Which fluid should be used for fluid therapy to protect kidneys in cardiogenic shock after cardiac arrest?

Abstract

We read with great interest the study by Adler et al.1Adler C. Reuter H. Seck C. Hellmich M. Zobel C. Fluid therapy and acute kidney injury in cardiogenic shock after cardiac arrest.Resuscitation. 2012; ([Epub ahead of print])PubMed Google Scholar investigating the effect of fluid management on the incidence of acute kidney injury (AKI) in patients with cardiogenic shock after cardiac arrest treated by mild therapeutic hypothermia. The authors compared two fluid management strategies: with and without hemodynamic and volumetric monitoring. Based on the RIFLE criteria, the incidence of AKI class I (kidney injury)/F (kidney failure) was significantly lower in the PICCO group, in comparison to the conventional group: 1/23 (4.3%) vs. 8/28 (28.6%), p = 0.03. The authors concluded that volume therapy guided by PICCO could reduce the incidence of AKI in patients with cardiogenic shock after cardiac arrest. In the method section, the authors stated: “for fluid therapy crystalloids and colloidal solution were used.” Crystalloids and colloids are both widely used for fluid resuscitation in intensive care units (ICUs). Colloids are generally considered to be more potent plasma volume expanders than crystalloids. However, concerns about the safety of colloids have been raised by numerous studies evaluating the incidence of AKI after colloids infusion. In a recent, international, blinded, randomized trial of fluid resuscitation of patients with severe sepsis, hydroxyethyl starch (HES) 130/0.4 significantly increased the risk of death or dependence on dialysis at day 90, as compared with Ringer's acetate.2Perner A. Haase N. Guttormsen A.B. et al.Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis.N Engl J Med. 2012; 367: 124-134Crossref PubMed Scopus (1322) Google Scholar Moreover, 87/398 (22%) patients in the HES group received renal replacement therapy vs. 65/400 (16%) in Ringer's acetate group (p = 0.04). Another multicentre randomised study assessed the frequency of AKI in patients with severe sepsis or septic shock treated with HES or gelatin: factors independently associated with an increased likelihood of AKI development included use of HES (adjusted OR = 2.57 [1.13–5.83], p = 0.026).3Schortgen F. Lacherade J.C. Bruneel F. et al.Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study.Lancet. 2001; 24: 911-916Abstract Full Text Full Text PDF Scopus (595) Google Scholar A meta-analysis was conducted of randomized controlled trials evaluating AKI after infusion of hyperoncotic albumin and HES solutions. This meta-analysis concluded that HES increased the odds of AKI by 92% and of death by 41%.4Wiedermann C.J. Dunzendorfer S. Gaioni L.U. Zaraca F. Joannidis M. Hyperoncotic colloids and acute kidney injury: a meta-analysis of randomized trials.Crit Care. 2010; 14: R191Crossref PubMed Scopus (97) Google Scholar Finally, in a prospective sequential comparison during ICU stay, patients with severe sepsis received during three different consecutive periods, either predominantly 6% HES, 4% gelatin, or only crystalloids: AKI occurred in 70% of patients receiving HES (adjusted p = 0.002) and in 68% of patients receiving gelatin (adjusted p = 0.025) vs. 47% patients receiving crystalloids.5Bayer O. Reinhart K. Sakr Y. et al.Renal effects of synthetic colloids and crystalloids in patients with severe sepsis: a prospective sequential comparison.Crit Care Med. 2011; 39: 1335-1342Crossref PubMed Scopus (99) Google Scholar Need for renal replacement therapy tended to be higher in the HES group (34%) and in the gelatin group (34%) in comparison to the crystalloid group (20%). Fluid resuscitation with only crystalloids, associated with a lesser incidence of AKI, was also equally effective. Potential for increased risk of AKI should be considered when using colloids, and particularly HES, for volume resuscitation, including in fluid management for cardiogenic shock after cardiac arrest. To conclude, since there is now a growing body of evidence revealing colloids, and particularly HES-related side effects, we would like to know if the authors could precise in which proportion HES was used and detail its specific association with AKI. •Disclose any financial and personal relationships with other people or organisations that could inappropriately influence (bias) this work.•Declare non-involvement of study sponsors in the study design; collection, analysis and interpretation of data; the writing of the manuscript; the decision to submit the manuscript for publication.