title: Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease.
abstract: OBJECTIVE
  Incident acute kidney injury and prevalent chronic kidney disease are commonly encountered in septic patients. We examined the differential effect of acute kidney injury and chronic kidney disease on the association between cumulative fluid balance and hospital mortality in critically ill septic patients.
  
  
  METHODS
  Retrospective cohort study.
  
  
  METHODS
  Urban academic medical center ICU.
  
  
  METHODS
  ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 hours of ICU admission. Patients with estimated glomerular filtration rate less than 15 mL/min/1.73 m or receiving chronic dialysis were excluded.
  
  
  METHODS
  None.
  
  
  RESULTS
  A total of 2,632 patients, 1,211 with chronic kidney disease, were followed up until hospital death or discharge. Acute kidney injury occurred in 1,525 patients (57.9%), of whom 679 (44.5%) had chronic kidney disease. Hospital mortality occurred in 603 patients (22.9%). Every 1-L increase in cumulative fluid balance at 72 hours of ICU admission was independently associated with hospital mortality in all patients (adjusted odds ratio, 1.06 [95% CI] 1.04-1.08; p < 0.001), and in each acute kidney injury/chronic kidney disease subgroup (adjusted odds ratio, 1.06 [1.03-1.09] for acute kidney injury+/chronic kidney disease+; 1.09 [1.05-1.13] for acute kidney injury-/chronic kidney disease+; 1.05 [1.03-1.08] for acute kidney injury+/chronic kidney disease-; and 1.07 [1.02-1.11] for acute kidney injury-/chronic kidney disease-). There was a significant interaction between acute kidney injury and chronic kidney disease on cumulative fluid balance (p =0.005) such that different cumulative fluid balance cut-offs with the best prognostic accuracy for hospital mortality were identified: 5.9 L for acute kidney injury+/chronic kidney disease+; 3.8 L for acute kidney injury-/chronic kidney disease+; 4.3 L for acute kidney injury+/chronic kidney disease-; and 1.5 L for acute kidney injury-/chronic kidney disease-. The addition of cumulative fluid balance to the admission Sequential Organ Failure Assessment score had increased prognostic utility for hospital mortality when compared with Sequential Organ Failure Assessment alone, particularly in patients with acute kidney injury.
  
  
  CONCLUSIONS
  Higher cumulative fluid balance at 72 hours of ICU admission was independently associated with hospital mortality regardless of acute kidney injury or chronic kidney disease presence. We characterized cumulative fluid balance cut-offs associated with hospital mortality based on acute kidney injury/chronic kidney disease status, underpinning the heterogeneity of fluid regulation in sepsis and kidney disease.
authors.affiliation: 1Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX.2Division of Nephrology, Bone, and Mineral Metabolism, University of Kentucky, Lexington, KY.3Division of Biostatistics, Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas, TX.4Department of Internal Medicine, Asante Health System, Grants Pass, OR.5Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI.6Renal Section, Medical Service, Veterans Affairs North Texas Health Care System, Dallas, TX.
authors.forename: Javier A
authors.initials: JA
authors.lastname: Neyra
authors.forename: Xilong
authors.initials: X
authors.lastname: Li
authors.forename: Fabrizio
authors.initials: F
authors.lastname: Canepa-Escaro
authors.forename: Beverley
authors.initials: B
authors.lastname: Adams-Huet
authors.forename: Robert D
authors.initials: RD
authors.lastname: Toto
authors.forename: Jerry
authors.initials: J
authors.lastname: Yee
authors.forename: S Susan
authors.initials: SS
authors.lastname: Hedayati
mesh_terms: D018806:APACHE; D000046:Academic Medical Centers; D058186:Acute Kidney Injury / Q000453:epidemiology*; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D007677:Kidney Function Tests; D008297:Male; D008875:Middle Aged; D051436:Renal Insufficiency, Chronic / Q000453:epidemiology*; D012189:Retrospective Studies; D012772:Shock, Septic / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology*; D014882:Water-Electrolyte Balance / Q000502:physiology*