Fluid balance and acute kidney injury

Abstract

Intravenous fluids are widely administered to patients who have, or are at risk of, acute kidney injury (AKI). However, deleterious consequences of overzealous fluid therapy are increasingly being recognized. Salt and water overload can predispose to organ dysfunction, impaired wound healing and nosocomial infection, particularly in patients with AKI, in whom fluid challenges are frequent and excretion is impaired. In this Review article, we discuss how interstitial edema can further delay renal recovery and why conservative fluid strategies are now being advocated. Applying these strategies in critical illness is challenging. Although volume resuscitation is needed to restore cardiac output, it often leads to tissue edema, thereby contributing to ongoing organ dysfunction. Conservative strategies of fluid management mandate a switch towards neutral balance and then negative balance once hemodynamic stabilization is achieved. In patients with AKI, this strategy might require renal replacement therapy to be given earlier than when more-liberal fluid management is used. However, hypovolemia and renal hypoperfusion can occur in patients with AKI if excessive fluid removal is pursued with diuretics or extracorporeal therapy. Thus, accurate assessment of fluid status and careful definition of targets are needed at all stages to improve clinical outcomes. A conservative strategy of fluid management was recently tested and found to be effective in a large, randomized, controlled trial in patients with acute lung injury. Similar randomized, controlled studies in patients with AKI now seem justified.

Key Points

  • Fluid therapy is common in patients at risk of acute kidney injury (AKI)

  • Prolonged fluid resuscitation leads to edema in the kidneys and other organs

  • Fluid overload is associated with increased morbidity

  • An early transition to a fluid-restrictive strategy might be beneficial in patients with AKI

  • Fluid removal in patients with or at risk of AKI should be implemented with appropriate monitoring

  • Biomarkers and/or novel fluid assessment methods might contribute to safer fluid management

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Figure 1: Normal glomerular hemodynamics.
Figure 2: Pathological sequelae of fluid overload in organ systems.
Figure 3: Cumulative fluid balances achieved in the FACTT trial of liberal (more-conventional) versus conservative (more-restrictive) fluid management strategies in critically ill patients with acute lung injury.88

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Acknowledgements

Désirée Lie, University of California, Orange, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the MedscapeCME-accredited continuing medical education activity associated with this article.

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Correspondence to Rinaldo Bellomo.

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Systematic search strategy used to identify clinical studies (shown in Table 2) that examine fluid balance or therapy in critically ill adults. (DOC 51 kb)

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Prowle, J., Echeverri, J., Ligabo, E. et al. Fluid balance and acute kidney injury. Nat Rev Nephrol 6, 107–115 (2010). https://doi.org/10.1038/nrneph.2009.213

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