Fluid management-in-aki-final-dr-kamalppt

Critical Care Chapter
August,13,2018
MIHCriticalcarenephrology,prof
KOkasha

Fluid Management in AKI
By
KamalOkashaMD
Prof ofMedicineandHeadofNephrology
TantaUniversity,Egypt
August,13,2018
KOkasha

Agenda
• AKI: Definition & Causes
• AKI: Classification
• AKI: Epidimiology
• AKI: Prognosis
• AKI: Treatment principles
• Role of loop diuretics
• Fluid balance
• Selection of Resuscitation Fluid
• Fluid overload in AKI and its mechanism
• Conclusion
August,13,2018
KOkasha

Agenda
• AKI: Prognosis
• Fluid balance
• Selection of Resuscitation Fluid
August,13,2018
KOkasha

AKI- Definition and causes
• Acute kidney injury (AKI) is defined as an abrupt or rapid decline in
renal filtration function. This condition is usually marked by a rise in
serum creatinine concentration or by azotemia (a rise in BUN
concentration).
• AKI may be classified into 3 general categories, as follows:
• Prerenal: in response to severe volume depletion and hypotension,
with structurally intact nephrons.
• Intrinsic: in response to cytotoxic, ischemic, or inflammatory insults
to the kidney, with structural and functional damage
• Postrenal: due to obstruction to the passage of urine.
Schrier RW, et al.: J Clin Invest. 2004. 114(1):5-14.
August,13,2018
KOkasha

AKI – Urine output
• Approximately 50-60% of all causes of AKI are nonoliguric.
• Oliguria is defined as a daily urine volume of less than 400 mL
and has a worse prognosis.
• Anuria is defined as a urine output of less than 100 mL/day
and, if abrupt in onset, suggests bilateral obstruction or
catastrophic injury to both kidneys.
Schrier RW, et al.: J Clin Invest. 2004. 114(1):5-14.
August,13,2018
KOkasha

AKI- cardiovascular complications
• Cardiovascular complications e.g. heart failure have been
observed in as many as 35% of patients with AKI.
• Fluid overload secondary to oliguric AKI is a particular risk for
elderly patients with limited cardiac reserve.
Ronco C, et al.: Cardiorenal syndrome. J Am Coll Cardiol. 2008. 52(19):1527-39.
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8/3/2018
KOkashaMD,CRSOmmAlOora
FirstAnnualMeeting.
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Management of AKI in Critical Cases, Kamal Okasha 29/7/2017
Definition and staging
August,13,2018
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AKI - Epidimiology
• The estimated incidence rate of AKI during hospitalization in
USA is 2-5%.
• AKI develops within 30 days postoperatively in approximately
1% of general surgery cases and arises in up to 67% of
intensive care unit (ICU) patients.
• In kidney transplants, 21% developed AKI within the first 6
months after transplantation.
Kheterpal S, et al.: Anesthesiology. 2009 Mar. 110(3):505-15.
Goldberg R & Dennen P.: Adv Chronic Kidney Dis. 2008. 15(3):297-307.
August,13,2018
KOkasha

