Journal of Nephrology

, Volume 29, Issue 2, pp 221–227 | Cite as

The impact of fluid balance on diagnosis, staging and prediction of mortality in critically ill patients with acute kidney injury

  • Charat Thongprayoon
  • Wisit Cheungpasitporn
  • Narat Srivali
  • Patompong Ungprasert
  • Wonngarm Kittanamongkolchai
  • Kianoush Kashani
Original Article



Fluid accumulation may delay recognition of acute kidney injury (AKI) in intensive care unit (ICU) patients. This study aims to evaluate the impact of fluid balance on the incidence, time of AKI diagnosis and predictive performance for outcomes of critically ill patients.


This study included a cohort of 7696 adult ICU patients at Mayo Clinic Hospital in year 2011 with at least one serum creatinine (SCr) measured in ICU. AKI was defined based on SCr criterion for stage I of KDIGO definition. The AKI incidence and predictive performance for 60-day mortality was compared before and after SCr adjustment for fluid balance.


AKI was detected in 1860 (24.2 %) before and 1947 (25.3 %) after fluid balance adjustment (P < 0.001). Patients with AKI both before and after SCr adjustment had significantly higher 60-day mortality in comparison with patients who did not develop AKI (OR 3.38; 95 % CI 2.84–4.02). The risk of 60-day mortality in patients who met AKI criteria after but not before SCr adjustment was significantly higher than patients without AKI (OR 2.00; 95 % CI 1.25–3.11). In contrast, the risk of 60-day mortality in patients who met AKI criteria before but not after SCr adjustment was similar to patients without AKI (OR 1.19; 95 % CI 0.48–2.50). The C-statistic for unadjusted and adjusted SCr to predict 60-day mortality were 0.68 and 0.70, respectively (P = 0.001).


Our study found that SCr adjustment for fluid balance could result in a more accurate detection of AKI cases. We suggest using fluid balance adjustment for volume overload critically ill patients.


Acute kidney injury Creatinine Fluid balance Mortality 


Conflict of interest


Ethical standards

All procedures performed in this study 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 all individual subjects included in the study.

Supplementary material

40620_2015_211_MOESM1_ESM.docx (36 kb)
Supplementary material 1 (DOCX 36 kb)


