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Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis

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Abstract

Fluid resuscitation, along with the early administration of antibiotics, is the cornerstone of treatment for patients with sepsis. However, whether differences in resuscitation fluids impact on the requirements for renal replacement therapy (RRT) remains unclear. To examine this issue, we performed a network meta-analysis (NMA), including direct and indirect comparisons, that addressed the effect of different resuscitation fluids on the use of RRT in patients with sepsis. The data sources MEDLINE, EMBASE, ACPJC, CINAHL and Cochrane Central Register were searched up to March 2014. Eligible studies included randomized trials reported in any language that enrolled adult patients with sepsis or septic shock and addressed the use of RRT associated with alternative resuscitation fluids. The risk of bias for individual studies and the overall certainty of the evidence were assessed. Ten studies (6664 patients) that included a total of nine direct comparisons were assessed. NMA at the four-node level showed that an increased risk of receiving RRT was associated with fluid resuscitation with starch versus crystalloid [odds ratio (OR) 1.39, 95 % credibility interval (CrI) 1.17–1.66, high certainty]. The data suggested no difference between fluid resuscitation with albumin and crystalloid (OR 1.04, 95 % CrI 0.78–1.38, moderate certainty) or starch (OR 0.74, 95 % CrI 0.53–1.04, low certainty). NMA at the six-node level showed a decreased risk of receiving RRT with balanced crystalloid compared to heavy starch (OR 0.50, 95 % CrI 0.34–0.74, moderate certainty) or light starch (OR 0.70, 95 % CrI 0.49–0.99, high certainty). There was no significant difference between balanced crystalloid and saline (OR 0.85, 95 % CrI 0.56–1.30, low certainty) or albumin (OR 0.82, 95 % CrI 0.49–1.37, low certainty). Of note, these trials vary in terms of case mix, fluids evaluated, duration of fluid exposure and risk of bias. Imprecise estimates contributed to low confidence in most estimates of effect. Among the patients with sepsis, fluid resuscitation with crystalloids compared to starch resulted in reduced use of RRT; the same may be true for albumin versus starch.

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Acknowledgments

The authors would like to acknowledge the following clinicians for providing us with information contributing to this paper: Dr. S. Finfer [13], Dr. K Reinhart [32], Dr. A Chopra, Dr. F Shortgen [34], Dr. B Wills, Dr. N Haase [9, 20], Dr. LL McIntyre [33], Dr. K Maitland and Dr J Myburgh [10]. We acknowledge librarians Lois Cottrell and Jean Maragno for their invaluable help with structuring and performing our search. We also acknowledge financial support from the Hamilton Chapter of The Canadian Intensive Care Foundation, the Critical Care Medicine Residency Program and the Critical Care Division Alternate Funding Plan both at McMaster University, Hamilton, Ontario.

Conflicts of interest

The authors declare no relevant financial conflict of interest. Dr. D. Cook is a Research Chair of the Canadian Institutes of Health Research. Dr. D. Cook coauthored a fluid trial cited herein. Dr. D. Annane was principal investigator of a fluid trial cited herein.

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Authors and Affiliations

  1. Department of Medicine, Division of Critical Care, McMaster University, 1200 Main St W, L8S 4L8, Hamilton, ON, Canada

    B. Rochwerg, W. Alhazzani, A Gibson, C. M. Ribic, A. Fox-Robichaud, F. Alshamsi, S. Altayyar, W. Ip, M. Wang, D. J. Cook, R. Jaeschke & G. H. Guyatt

  2. Department of Critical Care, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

    W. Alhazzani

  3. Department of Anaesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia

    A. Sindi

  4. Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

    D. Heels-Ansdell, L. Thabane, L. Mbuagbaw, G. Li, Q. Zhou, D. J. Cook, R. Jaeschke & G. H. Guyatt

  5. Department of Medicine, Jagiellonian University Medical College, Kraków, Poland

    W. Szczeklik & A. Włudarczyk

  6. Department of Critical Care, University of Versailles SQY, Garches, France

    D. Annane

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  1. B. Rochwerg
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  3. A Gibson
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  19. D. J. Cook
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  21. G. H. Guyatt
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for the FISSH Group (Fluids in Sepsis and Septic Shock)

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Correspondence to B. Rochwerg.

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Rochwerg, B., Alhazzani, W., Gibson, A. et al. Fluid type and the use of renal replacement therapy in sepsis: a systematic review and network meta-analysis. Intensive Care Med 41, 1561–1571 (2015). https://doi.org/10.1007/s00134-015-3794-1

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