Eric Hoste

2. •Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI

3. N Engl J Med 2004

5. •EGDT: fluids are good & prevent AKI
Lin et al, Shock 2006

6. Prowle et al Crit Care Med 2012
RF in non AKI
RRT: 9
Anuria: 3
CrCl>60 mL/min: 2
Phase-contrast MRI
10 septic AKI patients
11 normal volunteers

7. •Renal Plasma Flow and GFR
Prowle et al. Renal Failure 2010
Systematic review
Human studies
22 articles
250 patients

8. •RBF decreased in sepsis and early AKI?
Langenberg et al. Kidney Int 2006
7 Sheep
E. Coli infusion

9. •EGDT and AKI
Prowle et al. Crit Care 2012

10. •Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI

11. •Fluid bolus? The FEAST trial
Maitland et al. NEJM 2011
N = 3141 children
Severe infection

12. Conservative Liberal P
7 d volume balance (mL) -136 mL ± 491 +6992 ± 502 <0.001
Death at 60 days 25.5% 28.4% 0.30
Ventilator free days 14.6 ± 0.5 12.1 ± 0.5 <0.001
ICU free days:
Day 1-7 0.9 ± 0.1 0.6 ± 0.1 <0.001
Day 1-28 13.4 ± 0.4 11.2 ± 0.4 <0.001
Wiedemann, N Engl J Med 2006

13. •Fluid-Management in ARDS
0%
4%
8%
12%
16%
conservative liberal
RRT to day 60
P = 0.06
Wiedemann et al. N Engl J Med 2006

14. •Venous pressure &  renal bloodflow
Winton, J Physiol 1931

15. •AKI & CVP, CI, systolic BP, & PCWP
Mullens et al. JACC 2009
CVP
CI
PCWPSBP

16. •AKI & CVP, CI, systolic BP, & PCWP
Mullens et al. JACC 2009
CVP
CI
PCWPSBP

17. •Volume and outcome in AKI-RRT
0%
10%
20%
30%
40%
50%
60%
70%
<0 0-5 5-10 10-15 >15
90-dmortality
Fluid accumulation (% of body weight)
Bouchard et al. KI 2009, Payen et al. Crit Care 2008,
Grams et al. CJASN 2011, Vaara et al. Crit Care 2012

18. •Negative FB during CRRT is good
Bellomo et al. Crit Care Med 2012

19. •Negative FB during CRRT is good
Bellomo et al. Crit Care Med 2012

20. •Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI

21. •Summary Recent PRCT’s HES
Study N Survival
AKI Other side effects
Magder, CABG
10% HES 250/0,5
262 Less Better HD
FIRST, trauma
6% HES 130/0,4
67 P
42 B
Less
Same
Better lactate 
More blood
CRYSTMAS severe sepsis
6% HES 130/0,4
196 Same
6S severe sepsis
6% HES 130/0,42
798 Worse More More blood
CHEST ICU
6% HES 130/0,4
7000 Same More Liver, pruritus, blood
products
Magder et al Crit Care Med 2010, James et al. J Trauma 2011, Guidet et al.
Crit Care 2012, Perner et al. NEJM 2012, Myburgh et al. NEJM 2012

22. •AKI after gelatin
Schabinski et al. Intensive Care Med 2009
Observational
N = 1383 HES
N = 1528 GEL
MVR adjusted Risk for AKI after >33mL/kg
GEL: OR 1.99 (1.05-3.79)
HES: OR 1.85 (1.01 – 3.41)

23. •PRCT’s on albumin
n Survival
AKI Bleeding/coag
ulation
SAFE 6997 Same More PC
SAFE TBI 460 Worse More PC
FEAST sepsis 3141 Worse
SAFE severe sepsis 1218 No diff (trend) No diff No diff
CRYSTMAS severe sepsis 196 No diff No diff
EARSS severe sepsis 792 No diff No diff
ALBIOS severe sepsis 1818 No diff No diff No diff

24. •Saline vs. Plasmalyte ®?
Shaw et al. Ann Surg 2012
Saline = More complications and use of resources:
 Major infection
 Dialysis
 Blood transfusions
 Electrolyte disturbances
N = 30,994 vs. 926
Major abd surgery

25. •Chloride liberal/restrictive fluid therapy
AKI stage 2-3
Yunos et al. JAMA 2012

26. •Take home messages
Fluids and AKI: just enough!
Not too little
Not too much
Fluids and AKI: beware for the ugly.

28. •Thank you for your attention!
Eric.hoste@ugent.be

29. •Fluids & AKI
Fluids are GOOD
Volume overload is BAD
UGLY Fluids cause AKI

30. To pee or not to pee: Fluids & AKI
Eric Hoste MD, PhD
Ghent University
Hospital

31. •CHEST: HES 130/0.4 vs. Saline
Myburgh et al. NEJM 2012
HES Saline

33. •CHEST: HES 130/0.4 vs. Saline
Myburgh et al. NEJM 2012
HES Saline

36. Perner et al. NEJM 2012