Restrictive fluid management versus usual care in acute kidney injury (REVERSE-AKI): a pilot randomized controlled feasibility trial
Suvi T. Vaara, Marlies Ostermann, Laurent Bitker, Antoine Schneider, Elettra Poli, Eric A. J. Hoste, Jan Fierens, Michael Joannidis, Alexander Zarbock, Frank van Haren, John R. Prowle, Tuomas Selander, Minna Bäcklund, Ville Pettilä, Rinaldo Bellomo, on behalf of the REVERSE-AKI study team, Rinaldo Bellomo, Suvi Vaara, Laurent Bitker, Glenn M. Eastwood, Frank van Haren, Liam Byrne, Mary Nourse, Samantha Adam, Clare Robertson, Josie Russell-Brown, Shakira Spiller, Eric A. J. Hoste, Jan Fierens, Pieter Nepuydt, Daisy Vermeiren, Ingrid Herck, Druwe Patrick, Luc De Crop, Stephanie Bracke, Marlies Ostermann, Andy Retter, Sara Campos, Gill Arbane, Andrea Kelly, Neus Grau Novellas, Rosario Lim, Martina Marotti, Aneta Bociek, Tim Jones, R. Chris Whitton, Andrew Slack, Luigi Camporota, Simon Sparkes, Duncan Wyncoll, Suvi Vaara, Minna Bäcklund, Ville Pettilä, Jonna Heinonen, Leena Pettilä, Sari Sutinen, Elina Lappi, Antoine Schneider, Elettra Poli, Marco Altarelli, Michel Thibault, Philippe Eckert, Madeleine Schnorf, John R. Prowle, Ryan W. Haines, Richard Cashmore, Alex Fowler, Filipa Santos, Amaia Garcia, Maria Fernandez, Tim Martin, Ruzena Uddin
Abstract
PURPOSE: We compared a restrictive fluid management strategy to usual care among critically ill patients with acute kidney injury (AKI) who had received initial fluid resuscitation. METHODS: This multicenter feasibility trial randomized 100 AKI patients 1:1 in seven ICUs in Europe and Australia. Restrictive fluid management included targeting negative or neutral daily fluid balance by minimizing fluid input and/or enhancing urine output with diuretics administered at the discretion of the clinician. Fluid boluses were administered as clinically indicated. The primary endpoint was cumulative fluid balance 72 h from randomization. RESULTS: Mean (SD) cumulative fluid balance at 72 h from randomization was - 1080 mL (2003 mL) in the restrictive fluid management arm and 61 mL (3131 mL) in the usual care arm, mean difference (95% CI) - 1148 mL (- 2200 to - 96) mL, P = 0.033. Median [IQR] duration of AKI was 2 [1-3] and 3 [2-7] days, respectively (median difference - 1.0 [- 3.0 to 0.0], P = 0.071). Altogether, 6 out of 46 (13%) patients in the restrictive fluid management arm and 15 out of 50 (30%) in the usual care arm received renal replacement therapy (RR 0.42; 95% CI 0.16-0.91), P = 0.043. Cumulative fluid balance at 24 h and 7 days was lower in the restrictive fluid management arm. The dose of diuretics was not different between the groups. Adverse events occurred more frequently in the usual care arm. CONCLUSIONS: In critically ill patients with AKI, a restrictive fluid management regimen resulted in lower cumulative fluid balance and less adverse events compared to usual care. Larger trials of this intervention are justified.