John A Kellum1,2, Lakhmir S Chawla2,3, Christopher Keener1,4, Kai Singbartl2,5, Paul M Palevsky2,6,7, Francis L Pike1, Donald M Yealy8, David T Huang1, Derek C Angus1. 1. 1 CRISMA Center, Department of Critical Care Medicine. 2. 2 Center for Critical Care Nephrology. 3. 3 Department of Medicine, Divisions of Intensive Care Medicine and Nephrology, Veterans Affairs Medical Center, Washington, DC. 4. 4 Graduate School of Public Health. 5. 5 Department of Anesthesia, Penn State Hershey Medical Center, Hershey, Pennsylvania; and. 6. 7 Renal-Electrolyte Division, Department of Medicine, and. 7. 6 Renal Section, Medical Service, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania. 8. 8 Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.
Abstract
RATIONALE: Septic shock is a common cause of acute kidney injury (AKI), and fluid resuscitation is a major part of therapy. OBJECTIVES: To determine if structured resuscitation designed to alter fluid, blood, and vasopressor use affects the development or severity of AKI or outcomes. METHODS: Ancillary study to the ProCESS (Protocolized Care for Early Septic Shock) trial of alternative resuscitation strategies (two protocols vs. usual care) for septic shock. MEASUREMENTS AND MAIN RESULTS: We studied 1,243 patients and classified AKI using serum creatinine and urine output. We determined recovery status at hospital discharge, examined rates of renal replacement therapy and fluid overload, and measured biomarkers of kidney damage. Among patients without evidence of AKI at enrollment, 37.6% of protocolized care and 38.1% of usual care patients developed kidney injury (P = 0.90). AKI duration (P = 0.59) and rates of renal replacement therapy did not differ between study arms (6.9% for protocolized care and 4.3% for usual care; P = 0.08). Fluid overload occurred in 8.3% of protocolized care and 6.3% of usual care patients (P = 0.26). Among patients with severe AKI, complete and partial recovery was 50.7 and 13.2% for protocolized patients and 49.1 and 13.4% for usual care patients (P = 0.93). Sixty-day hospital mortality was 6.2% for patients without AKI, 16.8% for those with stage 1, and 27.7% for stages 2 to 3. CONCLUSIONS: In patients with septic shock, AKI is common and associated with adverse outcomes, but it is not influenced by protocolized resuscitation compared with usual care.
RCT Entities:
RATIONALE: Septic shock is a common cause of acute kidney injury (AKI), and fluid resuscitation is a major part of therapy. OBJECTIVES: To determine if structured resuscitation designed to alter fluid, blood, and vasopressor use affects the development or severity of AKI or outcomes. METHODS: Ancillary study to the ProCESS (Protocolized Care for Early Septic Shock) trial of alternative resuscitation strategies (two protocols vs. usual care) for septic shock. MEASUREMENTS AND MAIN RESULTS: We studied 1,243 patients and classified AKI using serum creatinine and urine output. We determined recovery status at hospital discharge, examined rates of renal replacement therapy and fluid overload, and measured biomarkers of kidney damage. Among patients without evidence of AKI at enrollment, 37.6% of protocolized care and 38.1% of usual care patients developed kidney injury (P = 0.90). AKI duration (P = 0.59) and rates of renal replacement therapy did not differ between study arms (6.9% for protocolized care and 4.3% for usual care; P = 0.08). Fluid overload occurred in 8.3% of protocolized care and 6.3% of usual care patients (P = 0.26). Among patients with severe AKI, complete and partial recovery was 50.7 and 13.2% for protocolized patients and 49.1 and 13.4% for usual care patients (P = 0.93). Sixty-day hospital mortality was 6.2% for patients without AKI, 16.8% for those with stage 1, and 27.7% for stages 2 to 3. CONCLUSIONS: In patients with septic shock, AKI is common and associated with adverse outcomes, but it is not influenced by protocolized resuscitation compared with usual care.
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