AKI - Prognosis
• The prognosis for patients with AKI is strongly relate to:
• Cause of renal failure.
• Presence or absence of preexisting kidney disease,
• The duration of renal dysfunction prior to therapeutic
intervention.
• AKI correlated inversely with eGFR and was associated with a
higher mortality rate and a higher incidence of subsequent
ESRD at each level of baseline eGFR.
Pannu N, et al.: Am J Kidney Dis. 2011 Aug. 58(2):206-13.
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AKI - Prognosis
• The in-hospital mortality rate for AKI is 40-50%.
• The mortality rate for ICU patients with AKI is higher (>50% in
most studies), particularly when AKI is severe enough to
require dialysis treatment.
• ICU patients with sepsis-associated AKI have significantly
higher mortality rates than do non-septic AKI patients.
Uchino S, et al.: JAMA. 2005 Aug 17. 294(7):813-8.
Bagshaw SM, et al.: Clin J Am Soc Nephrol. 2007 May. 2(3):431-9.
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AKI- Treatment principles
• There is no specific pharmacologic therapy proven to
treat AKI secondary to hypoperfusion and/or sepsis.
• The therapeutic or preventive intervention that has an
established beneficial effect in the management of AKI is
the IV administration of isotonic sodium chloride
solution.
• It should be given in quantities sufficient to keep the
patient euvolemic or even hypervolemic.
August,13,2018
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AKI- Treatment principles
• Sepsis has been reported to account for approximately 50% of
patients with AKI in ICUs.
• Fluid administration is frequently necessary to stabilize the
patient with severe sepsis or septic shock.
• Maintenance of volume homeostasis and correction of biochemical
abnormalities remain important treatment goals.
Shigehiko U, et al.: JAMA 2005. 294: 813–818.
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AKI- Role of loop diurtics
• Furosemide can be used to correct volume overload when
patients are still responsive; this often requires high
intravenous (IV) doses.
• The response to furosemide can be taken as a good
prognostic sign.
Chorin E, et al.: Int J Cardiol. 2016 Oct 11. 226:42-47.
Briguori C.: Cardioangiol. 2012. 60 (3):291-7.
Briguori C, et al.: Circulation. 2011. 124 (11):1260-9.
August,13,2018
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AKI- Role of loop diurtics
• Frequently, IV doses of loop diuretics are needed in AKI to
maintain urine output.
• IV infusions are often helpful in intensive care settings, in which
larger doses are necessary.
• This method promotes a sustained natriuresis with reduced
ototoxicity compared with conventional intermittent bolus
dosing.
Chorin E, et al.: Int J Cardiol. 2016 Oct 11. 226:42-47.
Briguori C.: Cardioangiol. 2012. 60 (3):291-7.
Briguori C, et al.: Circulation. 2011. 124 (11):1260-9.
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AKI: Treatmentprinciples : Fluid balance
• In the patient with septic shock, early intervention with fluid
resuscitation within the first 6 hours in the emergency
department (ED) has been described as Early Goal-Directed
Therapy (EGDT).
• The study included patients with systemic inflammatory
response syndrome.
Rivers E, et al.: N Engl J Med., 2001. 345: 1368–1377.
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EGDT
• The predefined physiologic goals of EGDT within 6 hours of
diagnosis are:
• Mean arterial pressure ≥ 65 mmHg
• Central venous pressure between 8 and 12 mmHg.
• Improvement of blood lactate levels
• Central venous oxygen saturation > 70%.
• Urine output ≥ 0.5 ml/kg/h.
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• The EGDT group received more fluid, blood transfusions, and
inotropic use with dobutamine.
• The physiologic parameters were improved in the EGDT group
during the first 6 hours and over the next 3 days.
• In-hospital mortality was less in the EGDT group.
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• This study examined liberal versus conservative fluid
management in intubated ICU patients.
• Greater cumulative fluid accumulation over an average of 6
days (10.2 L vs 3.7 L in the liberal vs conservative group,
respectively) was present..
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Cumulative fluid balance over the first 7 days by fluid-management group (median
values and interquartile range).
Grams ME, et al.: Clin J Am Soc Nephrol. 2011. 6(5):966-973.
August,13,2018
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Fluid balance and mortality
• The conclusion of this study: Patients
who can be stabilized with less
volume resuscitation fare better.
August,13,2018
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Agenda
• AKI: Prognosis
• Fluid balance
•Selection of Resuscitation Fluid
August,13,2018
KOkasha

