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Early fluid overload is associated with acute kidney injury and PICU mortality in critically ill children

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Abstract

Fluid overload (FO) has been associated with an increased risk for adverse outcomes in critically ill patients. Information on the impact of FO on mortality in a general population of pediatric intensive care unit (PICU) is limited. We aimed to determine the association of early FO with the development of acute kidney injury (AKI) and mortality during PICU stay and evaluate whether early FO predicts mortality, even after adjustment for illness severity assessed by pediatric risk of mortality (PRISM) III. This prospective study enrolled 370 critically ill children. The early FO was calculated based on the first 24-h total of fluid intake and output after admission and defined as cumulative fluid accumulation ≥5 % of admission body weight. Of the patients, 64 (17.3 %) developed early FO during the first 24 h after admission. The PICU mortality rate of the whole cohort was 18 of 370 (4.9 %). The independent factors significantly associated with early FO were PRISM III, age, AKI, and blood bicarbonate level. The early FO was associated with AKI (odds ratio [OR] = 1.34, p < 0.001) and mortality (OR = 1.36, p < 0.001). The association of early FO with mortality remained significant after adjustment for potential confounders including AKI and illness severity. The area under the receiver operating characteristic curve (AUC) of early FO for predicting mortality was 0.78 (p < 0.001). This result, however, was not better than PRISM III (AUC = 0.85, p < 0.001).

Conclusion: Early FO was associated with increased risk for AKI and mortality in critically ill children.

What is Known:

• Fluid overload is associated with an increased risk for adverse outcomes in specific clinical settings of pediatric population.

What is New:

• Early fluid overload during the first 24 h after PICU admission is independently associated with increased risk for acute kidney injury and mortality in critically ill children.

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Abbreviations

AKI:

Acute kidney injury

AUC:

Area under the receiver operating characteristic curve

CI:

Confidence interval

CRRT:

Continuous renal replacement therapy

FO:

Fluid overload

MODS:

Multi-organ dysfunction syndrome

MV:

Mechanical ventilation

ROC:

Receiver operating characteristic

IQR:

Interquartile range

OR:

Odds ratio

PICU:

Pediatric intensive care unit

PRISM III:

Pediatric Risk of Mortality III

VIF:

Variance inflation factor

References

  1. Alkandari O, Eddington KA, Hyder A, Gauvin F, Ducruet T, Gottesman R, Phan V, Zappitelli M (2012) Acute kidney injury is an independent risk factor for pediatric intensive care unit mortality, longer length of stay and prolonged mechanical ventilation in critically ill children: a two-center retrospective cohort study. Crit Care 15:R146

    Article  Google Scholar 

  2. Arikan AA, Zappitelli M, Goldstein SL, Naipaul A, Jefferson LS, Loftis LL (2012) Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 13:253–258

    Article  PubMed  Google Scholar 

  3. Askenazi DJ, Koralkar R, Hundley HE, Montesanti A, Patil N, Ambalavanan N (2013) Fluid overload and mortality are associated with acute kidney injury in sick near-term/term neonate. Pediatr Nephrol 28:661–666

    Article  PubMed  Google Scholar 

  4. Bagshaw SM, Bellomo R, Kellum JA (2008) Oliguria, volume overload, and loop diuretics. Crit Care Med 36:S172–S178

    Article  PubMed  Google Scholar 

  5. Bagshaw SM, Brophy PD, Cruz D, Ronco C (2008) Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury. Crit Care 12:169

    Article  PubMed  PubMed Central  Google Scholar 

  6. Bai Z, Zhu X, Li M, Hua J, Li Y, Pan J, Wang J, Li Y (2014) Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr 14:83

    Article  PubMed  PubMed Central  Google Scholar 

  7. Basu RK, Chawla LS, Wheeler DS, Goldstein SL (2012) Renal angina: an emerging paradigm to identify children at risk for acute kidney injury. Pediatr Nephrol 27:1067–1078

    Article  PubMed  PubMed Central  Google Scholar 

  8. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL (2009) Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 76:422–427

    Article  PubMed  Google Scholar 

  9. Butcher BW, Liu KD (2012) Fluid overload in AKI: epiphenomenon or putative effect on mortality? Curr Opin Crit Care 18:593–598

    Article  PubMed  PubMed Central  Google Scholar 

  10. Chertow GM, Soroko SH, Paganini EP, Cho KC, Himmelfarb J, Ikizler TA, Mehta RL (2006) Mortality after acute renal failure: models for prognostic stratification and risk adjustment. Kidney Int 70:1120–1126

