Abstract
Intravenous fluids are widely administered to maintain renal perfusion and prevent acute kidney injury (AKI). However, fluid overload is of concern during AKI. Using the Pubmed database (up to October 2011) we identified all randomised controlled studies of goal-directed therapy (GDT)-based fluid resuscitation (FR) reporting renal outcomes and documenting fluid given during perioperative care. In 24 perioperative studies, GDT was associated with decreased risk of postoperative AKI (odds ratio (OR) = 0.59, 95% confidence interval (CI) = 0.39 to 0.89) but additional fluid given was limited (median: 555 ml). Moreover, the decrease in AKI was greatest (OR = 0.47, 95% CI = 0.29 to 0.76) in the 10 studies where FR was the same between GDT and control groups. Inotropic drug use in GDT patients was associated with decreased AKI (OR = 0.52, 95% CI = 0.34 to 0.80, P = 0.003), whereas studies not involving inotropic drugs found no effect (OR = 0.75, 95% CI = 0.37 to 1.53, P = 0.43). The greatest protection from AKI occurred in patients with no difference in total fluid delivery and use of inotropes (OR = 0.46, 95% CI = 0.27 to 0.76, P = 0.0036). GDT-based FR may decrease AKI in surgical patients; however, this effect requires little overall FR and appears most effective when supported by inotropic drugs.
Highlights
Acute kidney injury (AKI) is a common condition and, even when mild, is associated with mortality and morbidity [1]
We aimed to determine whether such protocols have a beneficial effect on renal function and to what extent this treatment involves increased fluid administration in comparison with control groups treated according to the standard of care
Among the surgical studies not meeting the inclusion criteria, three recent studies examined a more restrictive perioperative maintenance fluid infusion combined with the use of goal-directed therapy (GDT) in one or both groups to facilitate a conservative maintenance fluid regimen [44,45,46]
Summary
Acute kidney injury (AKI) is a common condition and, even when mild, is associated with mortality and morbidity [1]. Fluid therapy is aimed at restoring systemic blood pressure (a major determinant of renal perfusion pressure) and cardiac output (a prerequisite for adequate renal blood flow (RBF)). Fluid administration aimed at restoring systemic blood pressure works mechanistically by increasing the preload and stroke volume. The effects of critical illness, pre-existing chronic disease and pharmacotherapy can unpredictably alter physiological determinants of fluid responsiveness. These effects make the effects of FR variable in extent and duration, and make the assessment of adequacy of FR very challenging
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