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Purpose <p>To estimate the effect of restrictive fluid management on renal function and mortality in critically ill patients with acute kidney injury (AKI) at high risk of developing positive fluid balance.</p> Methods <p>We conducted a target trial emulation using data from 12 intensive care units in Queensland, Australia (2015–2021). Adults with AKI within 72 h of intensive care unit (ICU) admission and an AKI-Fluid Balance Risk Score ≥ 32 were included. The intervention comprised conservative crystalloid administration, restricted nutritional fluid intake, and diuretic use for 72 h. We estimated per-protocol effects using a sequential doubly robust estimator for longitudinal modified treatment policies. The primary outcome was AKI Rank at day 7; secondary outcomes included 30-day mortality.</p> Results <p>Among 8,685 patients, the intervention was associated with substantial reduction in fluid balance (− 2,304 mL at 72 h; 95% CI, − 2,465 to − 2,144) and modest improvement in AKI Rank (mean difference − 0.8; 95% confidence interval (CI), − 1.3 to − 0.3). Heterogeneity by AKI stage was observed: the intervention was associated with improved renal function in stage 1 AKI (mean difference − 3.1; 95% CI, − 3.8 to − 2.5) but worse outcomes in stage 2 AKI (mean difference 4.5; 95% CI, 3.8 to 5.1) and stage 3 AKI (mean difference 6.3; 95% CI, 4.7 to 7.9) with increased 30-day mortality (relative risk 1.20; 95% CI, 1.09 to 1.33). Effective sample sizes were limited (7–16%), indicating reliance on extrapolation.</p> Conclusions <p>Restrictive fluid management was associated with improved renal function in early AKI but potentially harmful effects in stages 2 and 3 AKI. These hypothesis-generating findings suggest any future trial should incorporate safety criteria for patients with advanced renal injury.</p>

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Effect of restrictive fluid balance in critically ill patients with acute kidney injury: a target trial emulation

  • 期刊论文

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  • 发表日期：

    2026年5月30日

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  • Kyle Christopher White,
  • Ary Serpa Neto,
  • Kevin B. Laupland,
  • Michelle Gatton,
  • Mahesh Ramanan,
  • Anis Chaba,
  • Stephen Whebell,
  • Alexis Tabah,
  • Kiran Shekar,
  • James McCullough,
  • Aashish Kumar,
  • Peter Garrett,
  • Antony Attokaran,
  • Stephen Luke,
  • Sebastiaan Blank,
  • Kerina J. Denny,
  • Mandy Tallott,
  • Andrea Marshall,
  • David Moore,
  • Sunil Sane,
  • Lynette Morrison,
  • Pam Dipplesman,
  • Ahmad Nasser,
  • David Stewart,
  • Vikram Shah,
  • Adam Suliman,
  • Lachlan Quick,
  • Jason Meyer,
  • Ra’eesa Doola,
  • Rod Hurford,
  • Meg Harward,
  • James Walsham,
  • Adam Visser,
  • Judy Smith,
  • Neeraj Bhadange,
  • Wayne Stevens,
  • Hannah McCabe,
  • Vijo Kuruvilla,
  • Felicity Edwards,
  • Tess Evans,
  • Jayesh Dhanani,
  • Pierre Clement,
  • Nermin Karamujic,
  • Dinesh Parmar,
  • George Cornmell,
  • Jayshree Lavana,
  • Denzil Gill,
  • Stuart Baker,
  • Hamish Pollock,
  • Kylie Jacobs,
  • Prashanti Marella,
  • Jatinder Grewal,
  • Patrick Young,
  • Julia Affleck,
  • Emma Williams,
  • Paula Lister,
  • Vikram Masurkar,
  • Lauren Murray,
  • Jane Brailsford,
  • Janine Garrett,
  • Anamika Ganju,
  • Langa Lutshaba,
  • Cameron Anderson,
  • Jaco Poggenpoel,
  • Josephine Reoch,
  • Anni Paasilahti,
  • Jennifer Taylor,
  • Christopher Smart,
  • Siva Senthuran,
  • Sananta Dash,
  • Philippa McIlroy,
  • Ben Nash,
  • Zephanie Tyack,
  • Sam Keogh

摘要

Purpose

To estimate the effect of restrictive fluid management on renal function and mortality in critically ill patients with acute kidney injury (AKI) at high risk of developing positive fluid balance.

Methods

We conducted a target trial emulation using data from 12 intensive care units in Queensland, Australia (2015–2021). Adults with AKI within 72 h of intensive care unit (ICU) admission and an AKI-Fluid Balance Risk Score ≥ 32 were included. The intervention comprised conservative crystalloid administration, restricted nutritional fluid intake, and diuretic use for 72 h. We estimated per-protocol effects using a sequential doubly robust estimator for longitudinal modified treatment policies. The primary outcome was AKI Rank at day 7; secondary outcomes included 30-day mortality.

Results

Among 8,685 patients, the intervention was associated with substantial reduction in fluid balance (− 2,304 mL at 72 h; 95% CI, − 2,465 to − 2,144) and modest improvement in AKI Rank (mean difference − 0.8; 95% confidence interval (CI), − 1.3 to − 0.3). Heterogeneity by AKI stage was observed: the intervention was associated with improved renal function in stage 1 AKI (mean difference − 3.1; 95% CI, − 3.8 to − 2.5) but worse outcomes in stage 2 AKI (mean difference 4.5; 95% CI, 3.8 to 5.1) and stage 3 AKI (mean difference 6.3; 95% CI, 4.7 to 7.9) with increased 30-day mortality (relative risk 1.20; 95% CI, 1.09 to 1.33). Effective sample sizes were limited (7–16%), indicating reliance on extrapolation.

Conclusions

Restrictive fluid management was associated with improved renal function in early AKI but potentially harmful effects in stages 2 and 3 AKI. These hypothesis-generating findings suggest any future trial should incorporate safety criteria for patients with advanced renal injury.