Fluid balance, biomarkers of renal function and mortality in critically ill patients with AKI diagnosed before, or within 24 h of intensive care unit admission: a prospective study.

BACKGROUND: To evaluate fluid balance, biomarkers of renal function and its relation to mortality in patients with acute kidney injury (AKI) diagnosed before, or within 24 h of intensive care unit admission. METHODS: A prospective cohort study considered 773 critically ill patients observed over six years. Pre-intensive care unit-onset AKI was defined as AKI diagnosed before, or within 24 h of intensive care unit admission. Body weight-adjusted fluid balance and fluid balance-adjusted biomarkers of renal function were measured daily for the first three days of intensive care unit admission. Primary outcome was mortality in the intensive care unit. RESULTS: Prevalence of pre-intensive care unit-onset AKI was 55.1%, of which 55.6% of cases were hospital-acquired and 44.4% were community-acquired. Fluid balance was higher in AKI patients than in non-AKI patients (p < 0.001) and had a negative correlation with urine output (p < 0.01). Positive fluid balance and biomarkers of renal function were independently related to mortality. Multivariate analysis identified the following AKI-related variables associated with increased mortality: (1) In AKI patients: type 1 cardiorenal syndrome (OR 2.00), intra-abdominal hypertension (OR 1.71), AKI stage 3 (OR 2.15) and increase in AKI stage (OR 4.99); 2) In patients with community-acquired AKI: type 1 cardiorenal syndrome (OR 5.16), AKI stage 2 (OR 2.72), AKI stage 3 (OR 4.95) and renal replacement therapy (OR 3.05); and 3) In patients with hospital-acquired AKI: intra-abdominal hypertension (OR 2.31) and increase in AKI stage (OR 4.51). CONCLUSIONS: In patients with pre-intensive care unit-onset AKI, positive fluid balance is associated with worse renal outcomes. Positive fluid balance and decline in biomarkers of renal function are related to increased mortality, thus in this subpopulation of critically ill patients, positive fluid balance is not recommended and renal function must be closely monitored.

Fallo multiorgánico en adolescente con hígado graso agudo del embarazo / Multiorganic failure in adolescent with acute fatty liver of pregnancy

El hígado agudo graso del embarazo es considerado como una rara y catastrófica disfunción hepatocelular que se asocia con la gestación. Presentamos el caso de una joven adolescente con síntomas de la enfermedad a las 38,5 semanas de gestación. Ella en un periodo de 10 días desarrolla cuadro de astenia, vómitos, ictericia, dolor abdominal difuso y patrón humoral de insuficiencia hepática. Fue necesario una cesárea de urgencia para beneficio materno, ingresando de inmediato en cuidados intensivos. El perfil clínico-humoral, estudios imagenológicos y de laparoscopia confirmaron la hipótesis diagnóstica. Presentó complicaciones obstétricas que motivaron múltiples reintervenciones. Con una evolución adversa y fallo de múltiples órganos, requirió ventilación mecánica y soporte hemodinámico, hasta que fallece tras 11 días de tratamiento intensivo. Confirmamos la alta mortalidad de la enfermedad cuando produce fallo multiorgánico, y la necesidad de un diagnóstico precoz y tratamiento intensivo que incluya la posibilidad del trasplante hepático.

The acute fatty liver of pregnancy is considered like a rare and catastrophic hepatocellular dysfunction associated with the pregnancy. We present the case of a young adolescent with symptoms of the disease when she had 38.5 weeks of gestation. In a period of 10 days she develops asthenia, vomits, jaundice, diffuse abdominal pain and laboratory profile of hepatic insufficiency. Was necessary an emergent caesarean for maternal benefit and she were admitted immediately on intensive care unit. The clinical and humoral profile, image studies and laparoscopy confirmed the diagnostic hypothesis. She presented many obstetrical complications that motivated several surgeries. With an adverse evolution and multiorganic failure, she also required a mechanical ventilation and hemodynamic support, until she dies after 11 days of intensive treatment. We confirm the high mortality of the disease when it produces multiorganic failure, and the necessity of a precocious diagnosis and intensive treatment, including the possibility of liver transplant.