Excessive Positive Fluid Balance Has A Negative Effect On Short-Term Renal Outcomes After Kidney Transplantation

Background: Optimized postoperative fluid management is important for maintaining early allograft function after kidney transplantation (KT). However, there is still no clear guidance regarding fluid treatment after KT. In this study, we investigated the effect of perioperative fluid balance on postoperative allograft function.Methods: Recipients who underwent KT between March 2012 and August 2018 were included, and their medical records were reviewed retrospectively. We calculated fluid balance, which is the difference between total input and output during the 3 days after KT, and analyzed the change in estimated glomerular filtration rate (eGFR) according to fluid balance.Results: A total of 178 patients were included after excluding those with delayed graft function or urine output <2000 ml on the first day after KT. Among them, 116 received kidneys from living donors and 62 received kidneys from deceased donors. The total fluid balance up to day 3 was 4,236.9 ± 2830.4 ml. Old age, high body mass index (BMI), excessive positive fluid balance of the recipient, and high final creatinine of the donor were significantly associated with low eGFR at 1 week. In addition, old age, BMI, and fluid balance of the recipient predicted the 1-month eGFR. In multivariate analysis, an excessive positive fluid balance was an independent predictor of low 1-week eGFR (p=0.031). Conclusions: This study demonstrated that excessive positive fluid balance can negatively affect early graft function after KT. Proper fluid management strategies based on volume conditions may provide important therapeutic opportunities to improve early renal outcomes after KT.

Relationship Between Fluid Therapy Strategies and Mortality Among Sepsis Patients in ICU with high CVP: A Retrospective Analysis of the eICU Database

Objective: It is still debated whether sepsis patients with high CVP (central venous pressure) benefit from it. We performed a retrospective study of sepsis patients with CVP ≥ 12 mmHg to analyze mortality resulting from the different amounts of fluid administered in the fluid therapy at the first 6, 24, and 48 h of the course.Methods: This study included sepsis patients from the eICU database who met the sepsis-3 diagnostic criteria and showed CVP ≥ 12 mmHg on admission. We analyzed the differences between the survivors and the non-survivors at baseline and the difference in fluid balance at 6, 24, and 48 h. Restricted cubic spline (RCS) and logistic regression model were used to identify the association between fluid balance and mortality.Results: Out of the 1150 sepsis patients that showed a high CVP obtained from the eICU database, 847 were survivors and 303 were non-survivors. Compared to survivors, non-survivors had a larger positive fluid balance at 6, 24, and 48 h. The fluid balance and mortality in sepsis patients with high CVP showed an inverted U-type relationship. At 6 h, lower mortality was found in patients who required less than -5 ml/kg fluid therapy. At 24 h, mortality was the lowest at -40~-20 ml/kg. At 48 h, low mortality was observed in patients with < -40 ml/kg fluid balance. In septic shock patients with high CVP, positive balance decrease mortality. In sepsis patients with high CVP without a history of chronic heart failure, and with a history of heart failure negative fluid balance can decrease mortality.Conclusion: In the sepsis group without shock, achieving negative fluid balance possible may significantly improve the prognosis of patients with high CVP, and patients with no history of chronic heart failure and patients with history of chronic heart failure should limit fluid infusion. In patients with septic shock whose CVP ≥ 12 mmHg, positive fluid balance may decrease mortality.

A quantitative analysis of extension and distribution of lung injury in COVID-19: a prospective study based on chest computed tomography

Background Typical features differentiate COVID-19-associated lung injury from acute respiratory distress syndrome. The clinical role of chest computed tomography (CT) in describing the progression of COVID-19-associated lung injury remains to be clarified. We investigated in COVID-19 patients the regional distribution of lung injury and the influence of clinical and laboratory features on its progression. Methods This was a prospective study. For each CT, twenty images, evenly spaced along the cranio-caudal axis, were selected. For regional analysis, each CT image was divided into three concentric subpleural regions of interest and four quadrants. Hyper-, normally, hypo- and non-inflated lung compartments were defined. Nonparametric tests were used for hypothesis testing (α = 0.05). Spearman correlation test was used to detect correlations between lung compartments and clinical features. Results Twenty-three out of 111 recruited patients were eligible for further analysis. Five hundred-sixty CT images were analyzed. Lung injury, composed by hypo- and non-inflated areas, was significantly more represented in subpleural than in core lung regions. A secondary, centripetal spread of lung injury was associated with exposure to mechanical ventilation (p < 0.04), longer spontaneous breathing (more than 14 days, p < 0.05) and non-protective tidal volume (p < 0.04). Positive fluid balance (p < 0.01), high plasma D-dimers (p < 0.01) and ferritin (p < 0.04) were associated with increased lung injury. Conclusions In a cohort of COVID-19 patients with severe respiratory failure, a predominant subpleural distribution of lung injury is observed. Prolonged spontaneous breathing and high tidal volumes, both causes of patient self-induced lung injury, are associated to an extensive involvement of more central regions. Positive fluid balance, inflammation and thrombosis are associated with lung injury. Trial registration Study registered a priori the 20th of March, 2020. Clinical Trials ID NCT04316884.

