LACTATED RINGER'S VS SALINE AMONG CRITICALLY ILL ADULTS WITH CIRRHOSIS: A SECONDARY ANALYSIS OF THE ISOTONIC SOLUTIONS AND MAJOR ADVERSE RENAL EVENTS TRIAL

Abstract

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: The use of balanced crystalloids has been suggested to improve clinical outcomes among critically ill adults, compared to saline. However, some balanced crystalloids, such as lactated Ringer’s, include a significant concentration of lactate that could adversely impact patients with cirrhosis, who have an impaired ability to metabolize lactate. The purpose of this study was to determine, among critically ill patients with cirrhosis, the effect of lactated Ringer's, compared to saline, on plasma lactate levels, cirrhosis-related complications, and clinical outcomes. METHODS: We performed a secondary analysis of Isotonic Solutions and Major Adverse Renal Events Trial (SMART) using data from patients admitted to the medical intensive care unit with cirrhosis. A diagnosis of cirrhosis was determined using a screening algorithm that employed ICD-10 codes, followed by manual confirmation through chart review. SMART was a cluster-randomized, multiple-crossover trial that compared balanced crystalloids to saline for intravenous fluid administration among critically ill adults. The primary outcome of the SMART trial and this secondary analysis was major adverse kidney events (MAKE30), a composite of new renal replacement therapy, persistent renal dysfunction, or death. Secondary outcomes included plasma lactate levels and cirrhosis-related complications such as new ascites, variceal and nonvariceal bleeding, hepatorenal syndrome Type 1, hepatic encephalopathy, spontaneous bacterial peritonitis, or cerebral edema. Outcomes were compared using Pearson Chi-square test for categorical variables and Mann-Whitney U test for continuous variables. RESULTS: Of the 15,802 patients enrolled in SMART, 375 patients were admitted to the medical intensive care unit with a diagnosis of cirrhosis. Among the 169 patients with cirrhosis in the lactated Ringer’s group, 47 (28%) had a major adverse kidney event, compared to 78 (38%) of the 206 patients in the saline group (P = 0.04). In the lactated Ringer’s group, 31 patients (18%) developed a cirrhosis-related complication versus 46 (22%) in the saline group (P = 0.34). There was no significant difference in lactate levels between the two groups (P = 0.74). CONCLUSIONS: Among critically ill adults with cirrhosis in the medical intensive care unit, the use of lactated Ringer’s resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. There was no significant difference in cirrhosis-related complications or lactate levels between the two groups. CLINICAL IMPLICATIONS: Lactated Ringer’s appears to be associated with improved clinical outcomes compared to saline and may be the crystalloid of choice for many critically ill adults with cirrhosis. DISCLOSURES: No relevant relationships by Jonathan Casey, source=Web Response No relevant relationships by Taylor Coston, source=Web Response No relevant relationships by Muhammad Hashim Hayat, source=Web Response No relevant relationships by Michael Koenig, source=Web Response No relevant relationships by Rishi Naik, source=Web Response No relevant relationships by Matthew Semler, source=Web Response No relevant relationships by Li Wang, source=Web Response