Comparison of methods to normalize urine output in critically ill patients: a multicenter cohort study

Abstract

Background: Oliguria diagnosis includes the normalization of urine output (UO) by body weight. However, the rational and the method to apply to normalize UO to body weight are unclear. We aimed to explore the impact of the method applied to normalize UO on oliguria incidence and association with outcomes.

Methods: We included all adult patients admitted to a Swiss (derivation cohort) and a US (MIMIC-IV database, validation cohort) ICU, except those on maintenance hemodialysis, who declined consent or had < 6 consecutive UO measurements. Among a panel of candidate variables (ideal body weight, body mass index, body surface area and adjusted body weight), we identified the best predictor for UO (i.e. the variable that was most closely associated with mean UO during ICU stay). We then compared oliguria incidence and association with 90-day mortality and acute kidney disease (AKD) at hospital discharge, according to whether UO was normalized by actual body weight (ABW) or the identified best UO predictor.

Results: The derivation and validation cohorts included respectively 15 322 and 28 610 patients. Those in the validation cohort were heavier (mean ABW 81 versus 75 kg) older (65 versus 62 years) and had a lower SAPS-II score (38 versus 43). The best UO predictor was ideal body weight (IBW). Oliguria incidence increased almost linearly across weight categories with ABW normalization but remained constant with IBW normalization. Using IBW for UO normalization rather than ABW improved the association between oliguria and 90-day mortality and AKD. It increased the proportion of patients correctly classified from 37.6 to 48.3% (mortality) and from 37.8 to 47% (AKD). All findings persisted after correction for sex and SAPS-II score and were confirmed in sensitivity analyses.

Conclusion: UO normalization by IBW lead to a stable incidence of oliguria across categories of weight and improved the association between oliguria and outcomes. IBW should be preferred to normalize UO in critically ill patients.

Keywords: Definition; Oliguria; Urine output; Weight.

Fig. 1

Relationship between mean 6-h urine output (UO) during ICU stay and actual body weight (panel a) or height (panel b) in critically ill patients. Values are mean (with 95% confidence intervals), n = 15 322 (panel A) and 12 412 (panel B)

Fig. 2

Observed incidence and probability of oliguria across weight categories according to UO normalization method. Upper panels: Observed incidence of oliguria across body weight categories when UO is normalized by ABW (panel A) or IBW_d (panel B). Lower panels: Probability of oliguria (with 95% confidence intervals) across body weight categories accounting for sex, and corrected SAPS-II score, when UO is normalized by ABW (panel C) or IBW_d (panel D). Results obtained in the validation and derivation cohort are represented in red and in blue respectively. ABW: actual body weight; IBW_d: ideal body weight; UO: urine output. In the validation cohort, n = 15 322 (panels A and C) and 12 412 (panel B and D). In the derivation cohort, n = 28 591 (all panels)

Fig. 3

Difference in the proportion of patients correctly classified by type of UO normalization. Panel A: 90-day mortality (correct classification = patients with oliguria who were dead at day 90 AND patients without oliguria who were alive at day 90). Panel B: Acute Kidney Disease (correct classification = patients with oliguria who had AKD at hospital discharge AND patients without oliguria who did not have AKD at hospital discharge). ABW: actual body weight; IBWd: ideal body weight; UO: urine output; AKD: acute kidney disease