Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Nephron Clin Pract 2008;109:c206–c216 DOI: 10.1159/000142930 New Insights on Intravenous Fluids, Diuretics and Acute Kidney Injury Derek R. Townsend a, b Sean M. Bagshaw a a Division of Critical Care Medicine, Faculty of Medicine and Dentistry, and b Department of Anesthesiology and Pain Medicine, University of Alberta Hospital, University of Alberta, Edmonton, Alta., Canada review, we explore recent insights on intravenous fluid ther- apy, volume overload, and diuretic therapy in the context of the critically ill patients with AKI. Copyright © 2008 S. Karger AG, Basel Introduction Critically ill patients frequently present with or devel- op acute kidney injury (AKI). Recent studies would sug- gest the incidence is far greater than previously appreci- ated. Observational data have shown that AKI occurs in an estimated 36–67% of all ICU patients [1–3], while AKI severe enough to warrant commencement of renal re- placement therapy (RRT) occurs in 4–6% [4–6]. More- over, numerous investigations have now shown the inci- dence of AKI continues to rise [7–9]. This high and in- creasing burden of AKI also remains associated with an unacceptably high morbidity and mortality [5, 6, 8–12]. Fluid therapy represents an essential stratagem for the prevention and/or the management of critically ill pa- tients with AKI. New data have emerged that have raised concern that specific types of fluid (i.e. hydroxyethyl- starch; HES) may either contribute to or exacerbate AKI [13] . In addition, there is accumulating evidence that the unnecessary accumulation of fluid can negatively impact Key Words Acute kidney injury  Acute renal failure  Volume overload  Hydroxyethylstarch  Loop diuretic  Furosemide  Oliguria  Fluid therapy  Resuscitation Abstract Acute kidney injury (AKI) is commonly and increasingly en- countered in patients with critical illness. Fluid therapy is the cornerstone for the prevention and management of critical- ly ill patients with AKI. New data have emerged that have raised concern that specific types of fluid (i.e. hydroxyethyl- starch) may either contribute to or exacerbate AKI. Addition- al data have accumulated to indicate that the unnecessary accumulation of fluid and volume overload can negatively impact clinical outcomes. This finding may be further com- pounded in patients with oliguric AKI where solute and free water elimination are impaired. Diuretic therapy in AKI re- mains controversial. However, diuretic use is common, de- spite a paucity of evidence to show improved clinical out- comes. There are few therapeutic interventions proven to impact the clinical course and outcome of critically ill pa- tients with established AKI. Current management strategies center largely on supportive care, with rapid resuscitation, removal of the stimulus contributing to AKI, judicious avoid- ance of complications, and allowing time for recovery. In this Published online: September 18, 2008 Dr. Sean M. Bagshaw Division of Critical Care Medicine, University of Alberta Hospital 3C1.12 Walter C. Mackenzie Centre, 8440-112 Street Edmonton, Alta. T6G 2B7 (Canada) Tel. +1 780 407 6755, Fax +1 780 407 1228, E-Mail bagshaw@ualberta.ca © 2008 S. Karger AG, Basel 1660–2110/08/1094–0206$24.50/0 Accessible online at: www.karger.com/nec