Association of plasma chloride values with acute kidney injury in the critically ill – a prospective observational study

Marttinen, Maiju; Wilkman, Erika; Petäjä, Liisa; Suojaranta-Ylinen, Raili; Pettilä, Ville; Vaara, Suvi T.

doi:10.1111/aas.12694

Cited by 60 publications

(48 citation statements)

References 28 publications

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“…Normal saline is still the most commonly used crystalloid worldwide [5,24]. Many observational studies have shown that the use of normal saline is most likely associated with an increased incidence of AKI, hyperchloremic acidosis, coagulation disturbances, hemodynamic instability and mortality [25][26][27]. The balanced crystalloids in this meta-analysis contain Lactated Ringer's and Plasma-Lyte.…”

Section: Discussionmentioning

confidence: 99%

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Liu

Wang

et al. 2019

The American Journal of Emergency Medicine

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a b s t r a c tIntroduction: Fluid resuscitation is a fundamental component of the management of critically ill patients, but whether choice of crystalloid affects patient outcomes remains controversial. Therefore, we performed this meta-analysis to compare the efficacy and safety of balanced crystalloids with normal saline. Methods: We searched the MEDLINE, Cochrane Central and EMBASE up to October 2018 to identify randomized controlled trials (RCTs) that compared balanced crystalloids versus normal saline in critically ill patients. The primary outcome was mortality. The secondary results were the incidence of acute kidney injury (AKI) and risk of receiving renal replacement therapy (RRT). Two authors independently screened articles based on the inclusion and exclusion criteria. The meta-analysis was conducted using Revman 5.3, trial sequential analysis (TSA) 0.9 and STATA 12.0. Results: Nine RCTs were identified. The pooled analyses showed that there were no significant differences in mortality (relative risk (RR) = 0.93, 95% confidence interval (CI) = 0.86, 1.01, P = 0.08), incidence of AKI (RR 0.94, 95% CI 0.88, 1.00, P = 0.06) or RRT use rate (RR 0.94, 95% CI 0.69, 1.27, P = 0.67) between balanced crystalloids and normal saline groups. However, TSA did not provide conclusive evidence. Conclusions: Among critically ill patients receiving crystalloid fluid therapy, use of a balanced crystalloid compared with normal saline did not reduce the mortality, risk of severe AKI or RRT use rate. Further large randomized clinical trials are needed to confirm or refute this finding. Trial registration: A protocol of this meta-analysis has been registered on PROSPERO (registration number: CRD42018094857).

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Section: Discussionmentioning

confidence: 99%

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Liu

Wang

et al. 2019

The American Journal of Emergency Medicine

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“…Hyperchloremia has a high prevalence in critically ill patients with data showing that it may be observed in about 25–45% of ICU patients; however, this seems not acknowledged by previous research or textbooks. Data from a recent prospective observational investigation demonstrate that temporary hyperchloremia may even occur in 75% of ICU patients during the first 24 h of ICU stay [ 4 ]. However, despite a rather high prevalence in critically ill patients, few outcome-related data regarding systemic chloride levels exist.…”

Section: Reviewmentioning

confidence: 99%

“…Clinical studies, like animal experiments, showed mixed results regarding patient-centered clinical outcomes (e.g., need for renal replacement therapy (RRT)) in ICU patients [ 4 , 33 , 35 , 37 , 46 , 57 – 62 ] (see, Table 1 ). Whereas some clinical trials did not identify changes in serum creatinine or acute kidney injury (AKI) rates in mixed ICU cohorts, cardiac surgery, or sepsis [ 37 , 59 , 62 ], other reports demonstrate increased AKI incidence and need for renal replacement therapy (RRT) [ 4 , 46 , 57 ]. However, the sensitivity analysis of one of these trials showed that the incidence of AKI and need for renal replacement therapy were also influenced by other unidentified confounders [ 57 ], so the issue is far from being concluded.…”

