuresis; D010100:Oxygen; D011446:Prospective Studies; D012119:Respiration; D018805:Sepsis / Q000097:blood / Q000150:complications* / Q000503:physiopathology; D012720:Severity of Illness Index
D003404:Creatinine; D010100:Oxygen