• Vikram Balakumar, Raghavan Murugan, Florentina E Sileanu, Paul Palevsky, Gilles Clermont, and John A Kellum.
• 1The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.2The Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.3The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.4Renal Section, Veterans Affairs Pittsburgh Healthcare System, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.
• Crit. Care Med. 2017 Aug 1; 45 (8): e749-e757.

ObjectivesAmong critically ill patients with acute kidney injury, exposure to positive fluid balance, compared with negative fluid balance, has been associated with mortality and impaired renal recovery. However, it is unclear whether positive and negative fluid balances are associated with poor outcome compared to patients with even fluid balance (euvolemia). In this study, we examined the association between exposure to positive or negative fluid balance, compared with even fluid balance, on 1-year mortality and renal recovery.DesignRetrospective cohort study.SettingEight medical-surgical ICUs at the University of Pittsburgh Medical Center, Pittsburgh, PA.PatientsCritically ill patients admitted between July 2000 and October 2008.InterventionsNone.Measurements And Main ResultsAmong 18,084 patients, fluid balance was categorized as negative (< 0%), even (0% to < 5%), or positive (≥ 5%). Following propensity matching, positive fluid balance, compared with even or negative fluid balance, was associated with increased mortality (30.3% vs 21.1% vs 22%, respectively; p < 0.001). Using Gray's model, negative fluid balance, compared with even fluid balance, was associated with lower short-term mortality (adjusted hazard ratio range, 0.81; 95% CI, 0.68-0.96) but higher long-term mortality (adjusted hazard ratio range, 1.16-1.22; p = 0.004). Conversely, positive fluid balance was associated with higher mortality throughout 1-year (adjusted hazard ratio range, 1.30-1.92; p < 0.001), which was attenuated in those who received renal replacement therapy (positive fluid balance × renal replacement therapy interaction (adjusted hazard ratio range, 0.43-0.89; p < 0.001). Of patients receiving renal replacement therapy, neither positive (adjusted odds ratio, 0.98; 95% CI, 0.68-1.4) nor negative (adjusted odds ratio, 0.81; 95% CI, 0.43-1.55) fluid balance was associated with renal recovery.ConclusionsAmong critically ill patients, exposure to positive or negative fluid balance, compared with even fluid balance, was associated with higher 1-year mortality. This mortality risk associated with positive fluid balance, however, was attenuated by use of renal replacement therapy. We found no association between fluid balance and renal recovery.

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