Section: Reviewmentioning

confidence: 99%

Serum chloride levels in critical illness—the hidden story

Pfortmueller

Uehlinger

Haehling

et al. 2018

ICMx

108

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Chloride is the principal anion of the extracellular fluid and vital for both serum electroneutrality and acid-base homeostasis. The aim of this review is to investigate the relevance of dyschloremia in the critically ill.An extensive literature research was conducted on www.pubmed.org. In addition, the references of included articles were searched for further possible investigation regarding chloride.Articles investigating the relevance of dyschloremia in the critically ill were included.All articles were screened in regard to dyschloremia in the critically ill.Chloride is essential for blood pressure control, decarboxylation/gas transport, renal function, and gastrointestinal homeostasis. “Dyschloremia,” i.e., serum chloride levels not within the limits of normal, may commonly be observed on ICUs and appear mainly induced by iatrogenic measures (i.e., infusion of chloride-rich fluids). Hypo- and hyperchloremia appear linked to increased mortality in defined ICU populations, but evidence is sparse. Data show that hyperchloremia may not only be linked to hyperchloremic metabolic acidosis, but also to increased hemodynamic instability and vasopressor need (e.g., in patients after major surgery). Nevertheless, it is currently unknown whether such effects would be directly or indirectly mediated. Moreover, recent evidence points to an increased incidence of acute kidney injury and need for renal replacement therapy in patients with advanced hyperchloremia.Current knowledge on chloride is largely limited by heterogeneous trial design and mostly abundant data on specific fluid replacement strategies. The aim of this review is to summarize key consequences of chloride in critical illness and to discuss implications for daily clinical practice and future research.

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“…While this is likely multifactorial, one putative contributor is the extensive use of 0.9% saline as a resuscitative fluid in human medicine ( 22 , 23 ). It has been hypothesized that association between 0.9% saline administration and outcome relates to increased kidney injury in some patients ( 24 ).…”

Section: Introductionmentioning

confidence: 99%

Electrolyte Disturbances Are Associated with Non-Survival in Dogs—A Multivariable Analysis

2017

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Electrolyte disorders have been individually associated with mortality in small populations of dogs and cats with specific conditions, but the associations and interactions between electrolyte disturbances and outcome have not been evaluated in a large, heterogeneous population. It was hypothesized that abnormalities of sodium, chloride, potassium, and calcium concentrations would be independently and proportionately associated with death from natural causes and with all-cause mortality in dogs. An electronic database containing 33,117 electrolyte profiles was constructed to retrospectively assess the association between disorders of sodium, potassium, corrected chloride, and ionized calcium concentrations with non-survival and with death excluding euthanasia by multivariable modeling. A second database containing 11,249 records was used to validate the models constructed from the first database. All four electrolytes assessed had non-linear U-shaped associations with case fatality rates, wherein concentrations clustered around the reference interval had the lowest case fatality rates, while progressively abnormal concentrations were associated with proportionately increased risk of non-survival (AUROC 0.624) or death (AUROC 0.678). Multivariable modeling suggested that these electrolyte disturbances were associated with non-survival and with death from natural causes independent of each other. This study suggests that measurement of electrolyte concentrations is an important component of the assessment of dogs in emergency rooms or intensive care units. Future studies should focus on confirming these associations in a prospective manner accounting for disease severity.

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Association of plasma chloride values with acute kidney injury in the critically ill – a prospective observational study

Abstract: More than three of four critically ill patients had hyperchloremia and 1 of 10 had its severe form. Higher time-weighted mean chloride was independently associated with an increased risk for AKI.

Cited by 60 publications

References 28 publications

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Balanced crystalloids versus normal saline for fluid resuscitation in critically ill patients: A systematic review and meta-analysis with trial sequential analysis

Serum chloride levels in critical illness—the hidden story

Electrolyte Disturbances Are Associated with Non-Survival in Dogs—A Multivariable Analysis

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