Abstract
BackgroundTo investigate whether haemodynamic intolerance to fluid removal during intermittent renal replacement therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT.MethodsWe included 39 patients where intermittent RRT with weight loss was decided. Intradialytic hypotension was defined as hypotension requiring a therapeutic intervention, as decided by the physicians in charge. Before RRT, the maximal increase in cardiac index (CI, pulse contour analysis) induced by a PLR test was recorded. RRT was then started.ResultsUltrafiltration rate was similar in patients with and without intradialytic hypotension. Thirteen patients presented intradialytic hypotension, while 26 did not. In patients with intradialytic hypotension, it occurred 120 min [interquartile range 60–180 min] after onset of RRT. In the 26 patients without intradialytic hypotension, the PLR test induced no significant change in CI. Conversely, in patients with intradialytic hypotension, PLR significantly increased CI by 15 % [interquartile range 11–36 %]. The PLR-induced increase in CI predicted intradialytic hypotension with an area under the ROC curve of 0.89 (95 % interval confidence 0.75–0.97) (p < 0.05 from 0.50). The best diagnostic threshold was 9 %. The sensitivity was 77 % (95 % confidence interval 46–95 %), the specificity was 96 % (80–100 %), the positive predictive value was 91 % (57–100 %), and the negative predictive value was 89 % (72–98 %). Compared to patients without intolerance to RRT, CI decreased significantly faster in patients with intradialytic hypotension, with a slope difference of −0.17 L/min/m2/h.ConclusionThe presence of preload dependence, as assessed by a positive PLR test before starting RRT with fluid removal, predicts that RRT will induce haemodynamic intolerance.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0149-1) contains supplementary material, which is available to authorized users.
Highlights
To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replace‐ ment therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT
Intensive Care (2016) 6:46 alters renal recovery in patients with acute renal failure [10, 11]. In cases when it leads to premature termination of RRT, intradialytic hypotension reduces the dose of dialysis and the volume of fluid removal [9, 12]
Values are expressed as median [interquartile range] or number and frequency in % There was no significant difference between patients with and patients without intradialytic hypotension PEEP positive end-expiratory pressure; RRT renal replacement therapy
Summary
To investigate whether haemodynamic intolerance to fluid removal during intermittent renal replace‐ ment therapy (RRT) in critically ill patients can be predicted by a passive leg raising (PLR) test performed before RRT. Removing fluid is a common therapeutic option in patients with acute circulatory failure and/or acute respiratory distress syndrome (ARDS), especially at the late phase of disease [1, 2]. This is based on the evidence that the cumulative fluid balance is an independent factor that increases mortality in patients with septic shock [3] and ARDS [4], especially in the case of acute kidney injury [5]. In cases when it leads to premature termination of RRT, intradialytic hypotension reduces the dose of dialysis and the volume of fluid removal [9, 12]
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