Anchoring Sepsis Management: A Retrospective Cohort Study on Fluid Resuscitation in Advanced and ESRD

Background: Physicians are hesitant to give fluid boluses to renal failure patients, which is significant given the frequency end stage renal disease (ESRD) patients develop sepsis and septic shock. The aim of this study was to assess the relationship between the volume of fluid given for sepsis and mortality in patients with advanced chronic kidney disease (CKD) and ESRD. Methods: A multicenter retrospective cohort study of CKD and ESRD patients who were admitted for sepsis was conducted across 16 West Florida hospitals. Inclusion criteria was non-pregnant adult patients admitted between January 1, 2021 and December 31, 2022 with CKD4, CKD5 or ESRD for sepsis and having received a fluid bolus within 6 hours of admission. Patients (n=4,265) were grouped by Standard (greater than 30mL/kg), Conservative (15-30ml/kg), or Ultra-conservative (less than 15mL/kg) fluid bolus. Sub-analysis was then performed among those patients who were either oliguric (less than 0.5mL/kg/hr) or anuric (n=2,344). Inhospital mortality was the primary outcome assessed, with secondary outcomes of ICU admission, vasopressor use, mechanical ventilation, and inpatient initiation of dialysis (IID). Results: In the Ultra-conservative group there was a reduction in odds ratio (OR) of vasopressor use (OR 0.723) and ICU admission (OR 0.484), with an increase in IID (OR 1.45) compared to Standard. No difference was seen in mortality or mechanical ventilation. In the Conservative group there was a reduction in vasopressor use (OR 0.717) and ICU admission (OR 0.67). No difference was seen in mortality, mechanical ventilation or IID. Within the oliguric and anuric subgroup, the Ultra-conservative group only had a significant reduction in Mechanical ventilation (OR 0.703) and ICU admissions (OR 0.536). Within the oliguric and anuric subgroup, the Conservative group had no difference in outcomes compared to Standard. Conclusion: There was no significant difference in mortality in either decreased volume group compared to Standard, although differences in ICU, vasopressor and dialysis use were noted. This study supports physician discretion for fluid bolus to patients who have poor renal function.