The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores

Abstract

Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

Keywords: fluid balance; illness severity score; intravenous fluid therapy; mortality; oliguria; prediction.

Figure 1.

Fluid accumulation in the critically ill. FBT: fluid bolus therapy; MFT: maintenance fluid therapy; AKI: acute kidney injury; CPB: cardiopulmonary bypass; ECMO: extracorporeal membrane oxygenation; CRRT: continuous renal replacement therapy; Postop: postoperative; ADH: antidiuretic hormone; CKD: chronic kidney disease; HRS: hepatorenal syndrome; CCF: chronic cardiac failure; PLE: protein losing enteropathy.

Figure 2.

The complex relationship between acute kidney injury, fluid accumulation, and outcome. AKI: acute kidney injury; UO: urine output; sCr: serum creatinine; GFR: glomerular filtration rate; ΔFB: change in fluid balance.