Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

doi:10.1159/000538421

Observational Study

. 2024;53(8):624-633.

doi: 10.1159/000538421. Epub 2024 Apr 16.

Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

Kyle C White^{1

2

3}, Kevin B Laupland^{3

4}, Marlies Ostermann⁵, Ary Serpa Neto^{6

7}, Michelle L Gatton³, Rod Hurford¹, Pierre Clement⁴, Barnaby Sanderson⁵, Rinaldo Bellomo^{8

9

10}

Affiliations

¹ Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
² Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
³ Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
⁴ Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
⁵ King's College London, Guy's and St Thomas' Hospital, Department of Critical Care, London, UK.
⁶ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
⁷ Department of Critical Care, Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁸ Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia.
⁹ Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia.
¹⁰ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

PMID: 38626729
PMCID: PMC11309063
DOI: 10.1159/000538421

Observational Study

Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

Kyle C White et al. Blood Purif. 2024.

. 2024;53(8):624-633.

doi: 10.1159/000538421. Epub 2024 Apr 16.

Authors

Kyle C White^{1

2

3}, Kevin B Laupland^{3

4}, Marlies Ostermann⁵, Ary Serpa Neto^{6

7}, Michelle L Gatton³, Rod Hurford¹, Pierre Clement⁴, Barnaby Sanderson⁵, Rinaldo Bellomo^{8

9

10}

Affiliations

¹ Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
² Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.
³ Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
⁴ Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
⁵ King's College London, Guy's and St Thomas' Hospital, Department of Critical Care, London, UK.
⁶ Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
⁷ Department of Critical Care, Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
⁸ Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia.
⁹ Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia.
¹⁰ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.

PMID: 38626729
PMCID: PMC11309063
DOI: 10.1159/000538421

Abstract

Introduction: In critically ill patients undergoing continuous renal replacement therapy (CRRT), a positive fluid balance (FB) is associated with adverse outcomes. However, current FB management practices in CRRT patients are poorly understood. We aimed to study FB and its components in British and Australian CRRT patients to inform future trials.

Methods: We obtained detailed electronic health record data on all fluid-related variables during CRRT and hourly FB for the first 7 days of treatment.

Results: We studied 1,616 patients from three tertiary intensive care units (ICUs) in two countries. After the start of CRRT, the mean cumulative FB became negative at 31 h and remained negative over 7 days to a mean nadir of -4.1 L (95% confidence interval (CI) of -4.6 to -3.5). The net ultrafiltration (NUF) rate was the dominant fluid variable (-67.7 mL/h; standard deviation (SD): 75.7); however, residual urine output (-34.7 mL/h; SD: 54.5), crystalloid administration (48.1 mL/h; SD: 44.6), and nutritional input (36.4 mL/h; SD: 29.7) significantly contributed to FB. Patients with a positive FB after 72 h of CRRT were more severely ill, required high-dose vasopressors, and had high lactate concentrations (5.0 mmol/L; interquartile range: 2.3-10.5). A positive FB was independently associated with increased hospital mortality (odds ratio: 1.70; 95% CI; p = 0.004).

Conclusion: In the study ICUs, most CRRT patients achieved a predominantly NUF-dependent negative FB. Patients with a positive FB at 72 h had greater illness severity and haemodynamic instability. Achieving equipoise for conducting trials that target a negative early FB in such patients may be difficult.

Keywords: Acute kidney injury; Critical illness; Fluid management; Renal replacement therapy; Water and electrolyte imbalance.

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Conflict of interest statement

The authors have no conflict of interest to declare.

Figures

**Fig. 1.**
Cumulative hourly FB in all CRRT patients.

**Fig. 2.**
Cumulative hourly FB in CRRT patients by FB category.

See this image and copyright information in PMC

Cited by

Fluid balance neutralization secured by hemodynamic monitoring versus protocolized standard of care in patients with acute circulatory failure requiring continuous renal replacement therapy: results of the GO NEUTRAL randomized controlled trial.
Bitker L, Dupuis C, Pradat P, Deniel G, Klouche K, Mezidi M, Chauvelot L, Yonis H, Baboi L, Illinger J, Souweine B, Richard JC. Bitker L, et al. Intensive Care Med. 2024 Dec;50(12):2061-2072. doi: 10.1007/s00134-024-07676-1. Epub 2024 Oct 17. Intensive Care Med. 2024. PMID: 39417870 Free PMC article. Clinical Trial.
Ultrafiltration Tolerance and Improving Outcomes with Continuous Renal Replacement Therapies.
Ramírez-Guerrero G, Ronco C, Rosner M. Ramírez-Guerrero G, et al. Clin J Am Soc Nephrol. 2025 Mar 1;20(3):462-464. doi: 10.2215/CJN.0000000650. Epub 2024 Dec 26. Clin J Am Soc Nephrol. 2025. PMID: 39724028 No abstract available.

References

1. Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367(26):2505–14. - PubMed
1. STARRT-AKI InvestigatorsCanadian Critical Care Trials GroupAustralian and New Zealand Intensive Care Society Clinical Trials GroupUnited Kingdom Critical Care Research GroupCanadian Nephrology Trials NetworkIrish Critical Care Trials Group, et al. . Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383(3):240–51. - PubMed
1. Uusalo P, Hellman T, Löyttyniemi E, Peltoniemi J, Järvisalo MJ. Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT. Sci Rep. 2021;11(1):18216. - PMC - PubMed
1. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu C. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24(1):37–42. - PMC - PubMed
1. Tandukar S, Palevsky PM. Renal replacement therapy: who, when, why, and how. Chest. 2019;155(3):626–38. - PMC - PubMed

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[1] Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367(26):2505–14. - PubMed

[2] Tolwani A. Continuous renal-replacement therapy for acute kidney injury. N Engl J Med. 2012;367(26):2505–14. - PubMed

[3] STARRT-AKI InvestigatorsCanadian Critical Care Trials GroupAustralian and New Zealand Intensive Care Society Clinical Trials GroupUnited Kingdom Critical Care Research GroupCanadian Nephrology Trials NetworkIrish Critical Care Trials Group, et al. . Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383(3):240–51. - PubMed

[4] STARRT-AKI InvestigatorsCanadian Critical Care Trials GroupAustralian and New Zealand Intensive Care Society Clinical Trials GroupUnited Kingdom Critical Care Research GroupCanadian Nephrology Trials NetworkIrish Critical Care Trials Group, et al. . Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383(3):240–51. - PubMed

[5] Uusalo P, Hellman T, Löyttyniemi E, Peltoniemi J, Järvisalo MJ. Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT. Sci Rep. 2021;11(1):18216. - PMC - PubMed

[6] Uusalo P, Hellman T, Löyttyniemi E, Peltoniemi J, Järvisalo MJ. Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT. Sci Rep. 2021;11(1):18216. - PMC - PubMed

[7] Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu C. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24(1):37–42. - PMC - PubMed

[8] Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu C. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol. 2013;24(1):37–42. - PMC - PubMed

[9] Tandukar S, Palevsky PM. Renal replacement therapy: who, when, why, and how. Chest. 2019;155(3):626–38. - PMC - PubMed

[10] Tandukar S, Palevsky PM. Renal replacement therapy: who, when, why, and how. Chest. 2019;155(3):626–38. - PMC - PubMed

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Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

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Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study

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