Fluid Management in ICU, Kamal Okasha 27/2/2018
1. Acute resuscitation
 Goal is restoration of effective intravascular volume, organ perfusion
and tissue oxygenation.
 Fluid accumulation and a positive fluid balance.
2. Maintenance
 Goal is maintenance of the intravascular volume.
 Prevent unnecessary fluid loading and mitigate fluid accumulation.
3. Fluid removal
 Goal is ‘active de-escalation’ with fluid removal.
 Secondary organ injury may result from failure to remove unnecessary volume.
Hoste EA, Maitland K, Brudney CS, Mehta R, Vincent JL, Yates D, Kellum JA, Mythen MG, Shaw AD: Three
phases of intravenous fluid therapy: a conceptual model. Br J Anaesth 2014; 113: 740–747.
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Types of Fluids
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Fluids - Crystalloids and Colloids
Myburgh JA, Mythen MG: Resuscitation fluids. N Engl J Med 2013; 369: 1243–1251.
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• Cross sectional study of 391 ICUs in 25 countries to describe the types of fluids
administered during fluid resuscitation.
• Data collected in 2007 and published in 2010.
• Findings in a 24 hour period:
• 37.1% of patients received resuscitation fluid.
• Main indicators for administering crystalloid or colloid were impaired perfusion
(45%) or to correct abnormal vital signs (35%).
• Overall
• Colloid given to more patients than crystalloids (23 vs 15%) and Colloid given in
more episodes than crystalloid (48 vs 33%).
• The choice of fluid was most strongly related to location of the prescriber.
Finfer S, Liu B, Taylor C, Bellomo R, Billot L, Cook D, Du B, McArthur C, Myburgh J; SAFE TRIPS Investigators:
Resuscitation fluid use in critically ill adults: an international cross sectional study in 391 intensive care units. Crit
Care 2010; 14:R185.
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Selection of Resuscitation Fluid
• The Saline versus Albumin Fluid Evaluation (SAFE) randomized,
double-blind trial in medical and surgical ICUs in Australia and
New Zealand compared resuscitation in 7000 critically ill
patients with normal saline versus 4% human albumin
The SAFE Study Investigators: N Engl J Med, 2004. 350: 2247–2256.
August,13,2018
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Selection of Resuscitation Fluid
• The study demonstrated that albumin was safe, but there was no
difference in 28-day survival between saline and albumin
administration
• There were also no differences in number of days spent in the ICU or
hospital, and the days on mechanical ventilation were also
comparable.
• Because isotonic saline is less expensive than albumin, the
consensus has emerged that isotonic crystalloid solutions should be
the preferred resuscitation fluid in critically ill patients.
The SAFE Study Investigators: N Engl J Med, 2004. 350: 2247–2256.
August,13,2018
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August,13,2018
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• In cirrhotic patients who develop spontaneous bacterial
peritonitis, a randomized study compared antibiotic
alone (cefatoxine) versus the same antibiotic plus
albumin (1.5 g/kg immediately on diagnosis, then 1 g/kg
on day 3).
• The addition of albumin therapy
decreased renal failure and improved
survival.
Sort P, et al.: N Engl J Med, 1999. 341: 403–409.
August,13,2018
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HES
• Hydroxyethyl starch (HES) is a less expensive colloid alternative for
albumin.
• However, HES has negative effects on coagulation
and causes an “osmotic nephrosis” that can lead
to renal impairment
Dickenmann M, et al.: Am J Kidney Dis, 2008. 51: 491–503.
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• The fact that saline increases chloride levels more than
balanced crystalloids is likely the prime factor.
• There has been a hypothesis that balanced crystalloids are
more aligned with human blood, and there were theories
about why that might be better for use in humans.
August,13,2018
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• In the Isotonic Solutions and Major Adverse Renal Events
Trial (SMART), 15,802 adults treated in five ICUs at a
single academic center were assessed.
• The primary outcome of the trial was:
• major adverse kidney events within 30 days, defined as death,
new renal replacement therapy, or persistent renal dysfunction (a
doubling of creatinine from baseline)
• in the 30 days after administration and before hospital discharge.
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• Patients who received balanced crystalloids were more likely
to meet the primary outcome than those who received saline.
• There were fewer in-hospital deaths in the crystalloid group
than in the saline group
August,13,2018
KOkasha

Fluid Overload in AKI
• Although early fluid resuscitation is frequently necessary in
patients with severe sepsis or septic shock, several
observational studies have demonstrated a correlation
between fluid overload and mortality in critically ill adults and
children with AKI.
Brandstrup B, et al.: Ann Surg, 2003. 238: 641–648.
Foland JA, et al.: Crit Care Med, 2004. 32: 1771–1776.
Van Biesen W, et al.: J Nephrol, 2005. 18: 54–60.
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• A prospective, multicenter observational study of 618 critically
ill patients examined the effect of fluid overload
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Cumulative probability of survival by fluid overload status.
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Mortality rate by final fluid accumulation relative to baseline weight and
stratified by dialysis status
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Mortality rate by categorical percentage of dialysis days with fluid overload
August,13,2018
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Conclusion
• The clinical and physiological studies cited above demonstrate
that the ideal fluid strategy in AKI has not been developed.
• Early protocol-designed fluid resuscitation may prevent the
occurrence of AKI, particularly in patients with severe sepsis
and septic shock.
• The preferred evidence-based resuscitation fluid is a
crystalloid solution.
August,13,2018
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Conclusion
• Persistent fluid overload in AKI patients may lead to hypoxia,
mechanical ventilation, ARDS, and increased mortality.
• Judicious fluid removal, may improve survival in AKI patients
secondary to improved pulmonary, cardiac, and renal
function.
• The effects of conservative versus liberal fluid administration
on mortality in patients with AKI… studies.
• Balanced crystalloids are more aligned with human blood and
might be better for use in humans.
August,13,2018
KOkasha

•Thank you
August,13,2018
KOkasha

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