Effect of restrictive fluid resuscitation on severe acute kidney injury in septic shock: a systematic review and meta-analysis.

Summary

In nine RCTs (n=3718), restrictive fluid resuscitation reduced severe AKI in septic hypotension/shock (RR 0.87, 95% CI 0.79–0.96). Ventilator duration may also be shorter, though heterogeneity was substantial; overall certainty was moderate or higher by GRADE.

Key Findings

• Meta-analysis of nine RCTs (3718 patients) shows restrictive fluids reduce severe AKI (RR 0.87, 95% CI 0.79–0.96).
• Ventilation duration may be shorter with fluid restriction, but heterogeneity across trials is substantial.
• GRADE profiles indicate moderate-or-higher certainty; TSA, sensitivity, and subgroup analyses were performed.

Clinical Implications

Consider adopting restrictive fluid strategies with close hemodynamic monitoring to reduce severe AKI in septic shock, integrating vasopressors and dynamic preload assessment. Protocols should specify fluid thresholds and reassessment intervals.

Limitations

• Substantial heterogeneity in ventilation outcomes and potentially in fluid protocols and AKI definitions
• Mortality and long-term renal outcomes were not the primary focus in the abstracted results

Future Directions

Harmonize fluid restriction protocols (volume thresholds, monitoring) and evaluate mortality, dialysis dependence, and patient-centered outcomes in pragmatic multicenter RCTs.