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Randomized Controlled Trial
. 2024 Jul 11;28(1):231.
doi: 10.1186/s13054-024-05019-6.

Fluid management for sepsis-induced hypotension in patients with advanced chronic kidney disease: a secondary analysis of the CLOVERS trial

Anselm Jorda  1 , Ivor S Douglas  2 , Thomas Staudinger  3 , Gottfried Heinz  4 , Felix Bergmann  1 , Rainer Oberbauer  5 , Gürkan Sengölge  5 , Markus Zeitlinger  1 , Bernd Jilma  1 , Nathan I Shapiro  6 , Georg Gelbenegger  7
Affiliations
Randomized Controlled Trial

Fluid management for sepsis-induced hypotension in patients with advanced chronic kidney disease: a secondary analysis of the CLOVERS trial

Anselm Jorda et al. Crit Care. .

Abstract

Background: Early fluid management in patients with advanced chronic kidney disease (CKD) and sepsis-induced hypotension is challenging with limited evidence to support treatment recommendations. We aimed to compare an early restrictive versus liberal fluid management for sepsis-induced hypotension in patients with advanced CKD.

Methods: This post-hoc analysis included patients with advanced CKD (eGFR of less than 30 mL/min/1.73 m2 or history of end-stage renal disease on chronic dialysis) from the crystalloid liberal or vasopressor early resuscitation in sepsis (CLOVERS) trial. The primary endpoint was death from any cause before discharge home by day 90.

Results: Of 1563 participants enrolled in the CLOVERS trial, 196 participants had advanced CKD (45% on chronic dialysis), with 92 participants randomly assigned to the restrictive treatment group and 104 assigned to the liberal fluid group. Death from any cause before discharge home by day 90 occurred significantly less often in the restrictive fluid group compared with the liberal fluid group (20 [21.7%] vs. 41 [39.4%], HR 0.5, 95% CI 0.29-0.85). Participants in the restrictive fluid group had more vasopressor-free days (19.7 ± 10.4 days vs. 15.4 ± 12.6 days; mean difference 4.3 days, 95% CI, 1.0-7.5) and ventilator-free days by day 28 (21.0 ± 11.8 vs. 16.5 ± 13.6 days; mean difference 4.5 days, 95% CI, 0.9-8.1).

Conclusions: In patients with advanced CKD and sepsis-induced hypotension, an early restrictive fluid strategy, prioritizing vasopressor use, was associated with a lower risk of death from any cause before discharge home by day 90 as compared with an early liberal fluid strategy.

Trial registration: NCT03434028 (2018-02-09), BioLINCC 14149.

Keywords: Bacteremia; Chronic kidney disease; Dialysis; Hypervolemia; Septic shock; Vasopressor.

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Conflict of interest statement

No author reports conflict of interests relevant to this work.

Figures

Fig. 1
Fig. 1
Flow chart of the study
Fig. 2
Fig. 2
A–D Death from any cause before discharge home by day 90 (primary outcome) between the restrictive fluid group and liberal fluid group A in all patients with advanced chronic kidney disease (CKD), B in patients with advanced CKD receiving dialysis, C in patients with advanced CKD not receiving dialysis, (D) and in patients without advanced CKD
Fig. 3
Fig. 3
Effect estimates of the primary outcome (death from any cause before discharge home by day 90) between the restrictive fluid group and liberal fluid group in (i) patients with advanced chronic kidney disease (CKD), (ii) patients with no advanced CKD not receiving dialysis, (iii) patients with CKD receiving no dialysis, and (iv) patients with advanced CKD receiving dialysis
Fig. 4
Fig. 4
Key secondary outcomes in number of days by day 28 after randomization between the restrictive fluid group and liberal fluid group. Bars with error bars indicate means and 95% confidence intervals
See this image and copyright information in PMC

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