Impact of the Magnitude and Timing of Fluid Overload on Outcomes in Critically Ill Children: A Report From the Multicenter International Assessment of Worldwide Acute Kidney Injury, Renal Angina, and Epidemiology (AWARE) Study

Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology (AWARE) Icnvestigators

Research output: Contribution to journalArticlepeer-review

20 Scopus citations

Abstract

OBJECTIVES: With the recognition that fluid overload (FO) has a detrimental impact on critically ill children, the critical care nephrology community has focused on identifying clinically meaningful targets for intervention. The current study aims to evaluate the epidemiology and outcomes associated with FO in an international multicenter cohort of critically ill children. The current study also aims to evaluate the association of FO at predetermined clinically relevant thresholds and time points (FO ≥ 5% and FO ≥ 10% at the end of ICU days 1 and 2) with outcomes. DESIGN: Prospective cohort study. SETTING: Multicenter, international collaborative of 32 pediatric ICUs. PATIENTS: A total of 5,079 children and young adults admitted consecutively to pediatric ICUs as part of the Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology Study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The FO thresholds at the time points of interest occurred commonly in the cohort (FO ≥ 5%Day1 in 38.1% [n = 1753], FO ≥ 10%Day1 in 11.7% [n = 537], FO ≥ 5%Day2 in 53.3% [n = 1,539], FO ≥ 10%Day2 in 25.1% [n = 724]). On Day1, multivariable modeling demonstrated that FO ≥ 5% was associated with fewer ICU-free days, and FO ≥ 10% was associated with higher mortality and fewer ICU and ventilator-free days. On multivariable modeling, FO-peak, Day2 FO ≥ 5%, and Day2 FO ≥ 10% were associated with higher mortality and fewer ICU and ventilator-free days. CONCLUSIONS: This study found that mild-to-moderate FO as early as at the end of ICU Day1 is associated with adverse outcomes. The current study fills an important void in the literature by identifying critical combinations of FO timing and quantity associated with adverse outcomes (FO ≥ 5%Day1, FO ≥10%Day1, FO ≥ 5%Day2, and FO ≥ 10%Day2). Those novel findings will help guide the development of interventional strategies and trials targeting the treatment and prevention of clinically relevant FO.

Original languageEnglish (US)
Pages (from-to)606-618
Number of pages13
JournalCritical care medicine
Volume51
Issue number5
DOIs
StatePublished - May 1 2023

Funding

The Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology (AWARE) study was supported by a grant (NIH P50 DK096418, to Drs. Basu and Goldstein) from the Pediatric Nephrology Center of Excellence at Cincinnati Children's Hospital Medical Center. Drs. Soranno and Akcan-Arikan received support for article research from the National Institutes of Health (NIH). All authors declare no real or perceived conflicts of interest that could affect the study design, collection, analysis and interpretation of data, writing of the report, or the decision to submit for publication. For full disclosure, we provide here an additional list of other author’s commitments and funding sources that are not directly related to this study: Dr. Askenazi is a consultant for Baxter, Nuwellis, Medtronic Bioporto, and Seastar. Dr. Askenazi receives grant funding for education and research that is not related to this project from the NIH, Baxter, Nuwellis, Medtronic, Seastar, and Bioporto; he disclosed that he is the founder and Chief Scientific Officer of Zorroflow Inc. Dr. Selewski’s institution received funding from Travere. Drs. Selewski, Basu, and Zappitelli received funding from Bioporto. Dr. Gist is a consultant for Bioporto and Potrero Medical. Dr. Basu received funding from Potrero Medical. Dr. Zappitelli received funding from Baxter. Dr. Akcan-Arikan’s institution received funding from Bioporto and the National Institute of Allergy and Infectious Diseases. The remaining authors have disclosed that they do not have any potential conflicts of interest. The Assessment of the Worldwide Acute Kidney Injury, Renal Angina and Epidemiology (AWARE) study was supported by a grant (NIH P50 DK096418, to Drs. Basu and Goldstein) from the Pediatric Nephrology Center of Excellence at Cincinnati Children’s Hospital Medical Center.

Keywords

  • acute kidney injur1
  • fluid balance
  • fluid overload
  • pediatric critical care

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine

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