Fluid Overload

Fluid overload (FO) is characterized by hypervolemia, edema, or both. In clinical practice it is usually suspected when a patient shows evidence of pulmonary edema, peripheral edema, or body cavity effusion. FO may be a consequence of spontaneous disease, or may be a complication of intravenous fluid therapy. Most clinical studies of the association of FO with fluid therapy and risk of harm define it in terms of an increase in body weight of at least 5–10%, or a positive fluid balance of the same magnitude when fluid intake and urine output are measured. Numerous observational clinical studies in humans have demonstrated an association between FO, adverse events, and mortality, as have two retrospective observational studies in dogs and cats. The risk of FO may be minimized by limiting resuscitation fluid to the smallest amount needed to optimize cardiac output and then limiting maintenance fluid to the amount needed to replace ongoing normal and pathological losses of water and sodium.

Association of fluid balance with mortality in sepsis is modified by admission hemoglobin levels: A large database study

Purpose Sepsis involves a dysregulated inflammatory response to infection that leads to organ dysfunction. Early fluid resuscitation has been advocated by the Surviving Sepsis Campaign guidelines. However, recent studies have shown that a positive fluid balance is associated with increased mortality in septic patients. We investigated if haemoglobin levels on admission to the intensive care unit (ICU) could modify the association of fluid balance with mortality in patients with sepsis. We hypothesized that with increasing fluid balance, patients with moderate anemia (hemoglobin 7-10g/dL) would have poorer outcomes compared to those without moderate anemia (hemoglobin >10g/dL). Materials and methods This retrospective study utilized the Medical Information Mart for Intensive Care-III (MIMIC-III) database. Patients with sepsis, as identified by the International Classification of Diseases, 9th, Clinical Modification codes, were studied. Patients were stratified into those with and without moderate anemia at ICU admission. We investigated the influence of fluid balance measured within 24 hours of ICU admission on 28-day mortality for both patient groups using multivariable logistic regression models. Subgroup and sensitivity analyses were conducted. Results 8,132 patients (median age 68.6 years, interquartile range 55.1–79.8 years; 52.8% female) were included. Increasing fluid balance (in L) was associated with a significantly decreased risk of 28-day mortality in patients without moderate anemia (OR 0.91, 95%CI 0.84–0.97, p = 0.005, at 6-hour). Conversely, increasing fluid balance was associated with a significantly increased risk of 28-day mortality in patients with moderate anemia (OR 1.05, 95% CI 1.01–1.1, p = 0.022, at 24-hour). Interaction analyses showed that mortality was highest when haemoglobin decreased in patients with moderate anemia who had the most positive fluid balance. Multiple subgroups and sensitivity analyses yielded consistent results. Conclusions In septic patients admitted to ICU, admission hemoglobin levels modified the association between fluid balance and mortality and are an important consideration for future fluid therapy trials.

The Association between Daily Fluid Balance and Mean Perfusion Pressure as a Critical Sign in the Intensive Care Unit of Adam Malik Central Hospital, Medan

BACKGROUND: The patient mortality rate in intensive care unit (ICU) is still high. However, we still lack measures to reduce this high mortality rate. Fluid balance is known as a marker for mortality in ICU. If the balance of fluid becomes more positive, the mortality rate consequently becomes higher. Positive fluid balance elevates central venous pressure (CVP), while this elevation increases the risk of renal failure and mortality. Mean perfusion pressure (MPP) is the difference between mean arterial pressure and CVP. AIM: We propose that the MPP value can be used as an alternative indicator to monitor excessive fluid balance since its measurement is faster and more accurate than the manual 24 h record of fluid balance. PATIENTS AND METHODS: It is expected that we can prevent excessive fluid accumulation and the subsequent mortality risk by monitoring MPP in the ICU. To investigate the association between MPP and daily fluid balance in the ICU, a prospective study was conducted from March 2016 to August 2018 in the ICU of Adam Malik Hospital, Medan. During the study period, 76 patients were admitted. Sixty-point 5% were male, with the mean age of 48.3 ± 16.5 years old. RESULTS: The overall mortality of 76 patients was 10.5%, and there was a significant negative correlation found between MPP and fluid balance (r = −0.204; p = 0.048), where a lower MPP value was associated with a more positive fluid balance. CONCLUSIONS: We conclude that there is a negative correlation between MPP and fluid balance, where a more positive fluid balance is associated with a lower MPP value. The positive fluid balance had been previously associated with increased mortality risk in the ICU.

Examination of the association of steroids with fluid accumulation in critically ill patients, considering the possibility of biases

Glucocorticoids might have significant influence on positive fluid balance, mostly due to their mineralocorticoid effect. We assessed the association between glucocorticoid therapy and fluid balance in septic patients, in the intensive care unit (ICU). We considered two definitions of exposure: daily exposure to glucocorticoids and glucocorticoid treatment at any time. Of 945 patients, 375 were treated with glucocorticoids in the ICU. We applied four regression models. In the first, fluid balance did not differ during days with and without glucocorticoid treatment, among patients treated and not treated with glucocorticoids in the ICU. In our second model, daily fluid balance was increased in patients who were ever treated with glucocorticoids during their ICU stay compared to untreated patients. In the third model, which included only patients treated with glucocorticoids during their ICU stay, glucocorticoid treatment days were not associated with daily fluid balance. In the last model, on "steroid-free days", patients who received glucocorticoid treatment during their ICU stay had a positive fluid balance compared to those who were never treated with steroids. Despite their known mineralocorticoid activity, glucocorticoids themselves appear not to contribute substantially to fluid retention. This work highlights the importance of precise selection of variables to mitigate biases.