Targeting Oliguria Reversal in Goal-Directed Hemodynamic Management Does Not Reduce Renal Dysfunction in Perioperative and Critically Ill Patients: A Systematic Review and Meta-Analysis.
BACKGROUND
We investigated whether resuscitation protocols to achieve and maintain urine output above a predefined threshold-including oliguria reversal as a target--prevent acute renal failure (ARF).


METHODS
We performed a systematic review and meta-analysis using studies found by searching MEDLINE, EMBASE, and references in relevant reviews and articles. We included all studies that compared "conventional fluid management" (CFM) with "goal-directed therapy" (GDT) using cardiac output, urine output, or oxygen delivery parameters and reported the occurrence of ARF in critically ill or surgical patients. We divided studies into groups with and without oliguria reversal as a target for hemodynamic optimization. We calculated the combined odds ratio (OR) and 95% confidence intervals (CIs) using random-effects meta-analysis.


RESULTS
We based our analyses on 28 studies. In the overall analysis, GDT resulted in less ARF than CFM (OR, 0.58; 95% CI, 0.44-0.76; P < 0.001; I = 34.3%; n = 28). GDT without oliguria reversal as a target resulted in less ARF (OR, 0.45; 95% CI, 0.34-0.61; P < 0.001; I = 7.1%; n = 7) when compared with CFM with oliguria reversal as a target. The studies comparing GDT with CFM in which the reversal of oliguria was targeted in both or in neither group did not provide enough evidence to conclude a superiority of GDT (targeting oliguria reversal in both protocols: OR, 0.63; 95% CI, 0.36-1.10; P = 0.09; I = 48.6%; n = 9, and in neither protocol: OR, 0.66; 95% CI, 0.37-1.16; P = 0.14; I = 20.2%; n = 12).


CONCLUSIONS
Current literature favors targeting circulatory optimization by GDT without targeting oliguria reversal to prevent ARF. Future studies are needed to investigate the hypothesis that targeting oliguria reversal does not prevent ARF in critically ill and surgical patients.
From the Departments of *Intensive Care, †Biostatistics, and ‡Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
Mohamud
M
Egal
Nicole S
NS
Erler
Hilde R H
HR
de Geus
Jasper
J
van Bommel
A B Johan
AB
Groeneveld
D058186:Acute Kidney Injury / Q000175:diagnosis / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control*; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness; D018450:Disease Progression; D005440:Fluid Therapy / Q000009:adverse effects; D006040:Goals; D006439:Hemodynamics; D006801:Humans; D007262:Infusions, Intravenous; D007668:Kidney / Q000503:physiopathology*; D016017:Odds Ratio; D009846:Oliguria / Q000150:complications / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy*; D019990:Perioperative Care / Q000009:adverse effects / Q000379:methods*; D012151:Resuscitation / Q000009:adverse effects / Q000379:methods*; D012307:Risk Factors; D016896:Treatment Outcome; D014554:Urination