Compared to conservative fluid resuscitation strategies, guideline-directed fluid resuscitation potentially harmful in sepsis with ESRD: Study
USA: A recent systematic review and meta-analysis has revealed significant findings regarding fluid resuscitation strategies for end-stage renal disease (ESRD) patients presenting with sepsis. The study challenges widely held assumptions about the benefits of guideline-directed fluid resuscitation (GDFR) in this vulnerable population, suggesting that this approach might not only be less effective than previously thought but could also pose potential risks.
"Our research challenges the prevailing assumption regarding the effectiveness of GDFR for sepsis patients with end-stage renal disease," the researchers wrote in the Journal of Intensive Care Medicine.
Sepsis, a severe and often life-threatening infection, frequently necessitates fluid resuscitation to stabilize blood pressure and improve organ perfusion. For patients with ESRD, however, this treatment can be particularly complex due to their compromised renal function. Traditionally, GDFR—an aggressive strategy aimed at achieving specific hemodynamic targets through fluid administration—has been considered a key intervention for managing sepsis in critically ill patients.
Against the above background, Georges Khattar, Department of Internal Medicine, Staten Island University Hospital/Northwell Health, Staten Island, NY, USA, and colleagues aimed to examine the efficacy and safety of guideline-directed fluid resuscitation compared with conservative fluid management in ESRD patients with sepsis by evaluating 90-day mortality and intubation rate.
For this purpose, the researchers conducted a systematic review adhering to PRISMA guidelines, searching multiple databases with specific keywords and controlled vocabulary. The search, conducted up to October 1, 2023, aimed to identify studies on fluid resuscitation in ESRD patients with sepsis.
The review process was streamlined using Covidence software, with a fourth reviewer addressing any discrepancies in study inclusion. The analysis employed a random-effects model with the Mantel–Haenszel method to integrate odds ratios (ORs) and included sensitivity analysis and publication bias assessment.
Based on the study, the researchers reported the following findings:
- Of the 1274 identified studies, 10 were selected for inclusion, examining 1184 patients, 593 of whom received GDFR. Four studies were selected to investigate the intubation rate, including 304 patients.
- There were no significant mortality or intubation rate differences between the groups [OR = 1.23 and OR = 1.91].
- In most studies, sensitivity analysis using the leave-one-out approach revealed higher mortality and intubation rates.
- The Egger test results indicated no statistically significant publication bias across the included studies.
"The results indicate that goal-directed fluid resuscitation is not more effective than a conservative resuscitation strategy for patients with sepsis and end-stage renal disease and may even be harmful. This highlights a significant research gap, underscoring the need for further studies to better understand the optimal approach in this area," the researchers concluded.
Reference:
Khattar, G., El Gharib, K., Pokima, N., Kotys, J., Kandala, V., Mina, J., Haddadin, F., Abu Baker, S., Asmar, S., Rizvi, T., Flamenbaum, M., Elsayegh, D., Chalhoub, M., El Hage, H., & El Sayegh, S. (2024). Fluid Resuscitation Dilemma in End-stage Renal Disease Patients Presenting with Sepsis: A Systematic Review and Meta-analysis. Journal of Intensive Care Medicine. https://doi.org/10.1177/08850666241261673