    Article  PubMed  CAS  Google Scholar 

  11. Clec'h C, Gonzalez F, Lautrette A, Nguile-Makao M, Garrouste-Orgeas M, Jamali S, Golgran-Toledano D, Descorps-Declere A, Chemouni F, Hamidfar-Roy R, Azoulay E, Timsit JF (2011) Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis. Crit Care 15:R128

    Article  PubMed  PubMed Central  Google Scholar 

  12. Foland JA, Fortenberry JD, Warshaw BL, Pettignano R, Merritt RK, Heard ML, Rogers K, Reid C, Tanner AJ, Easley KA (2004) Fluid overload before continuous hemofiltration and survival in critically ill children: a retrospective analysis. Crit Care Med 32:1771–1776

    Article  PubMed  Google Scholar 

  13. Gillespie RS, Seidel K, Symons JM (2004) Effect of fluid overload and dose of replacement fluid on survival in hemofiltration. Pediatr Nephrol 19:1394–1399

    Article  PubMed  Google Scholar 

  14. Goldstein B, Giroir B, Randolph A (2005) International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 6:2–8

    Article  PubMed  Google Scholar 

  15. Goldstein SL (2012) Fluid management in acute kidney injury. J Intensive Care Med 29:183–189

    Article  PubMed  Google Scholar 

  16. Goldstein SL, Somers MJ, Baum MA, Symons JM, Brophy PD, Blowey D, Bunchman TE, Baker C, Mottes T, McAfee N, Barnett J, Morrison G, Rogers K, Fortenberry JD (2005) Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 67:653–658

    Article  PubMed  Google Scholar 

  17. Goldstein SL, Currier H, Graf C, Cosio CC, Brewer ED, Sachdeva R (2001) Outcome in children receiving continuous venovenous hemofiltration. Pediatrics 107:1309–1312

    Article  PubMed  CAS  Google Scholar 

  18. Hassinger AB, Wald EL, Goodman DM (2014) Early postoperative fluid overload precedes acute kidney injury and is associated with higher morbidity in pediatric cardiac surgery patients. Pediatr Crit Care Med 15:131–138

    Article  PubMed  Google Scholar 

  19. Heung M, Wolfgram DF, Kommareddi M, Hu Y, Song PX, Ojo AO (2011) Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury. Nephrol Dial Transplant 27:956–961

    Article  PubMed  PubMed Central  Google Scholar 

  20. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A (2007) Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 11:R31

    Article  PubMed  PubMed Central  Google Scholar 

  21. Michael M, Kuehnle I, Goldstein SL (2004) Fluid overload and acute renal failure in pediatric stem cell transplant patients. Pediatr Nephrol 19:91–95

    Article  PubMed  Google Scholar 

  22. Pickering JW, Endre ZH (2010) Back-calculating baseline creatinine with MDRD misclassifies acute kidney injury in the intensive care unit. Clin J Am Soc Nephrol 5:1165–1173

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  23. Pollack MM, Patel KM, Ruttimann UE (1996) PRISM III: an updated pediatric risk of mortality score. Crit Care Med 24:743–752

    Article  PubMed  CAS  Google Scholar 

  24. Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R (2010) Fluid balance and acute kidney injury. Nat Rev Nephrol 6:107–115

    Article  PubMed  Google Scholar 

  25. Seguin J, Albright B, Vertullo L, Lai P, Dancea A, Bernier PL, Tchervenkov CI, Calaritis C, Drullinsky D, Gottesman R, Zappitelli M (2014) Extent, risk factors, and outcome of fluid overload after pediatric heart surgery. Crit Care Med

  26. Selewski DT, Cornell TT, Lombel RM, Blatt NB, Han YY, Mottes T, Kommareddi M, Kershaw DB, Shanley TP, Heung M (2011) Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 37:1166–1173

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  27. Singbartl K, Kellum JA (2012) AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int 81:819–825

    Article  PubMed  CAS  Google Scholar 

  28. Soler YA, Nieves-Plaza M, Prieto M, Garcia-De Jesus R, Suarez-Rivera M (2013) Pediatric risk, injury, failure, loss, end-stage renal disease score identifies acute kidney injury and predicts mortality in critically ill children: a prospective study. Pediatr Crit Care Med 14:e189–e195

