CLOVERS and CKD – How Much Is Too Much Fluid?

August 20, 2024

Written by Clark Strunk

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This secondary analysis of the CLOVERS trial demonstrated a significant reduction in 90-day mortality, more ventilator free days, and more vasopressor free days among patients with advanced CKD and sepsis-induced hypotension randomized to a restrictive fluid strategy with earlier vasopressor use compared to a more liberal fluid strategy.

In advanced chronic kidney disease, fluid restriction will put you at ease…
This article is a secondary analysis of the CLOVERS RCT which compared a restrictive to a liberal fluid strategy in patients with sepsis-induced hypotension. The original study did not demonstrate a significant difference between approaches and was ultimately stopped due to futility. This post-hoc analysis included patients with advanced CKD (eGFR <30) and found in the restrictive group vs the liberal group a 90-day mortality of 21.7% vs 39.4% (p=0.009), 21 vs 16.5 ventilator-free days at 28 days (p=0.015), and 19.7 vs. 15.4 vasopressor-free days at 28 days (p=0.010), respectively. This effect was most prominent in the subgroup of patients with advanced CKD on dialysis. There was also more AKI in restrictive group compared to the liberal fluid group.

How will this change my practice?
Although the results of this analysis align with my bias, this trial will not change my practice as by the nature of its design, it is hypothesis generating. The amount of fluid I give a patient, and how much I rely on vasopressors, reflects my goal when providing a patient with intravenous fluid, including those with advanced CKD, which is to have sustained, salient hemodynamic effects while limiting adverse effects on other aspects of their physiology, which is always a patient specific determination. I will continue to make this judgement through the combination of considering a patient’s history, exam, comorbidities, current organ dysfunctions, while incorporating static and dynamic measures of fluid responsiveness, and being cognizant of current guidelines, and the limitations thereof.

Source
Fluid management for sepsis-induced hypotension in patients with advanced chronic kidney disease: a secondary analysis of the CLOVERS trial. Crit Care. 2024 Jul 11;28(1):231. doi: 10.1186/s13054-024-05019-6. PMID: 38992663; PMCID: PMC11238412.