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Association Between Unbalanced Solutions and Acute Kidney Injury During Fluid Resuscitation in Children With Sepsis
Jaime Fernández-Sarmiento1, Catalina Alcalá-Lozano2, Pedro Alexander Barrera3
1Department of Pediatrics and Intensive Care, Universidad de la Sabana, 42705Fundación Cardioinfantil-Instituto de Cardiología, Universidad CES Graduate School, Bogotá, Colombia.
Insights
Balanced solutions in fluid resuscitation for pediatric sepsis-associated organ dysfunction and septic shock reduced acute kidney injury and continuous renal replacement therapy needs. This study highlights improved outcomes with balanced fluids in a middle-income country.
Area of Science:
- Pediatric Critical Care Medicine
- Nephrology
- Infectious Diseases
Background:
- Sepsis-associated organ dysfunction and septic shock are critical conditions in children.
- Fluid resuscitation is a cornerstone of management, but the type of fluid (balanced vs. unbalanced solutions) may impact outcomes.
- Limited data exist on fluid choice impact in middle-income countries.
Purpose of the Study:
- To compare the outcomes of pediatric patients with sepsis-associated organ dysfunction and septic shock receiving fluid resuscitation with balanced versus unbalanced solutions.
- To evaluate the incidence of acute kidney injury, need for continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay, and mortality.
Main Methods:
- Observational, analytical cohort study with propensity score matching (PSM) in a pediatric intensive care unit (PICU).
- Included children aged one month to 17 years requiring fluid boluses for hemodynamic instability.
- Primary outcome: acute kidney injury; Secondary outcomes: CRRT, metabolic acidosis, PICU stay, mortality.
Main Results:
- Balanced solutions were associated with significantly less acute kidney injury (20.3% vs. 25.7%, P=0.006) compared to unbalanced solutions.
- Patients receiving balanced solutions required CRRT less frequently (3.3% vs. 6.5%, P=0.02) and had a shorter PICU length of stay (6 days vs. 10.2 days, P<0.001).
- No significant differences were observed in metabolic acidosis, hyperchloremia, or mortality between the groups.
Conclusions:
- In children with sepsis-associated organ dysfunction and septic shock, unbalanced fluid solutions are linked to higher rates of acute kidney injury, increased need for renal support, and longer PICU stays.
- Balanced solutions appear to be a safer and more effective choice for fluid resuscitation in this vulnerable pediatric population.
- Findings are particularly relevant for resource-limited settings in middle-income countries.
Objective:
To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country.
Design:
An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality.
Measurements And Main Results:
Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis (P = 0.37), hyperchloremia (P = 0.11) and mortality (P = 0.25) between the 2 groups.
Conclusion:
In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.
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