    Article  PubMed  PubMed Central  Google Scholar 

  29. Stein A, de Souza LV, Belettini CR, Menegazzo WR, Viegas JR, Costa Pereira EM, Eick R, Araujo L, Consolim-Colombo F, Irigoyen MC (2012) Fluid overload and changes in serum creatinine after cardiac surgery: predictors of mortality and longer intensive care stay. A prospective cohort study. Crit Care 16:R99

    Article  PubMed  PubMed Central  Google Scholar 

  30. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55:316–325

    Article  PubMed  Google Scholar 

  31. Symons JM, Chua AN, Somers MJ, Baum MA, Bunchman TE, Benfield MR, Brophy PD, Blowey D, Fortenberry JD, Chand D, Flores FX, Hackbarth R, Alexander SR, Mahan J, McBryde KD, Goldstein SL (2007) Demographic characteristics of pediatric continuous renal replacement therapy: a report of the prospective pediatric continuous renal replacement therapy registry. Clin J Am Soc Nephrol 2:732–738

    Article  PubMed  Google Scholar 

  32. Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, Forfori F, Pelaia P, Rocco M, Ronco C, Anello CB, Bove T, Carlini M, Michetti V, Cruz DN (2013) Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care 17:R14

    Article  PubMed  PubMed Central  Google Scholar 

  33. Typpo KV, Petersen NJ, Hallman DM, Markovitz BP, Mariscalco MM (2009) Day 1 multiple organ dysfunction syndrome is associated with poor functional outcome and mortality in the pediatric intensive care unit. Pediatr Crit Care Med 10:562–570

    Article  PubMed  PubMed Central  Google Scholar 

  34. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C (2005) Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 294:813–818

    Article  PubMed  CAS  Google Scholar 

  35. Vaara ST, Korhonen AM, Kaukonen KM, Nisula S, Inkinen O, Hoppu S, Laurila JJ, Mildh L, Reinikainen M, Lund V, Parviainen I, Pettila V (2012) Fluid overload is associated with an increased risk for 90-day mortality in critically ill patients with renal replacement therapy: data from the prospective FINNAKI study. Crit Care 16:R197

    Article  PubMed  PubMed Central  Google Scholar 

  36. Wang JN, Wu JM, Chen YJ (2001) Validity of the updated pediatric risk of mortality score (PRISM III) in predicting the probability of mortality in a pediatric intensive care unit. Acta Paediatr Taiwan 42:333–337

    PubMed  CAS  Google Scholar 

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Compliance with ethical standards

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from the parents of all individual children included in the study.

Funding

This study was funded by the Natural Science Foundation for Research Projects in the Colleges and Universities of Jiangsu Province (12KJB320006), the Natural Science Foundation of Jiangsu Province (BK2012604), and the National Natural Science Foundation of China (81370773).

Conflict of interest

The authors declare that they have no competing interests.

Authors’ contributions

Dr. Yanhong Li had primary responsibility for study design, data analysis, interpretation of data, and writing of the manuscript. Dr. Jian Wang and Dr. Zhenjiang Bai participated in study design. Jiao Chen, Xueqin Wang, and Dr. Jian Pan were responsible for clinical data collection and participated in data analysis. Dr. Xiaozhong Li and Dr. Xing Feng participated in the design of the study and coordination. All authors read and approved the final manuscript.

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    Authors and Affiliations

    1. Department of Nephrology, Children’s Hospital of Soochow University, Suzhou, China

      Yanhong Li, Xueqin Wang & Xiaozhong Li

    2. Institute of Pediatric Research, Children’s Hospital of Soochow University, Suzhou, China

      Yanhong Li, Jian Wang & Jian Pan

    3. Pediatric Intensive Care Unit, Children’s Hospital of Soochow University, Suzhou, China

      Zhenjiang Bai & Jiao Chen

    4. Department of Neonatology, Children’s Hospital of Soochow University, Suzhou, China

      Xing Feng

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    1. Yanhong Li
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    Correspondence to Xiaozhong Li or Xing Feng.

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    Communicated by Patrick Van Reempts

    Xiaozhong Li and Xing Feng contributed equally to this work.

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    Li, Y., Wang, J., Bai, Z. et al. Early fluid overload is associated with acute kidney injury and PICU mortality in critically ill children. Eur J Pediatr 175, 39–48 (2016). https://doi.org/10.1007/s00431-015-2592-7

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    • DOI: https://doi.org/10.1007/s00431-015-2592-7

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