Forced Fluid Removal in High Risk Acute Kidney Injury

Forced Fluid Removal vs. Usual Intensive Care in High-risk Acute Kidney Injury With Severe Fluid Overload - A Randomized Controlled Trial

The objective of this pilot trial is to assess the feasibility of forced fluid removal in patients admitted to the intensive care unit (ICU) with high-risk AKI and severe fluid overload. The intervention will use furosemide infusion and/or continuous renal replacement therapy (CRRT) to achieve and maintain a neutral cumulative fluid balance. The intervention will be compared to standard of care as reflected in the kidney disease improving global outcome (KDIGO) guidelines.

Acute kidney injury (AKI) is a common and serious complication in patients admitted to ICU. A core element of critical care is resuscitation with crystalloid solutions. In many cases fluid accumulates and patients become fluid overloaded (positive fluid balance > 10% of bodyweight). This is especially true in patients with AKI, since they often have impaired ability to excrete salt and water. Most observational suggests harm with increased positive fluid balance.

Objectives: To assess feasibility of forced fluid removal with diuretics and/or CRRT in ICU patients with AKI and severe fluid overload, compared to current clinical practice.

Design: Multicentre, parallel group, randomized, assessor blinded pilot-trial with adequate generation of allocation sequence, and allocation concealment.

Trial Size: The pilot study is planned to include 50 patients. Inclusion is expected to start in August 2015.

Inclusion Criteria:

• Age ≥ 18 years of age
• Acute Kidney Injury defined according to the KDIGO criteria
• Renal Recovery Score ≤ 60%. (Calculated using www.renal-recovery-score.com)
• Fluid overload defined as a positive fluid balance ≥ 10% of ideal body weight.
• Able to undergo randomization within 12 hours of fulfilling other inclusion criteria

Exclusion Criteria:

• Known pre-hospitalization advanced chronic kidney disease. (eGFR < 30 mL/minute/1.73 m2 or chronic RRT.)
• Severe hypoxic respiratory failure (use of invasive ventilation and FiO2 > 80% and PEEP > 10 cm H2O)
• Severe burn injury (≥ 10% TBSA)
• Severe hypo- or hyper- natremia (< 120 or > 155 mmol/l)
• Hepatic coma
• Mentally disabled undergoing forced treatment
• Pregnancy/breast feeding
• Lack of commitment for on-going life support including RRT
• Lack of informed consent