  1. 1.
    KDIGO AKI Work Group (2012) KDIGO clinical practice guidelines for acute kidney injury. Kidney Int suppl 2:1–138Google Scholar
  2. 2.
    Srisawat N, Kellum JA (2011) Acute kidney injury: definition, epidemiology, and outcome. Curr Opin Crit Care 17:548–555CrossRefPubMedGoogle Scholar
  3. 3.
    Chertow GM, Burdick E, Honour M, Bonventre JV, Bates DW (2005) Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. J Am Soc Nephrol 16:3365–3370CrossRefPubMedGoogle Scholar
  4. 4.
    Ricci Z, Cruz D, Ronco C (2008) The RIFLE criteria and mortality in acute kidney injury: a systematic review. Kidney Int 73:538–546CrossRefPubMedGoogle Scholar
  5. 5.
    Ricci Z, Cruz DN, Ronco C (2011) Classification and staging of acute kidney injury: beyond the RIFLE and AKIN criteria. Nat Rev Nephrol 7:201–208CrossRefPubMedGoogle Scholar
  6. 6.
    Thongprayoon C, Cheungpasitporn W, Akhoundi A, Ahmed AH, Kashani KB (2014) Actual versus ideal body weight for acute kidney injury diagnosis and classification in critically Ill patients. BMC Nephrol 15:176CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Susantitaphong P, Cruz DN, Cerda J et al (2013) World incidence of AKI: a meta-analysis. Clin J Am Soc Nephrol 8:1482–1493CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P (2004) Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 8:R204–R212CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Mehta RL, Kellum JA, Shah SV et al (2007) Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 11:R31CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Lassnigg A, Schmidlin D, Mouhieddine M et al (2004) Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 15:1597–1605CrossRefPubMedGoogle Scholar
  11. 11.
    Koyner JL, Bennett MR, Worcester EM et al (2008) Urinary cystatin C as an early biomarker of acute kidney injury following adult cardiothoracic surgery. Kidney Int 74:1059–1069CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Bellomo R, Raman J, Ronco C (2001) Intensive care unit management of the critically ill patient with fluid overload after open heart surgery. Cardiology 96:169–176CrossRefPubMedGoogle Scholar
  13. 13.
    Liu KD, Thompson BT, Ancukiewicz M et al (2011) Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes. Crit Care Med 39:2665–2671CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Macedo E, Bouchard J, Soroko SH et al (2010) Fluid accumulation, recognition and staging of acute kidney injury in critically-ill patients. Crit Care 14:R82CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Levey AS, Stevens LA, Schmid CH et al (2009) A new equation to estimate glomerular filtration rate. Ann Intern Med 150:604–612CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Knaus WA, Wagner DP, Draper EA et al (1991) The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 100:1619–1636CrossRefPubMedGoogle Scholar
  17. 17.
    Ferreira FL, Bota DP, Bross A, Melot C, Vincent JL (2001) Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 286:1754–1758CrossRefPubMedGoogle Scholar
  18. 18.
    Wentworth DN, Neaton JD, Rasmussen WL (1983) An evaluation of the Social Security Administration master beneficiary record file and the National Death Index in the ascertainment of vital status. Am J Public Health 73:1270–1274CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Hoste EA, Clermont G, Kersten A et al (2006) RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care 10:R73CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Coca SG, Peixoto AJ, Garg AX, Krumholz HM, Parikh CR (2007) The prognostic importance of a small acute decrement in kidney function in hospitalized patients: a systematic review and meta-analysis. Am J Kidney Dis 50:712–720CrossRefPubMedGoogle Scholar
  21. 21.
    Weisbord SD, Palevsky PM (2006) Acute renal failure in the intensive care unit. Semin Respir Crit Care Med 27:262–273CrossRefPubMedGoogle Scholar
  22. 22.
    Fliser D, Laville M, Covic A et al (2012) A European Renal Best Practice (ERBP) position statement on the Kidney Disease Improving Global Outcomes (KDIGO) clinical practice guidelines on acute kidney injury: part 1: definitions, conservative management and contrast-induced nephropathy. Nephrol Dial Transplant 27:4263–4272CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Odden MC, Shlipak MG, Tager IB (2009) Serum creatinine and functional limitation in elderly persons. J Gerontol A Biol Sci Med Sci 64:370–376CrossRefPubMedGoogle Scholar
  24. 24.
    Englberger L, Suri RM, Li Z et al (2011) Clinical accuracy of RIFLE and Acute Kidney Injury Network (AKIN) criteria for acute kidney injury in patients undergoing cardiac surgery. Crit Care 15:R16CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Ho J, Reslerova M, Gali B et al (2012) Serum creatinine measurement immediately after cardiac surgery and prediction of acute kidney injury. Am J Kidney Dis 59:196–201CrossRefPubMedGoogle Scholar
  26. 26.
    Bouchard J, Soroko SB, Chertow GM et al (2009) Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 76:422–427CrossRefPubMedGoogle Scholar
  27. 27.
    Plataki M, Kashani K, Cabello-Garza J et al (2011) Predictors of acute kidney injury in septic shock patients: an observational cohort study. Clin J Am Soc Nephrol 6:1744–1751CrossRefPubMedGoogle Scholar
  28. 28.
    Bagshaw SM, Uchino S, Bellomo R et al (2007) Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. Clin J Am Soc Nephrol 2:431–439CrossRefPubMedGoogle Scholar
  29. 29.
    Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M (2012) Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 308:1566–1572CrossRefPubMedGoogle Scholar
  30. 30.
    Devarajan P (2008) Neutrophil gelatinase-associated lipocalin (NGAL): a new marker of kidney disease. Scand J Clin Lab Invest Suppl 241:89–94CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Matsui K, Kamijo-Ikemorif A, Sugaya T, Yasuda T, Kimura K (2011) Renal liver-type fatty acid binding protein (L-FABP) attenuates acute kidney injury in aristolochic acid nephrotoxicity. Am J Pathol 178:1021–1032CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Han WK, Bailly V, Abichandani R, Thadhani R, Bonventre JV (2002) Kidney injury molecule-1 (KIM-1): a novel biomarker for human renal proximal tubule injury. Kidney Int 62:237–244CrossRefPubMedGoogle Scholar
  33. 33.
    Kashani K, Al-Khafaji A, Ardiles T et al (2013) Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care 17:R25CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Italian Society of Nephrology 2015

Authors and Affiliations

  • Charat Thongprayoon
    • 1
  • Wisit Cheungpasitporn
    • 1
  • Narat Srivali
    • 2
  • Patompong Ungprasert
    • 3
  • Wonngarm Kittanamongkolchai
    • 1
  • Kianoush Kashani
    • 1
    • 2
  1. 1.Division of Nephrology and HypertensionMayo ClinicRochesterUSA
  2. 2.Division of Pulmonary and Critical Care MedicineMayo ClinicRochesterUSA
  3. 3.Division of RheumatologyMayo ClinicRochesterUSA

Personalised recommendations