Acute Kidney Injury, Critical Illness
Conditions
Brief summary
Observational studies among patients with acute kidney injury (AKI) have shown an association with fluid accumulation and increased mortality. Trials among other subgroups of critically ill patients have demonstrated that restricting fluid input after the initial resuscitation appears safe. The objective if this study is to determine whether a fluid restrictive treatment regimen will lead to a lower cumulative fluid balance at 72 hours from randomization in critically ill patients with AKI and whether this approach is safe and feasible.
Detailed description
Acute kidney injury (AKI) is common in the critically ill and associates with adverse outcomes. Patients with AKI are frequently have low urine output and are at high risk of developing fluid overload. Fluid overload has been associated with an increased risk for mortality in such patients. Previous trials in critically ill patients found that a 'restrictive fluid therapy' after resuscitation was safe. Implementing a restrictive fluid therapy approach in patients with AKI may also be of benefit. To date, however, no randomized trial has been performed to evaluate the safety and feasibility of implementing a 'restrictive fluid therapy' approach compared to standard fluid therapy in patients with AKI. In this pilot randomized controlled trial we will evaluate the implementation of a fluid restrictive approach, compared to standard therapy, in adult critically ill patients with acute kidney injury.
Interventions
Daily fluid input is restricted to drugs and nutrition. Fluid boluses and blood products can be given if clinically indicated. Matching fluid output to fluid input whenever possible using diuretics if needed, and additionally, if clinically necessary and plausible, commencing renal replacement therapy. If renal replacement therapy is not deemed clinically desirable, acceptance of a less than targeted fluid balance.
Sponsors
Austin Hospital, Melbourne Australia
Guy's and St Thomas' NHS Foundation Trust
University Hospital, Ghent
Medical University Innsbruck
University of Lausanne Hospitals
Helsinki University Central Hospital
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
SINGLE (Outcomes Assessor)
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. 18-years or older and admitted to critical care with an arterial line in place 2. The patient has been in critical care for at least 12 hours but no more than 72 hours 3. The patient has AKI but is not receiving acute RRT: For the purpose of the study AKI is defined the by the following criteria: 1. Increase in serum creatinine over 1.5-times above baseline without a decline of 27umol/l or more from the last preceding measurement (at least 12 hours apart) AND/OR 2. Overall urine output less than 0.5ml/kg/h (or 6ml/kg) for the previous 12h (with urine catheter in place for the period) 4. The patient is judged by the treating clinician not to be intravascularly hypovolemic 5. The patient is likely to remain in critical care for 48 hours after randomization
Exclusion criteria
1. Active bleeding necessitating transfusion 2. Maintenance fluid therapy is necessary due to diabetic ketoacidosis, non-ketotic coma, severe burns or other clinical reason determined by the medical staff 3. Need for RRT due to intoxication of a dialyzable toxin 4. Commencement of RRT is expected in the next 6 hours 5. On chronic renal replacement therapy (maintenance dialysis or renal transplant) 6. Presence or a strong clinical suspicion of parenchymal AKI (for example glomerulonephritis, vasculitis, acute interstitial nephritis), or post-renal obstruction 7. Severe hyponatremia (Na \<125mmol/L) or hypernatremia (Na \>155mmol/L) 8. Need for extracorporeal membrane oxygenation or molecular absorbent recirculating system (MARS-therapy) 9. Pregnant or lactating 10. Patients who are not to receive full active treatment 11. No baseline creatinine available 12. Lack of consent 13. The patient has been enrolled in another trial where co-enrollment is not feasible
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Cumulative fluid balance | 72 hours |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of patients requiring renal replacement therapy | 14 days | — |
| Cumulative fluid balance | 24 hours | — |
| Cumulative dose of diuretics | ICU discharge/ 7 days | — |
| Duration of acute kidney injury | ICU discharge/14 days | Defined according to Kidney Disease: Improving Global Outcomes criteria |
Other
| Measure | Time frame | Description |
|---|---|---|
| Number of patients with serious adverse events and reactions | 7 days | a Ventricular tachycardia/fibrillation b. New onset of atrial fibrillation requiring medication/defibrillation c. Ischemic events i. Acute myocardial infarction ii. Cerebral ischemia verified by CT or MRI scan. iii. Intestinal ischemia verified by endoscopy or open surgery. iv. Acute peripheral limb ischemia d. Radiologically diagnosed pulmonary edema e. Adverse events related to renal replacement therapy and diuretics use f. Frequency of hypokalaemia (serum K \<3.5mmol/L) g. Frequency of hypomagnesaemia (serum Mg \<0.8mmol/L) h. frequency of serum pH \>7.5 i. other |
| All-cause mortality | 90 days | — |
| Mechanical ventilation free days alive | 14 days | — |
| Vasopressor free days and alive | 14 days | — |
| Renal replacement therapy free days and alive | 90 days | — |
| Dialysis dependence | 90 days | — |
Countries
Australia, Belgium, Finland, Switzerland, United Kingdom
Outcome results
None listed