2. Fluids & AKI Fluids are GOOD Volume overload is BAD UGLY Fluids cause AKI

3. N Engl J Med 2004

5. EGDT: fluids are good & prevent AKI Lin et al, Shock 2006

6. Prowle et al Crit Care Med 2012 RF in non AKI RRT: 9 Anuria: 3 CrCl>60 mL/min: 2 Phase-contrast MRI 10 septic AKI patients 11 normal volunteers

7. Renal Plasma Flow and GFR Prowle et al. Renal Failure 2010 Systematic review Human studies 22 articles 250 patients

8. RBF decreased in sepsis and early AKI? Langenberg et al. Kidney Int 2006 7 Sheep E. Coli infusion

9. EGDT and AKI Prowle et al. Crit Care 2012

10. Fluids & AKI Fluids are GOOD Volume overload is BAD UGLY Fluids cause AKI

11. Fluid bolus? The FEAST trial Maitland et al. NEJM 2011 N = 3141 children Severe infection

12. ConservativeLiberalP 7 d volume balance (mL) -136 mL ± 491+6992 ± 502<0.001 Death at 60 days25.5%28.4%0.30 Ventilator free days14.6 ± 0.512.1 ± 0.5<0.001 ICU free days: Day 1-70.9 ± 0.10.6 ± 0.1<0.001 Day 1-2813.4 ± 0.411.2 ± 0.4<0.001 Wiedemann, N Engl J Med 2006 PRCT N = 1000

13. Fluid-Management in ARDS Wiedemann et al. N Engl J Med 2006

14. Venous pressure & ↘ renal bloodflow Winton, J Physiol 1931

15. AKI & CVP, CI, systolic BP, & PCWP Mullens et al. JACC 2009 CVP CI PCWPSBP

16. AKI & CVP, CI, systolic BP, & PCWP Mullens et al. JACC 2009 CVP CI PCWPSBP

17. Volume and outcome in AKI-RRT Bouchard et al. KI 2009, Payen et al. Crit Care 2008, Grams et al. CJASN 2011, Vaara et al. Crit Care 2012

18. Negative FB during CRRT is good Bellomo et al. Crit Care Med 2012

19. Negative FB during CRRT is good Bellomo et al. Crit Care Med 2012

20. Fluids & AKI

21. Summary Recent PRCT’s HES StudyNSurviv al AKI Other side effects Magder, CABG 10% HES 250/0,5 262LessBetter HD FIRST, trauma 6% HES 130/0,4 67 P 42 B Less Same Better lactate ↘ More blood CRYSTMAS severe sepsis 6% HES 130/0,4 196Same 6S severe sepsis 6% HES 130/0,42 798Worse Mor e More blood CHEST ICU 6% HES 130/0,4 700 0 Same Mor e Liver, pruritus, blood products Magder et al Crit Care Med 2010, James et al. J Trauma 2011, Guidet et al. Crit Care 2012, Perner et al. NEJM 2012, Myburgh et al. NEJM 2012

22. AKI after gelatin Schabinski et al. Intensive Care Med 2009 Observational N = 1383 HES N = 1528 GEL MVR adjusted Risk for AKI after >33mL/kg GEL: OR 1.99 (1.05-3.79) HES: OR 1.85 (1.01 – 3.41)

23. PRCT’s on albumin nSurvival AKI Bleeding/coa gulation SAFE6997SameMore PC SAFE TBI460WorseMore PC FEAST sepsis3141Worse SAFE severe sepsis1218No diff (trend) No diff CRYSTMAS severe sepsis 196 No diff EARSS severe sepsis792No diff ALBIOS severe sepsis 1818No diff

24. Saline vs. Plasmalyte ®? Shaw et al. Ann Surg 2012 Saline = More complications and use of resources: ❖ Major infection ❖ Dialysis ❖ Blood transfusions ❖ Electrolyte disturbances N = 30,994 vs. 926 Major abd surgery

25. Chloride liberal/restrictive fluid therapy AKI stage 2-3 Yunos et al. JAMA 2012

26. Take home messages Fluids and AKI: just enough! ✓ Not too little ✓ Not too much Fluids and AKI: beware for the ugly.

28. Thank you for your attention! Eric.hoste@ugent.be

29. Fluids & AKI

30. To pee or not to pee: Fluids & AKI Eric Hoste MD, PhD Ghent University Hospital

31. CHEST: HES 130/0.4 vs. Saline Myburgh et al. NEJM 2012 HES Saline

33. CHEST: HES 130/0.4 vs. Saline Myburgh et al. NEJM 2012 HES Saline

36. Perner et al. NEJM 2012