title: The passive leg raising test to guide fluid removal in critically ill patients.
abstract: BACKGROUND
  To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replacement therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT.
  
  
  METHODS
  We included 39 patients where intermittent RRT with weight loss was decided. Intradialytic hypotension was defined as hypotension requiring a therapeutic intervention, as decided by the physicians in charge. Before RRT, the maximal increase in cardiac index (CI, pulse contour analysis) induced by a PLR test was recorded. RRT was then started.
  
  
  RESULTS
  Ultrafiltration rate was similar in patients with and without intradialytic hypotension. Thirteen patients presented intradialytic hypotension, while 26 did not. In patients with intradialytic hypotension, it occurred 120 min [interquartile range 60-180 min] after onset of RRT. In the 26 patients without intradialytic hypotension, the PLR test induced no significant change in CI. Conversely, in patients with intradialytic hypotension, PLR significantly increased CI by 15 % [interquartile range 11-36 %]. The PLR-induced increase in CI predicted intradialytic hypotension with an area under the ROC curve of 0.89 (95 % interval confidence 0.75-0.97) (p < 0.05 from 0.50). The best diagnostic threshold was 9 %. The sensitivity was 77 % (95 % confidence interval 46-95 %), the specificity was 96 % (80-100 %), the positive predictive value was 91 % (57-100 %), and the negative predictive value was 89 % (72-98 %). Compared to patients without intolerance to RRT, CI decreased significantly faster in patients with intradialytic hypotension, with a slope difference of -0.17 L/min/m(2)/h.
  
  
  CONCLUSIONS
  The presence of preload dependence, as assessed by a positive PLR test before starting RRT with fluid removal, predicts that RRT will induce haemodynamic intolerance.
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. xavier.monnet@aphp.fr.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France. xavier.monnet@aphp.fr.|Service de réanimation médicale, Centre Hospitalier Universitaire de Bicêtre, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France. xavier.monnet@aphp.fr.
authors.forename: Xavier
authors.initials: X
authors.lastname: Monnet
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Flora
authors.initials: F
authors.lastname: Cipriani
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Laurent
authors.initials: L
authors.lastname: Camous
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Pierre
authors.initials: P
authors.lastname: Sentenac
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Martin
authors.initials: M
authors.lastname: Dres
authors.affiliation: Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.|Service de santé publique, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Evguenia
authors.initials: E
authors.lastname: Krastinova
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Nadia
authors.initials: N
authors.lastname: Anguel
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Christian
authors.initials: C
authors.lastname: Richard
authors.affiliation: Service de réanimation médicale, Hôpital de Bicêtre, Hôpitaux universitaires Paris-Sud, 78, rue du Général Leclerc, 94270, Le Kremlin-Bicêtre, France.|Faculté de médecine Paris-Sud, Inserm UMR S_999, Univ Paris-Sud, 63, rue Gabriel Péri, 94270, Le Kremlin-Bicêtre, France.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Teboul
keywords: Acute kidney injury; Hypotension; Passive leg raising; Renal replacement therapy; Ultrafiltration; Volume responsiveness