Supplemental Digital Content Supplemental Methods Inclusion/exclusion criteria : Patients were included who presented with severe sepsis and/or septic shock on the day of admission to the ICU, i.e. on day 0. Day 0 had a variable amount of hours up to a maximum of 24 hours, depending on the time of admission. Day 1 started on midnight following admission. Patients were excluded from analysis if they were < 18 years, had received solid organ transplantation, had renal failure requiring hemodialysis before ICU, received extracorporeal membrane oxygenation, if serum creatinine values were missing at admission, or if they were admitted during the 1 month wash-out period between changes in resuscitative fluid regimens. Sepsis was defined according to consensus conference definitions, and severe sepsis was defined by sepsis plus at least one organ failure (27). Screening for the presence of severe sepsis or septic shock was performed routinely by the senior ICU physicians and documented by trained research nurses.
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Supplemental Digital Content
Supplemental Methods
Inclusion/exclusion criteria: Patients were included who presented with severe sepsis and/or
septic shock on the day of admission to the ICU, i.e. on day 0. Day 0 had a variable amount of
hours up to a maximum of 24 hours, depending on the time of admission. Day 1 started on
midnight following admission. Patients were excluded from analysis if they were < 18 years, had
received solid organ transplantation, had renal failure requiring hemodialysis before ICU,
received extracorporeal membrane oxygenation, if serum creatinine values were missing at
admission, or if they were admitted during the 1 month wash-out period between changes in
resuscitative fluid regimens.
Sepsis was defined according to consensus conference definitions, and severe sepsis was defined
by sepsis plus at least one organ failure (27). Screening for the presence of severe sepsis or septic
shock was performed routinely by the senior ICU physicians and documented by trained research
nurses.
Severe sepsis was defined as the presence of microbiologically proven, clinically proven, or
suspected infection; presence of Systemic Inflammatory Response Syndrome (SIRS); and
development of at least one organ dysfunction within the last 24 hours. Diagnosis of SIRS
required the fulfillment of at least two of the following criteria: hypo- (≤36°C) or hyperthermia
HES hydroxyethyl starch. P values were calculated with Fisher’s exact test. For p value adjustment the Bonferroni-Holm method was used.a Nonsteroidal anti-inflammatory drugs, including ibuprofen and diclofenacb including mannitol and furosemidec angiotensin-converting enzyme (ACE) inhibitors, including ramipril, perindopril, lisinopril and enalaprild including tobramycin and gentamicine including amphotericin B and fluconazole
Supplemental Table 2: Parameters at onset of renal replacement therapy
HES group(n = 120)
p value Gelatin group(n = 111)
p value Crystalloid group(n = 74)
Serum creatinine (µmol/l) at onset renal replacement therapy, median [IQR]
277 [213-363]
< 0.001 162[121-244]
0.209 191[137-248]
Mean urine output at onset renal replacement therapy, (ml/kgBW/h), median [IQR]
0.19[0.06-0.49]
0.602 0.25[0.12-0.58]
0.237 0.22[0.06-0.53]
Serum potassium levels at onset renal replacement therapy, (mmol/L), median [IQR]
5.0[4.6-5.4]
0.591 4.9[4.6-5.4]
0.648 4.8 [4.6-5.3]
Serum bicarbonate levels at onset renal replacement therapy, (mmol/L), median [IQR]
20.1[17.6-22.2]
0.911 20.8[17.2-23.2]
0.331 20.1[17.7-22.2]
paO2/FiO2-ratios at onset renal replacement therapy, (%), median [IQR]
218[170-283]
0.789 203[157-270]
0.344 218[153-289]
HES hydroxyethyl starch, IQR interquartile range. P values were calculated with the Mann–Whitney test.
Supplemental Table 3: Multiple logistic regression analysis with RRT as dependent binary variable.
Cardiac / thoracic surgery: yes vs. no 1024 2.96 (2.14,4.11) < 0.001
Liver cirrhosis: yes vs. no 1024 2.30 (1.31,4.03) 0.004
Antimycotics: yes vs. no 1024 1.50 (0.99,2.29) 0.057
Vancomycin: yes vs. no 1024 2.58 (1.86,3.58) < 0.001
Ionidated contrast media: yes vs. no 1024 2.32 (1.61,3.35) < 0.001
Human albumin 20%: yes vs. no 1024 2.06 (1.51,2.83) < 0.001
Added after model selection:
Period effects:Period: ref.=Crystalloids
Gelatin 4% 1024 1.92 (1.32,2.82) < 0.001
HES 6% (130/0.4) 1024 2.01 (1.34,3.02) < 0.001HES hydroxyethyl starch Variables considered in the analysis: age, liver cirrhosis, diabetes, baseline creatinine, baseline SAPS-II, cardiac / thoracic surgery, non-steroidal anti-inflammatory drugs, ACE inhibitors, aminoglycosides, antimycotics, vancomycin, ionidated contrast media, diuretics, human albumin 20%, study period using dummy coding. Forward and backward stepwise multiple logistic regression analysis based on AIC (Akaike Information Criterion) was used to derive a multivariable model where the Hosmer-Lemeshow goodness of fit test (C-test: p = 0.108, H-test: p = 0.281) and ROC curve analysis (AUC = 0.67) indicate an acceptable fit and discrimination, respectively. P values were obtained by Wald's test. After model selection the period effect was studied.
Supplemental Figure 1: Patient flow
1 Mainly patients receiving heart, lung or liver transplants. Patients undergoing renal transplantation were treated by urologists at a different location and are therefore not included.
All surgical ICU patients (1st Jan 2004 – 30th Apr 2010), n = 24326
Excluded: < 18 years n = 428Prior renal replacement therapy n = 718Solid organ transplantation1 n = 575Extracorporal membrane oxygenation (ECMO) n = 155No baseline creatinine n = 511 month wash-out period between fluid changes n = 642
HES periodn = 7069
Gelatin periodn = 7783
Crystalloid periodn = 6905
HES periodn = 7069
Gelatin periodn = 7783
Crystalloid periodn = 6905
Excluded: No criteria for severe sepsis / septic shock n = 20711
HES periodn = 360
Gelatin periodn = 352
Crystalloid periodn = 334
HES periodn = 360
Gelatin periodn = 352
Crystalloid periodn = 334
Supplemental Figure 2: Heart rate, MAP, CVP, ScvO2, hemoglobin and noradrenaline dose during the ICU stay. Daily means of heart rate, mean arterial pressure (MAP), central venous pressure (CVP), central venous saturation concentrations (ScvO2), hemoglobin values, and cumulative daily dose of noradrenaline, presented as median and interquartile ranges. ***/+++ p < .001, **/++p < .01, */+p < .05 (*comparisons between HES and crystalloid groups; +comparisons between gelatin and crystalloid groups); n denotes patients with available data.
Supplemental Figure 3: Daily procalcitonin serum levels. Presented as median and interquartile ranges, +p < .05 (+comparisons between gelatin and HES groups); n denotes patients with available data.