Chloride: The queen of electrolytes?

Berend, Kenrick; Hulsteijn, Leonard Hendrik van; Gans, Rijk O. B.

doi:10.1016/j.ejim.2011.11.013

Cited by 254 publications

(272 citation statements)

References 67 publications

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“…Chloride is the main anion of the extracellular fluid, and although its concentration in plasma is not as tightly regulated as that of Na + and K + , it has a central role in acidbase equilibrium [22,23]. Because of such physiological features, Cl -is also the main anion of any crystalloid solution given intravenously for fluid resuscitation and volume maintenance [7].…”

Section: The Importance Of Chloride Content and Its Pathophysiologic mentioning

confidence: 99%

Intravenous balanced solutions: from physiology to clinical evidence

Länger

Santini

Scotti

et al. 2015

Anaesthesiol Intensive Ther

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Abstract"Balanced" solutions are commonly defined as intravenous fluids having an electrolyte composition close to that of plasma. As such, they should minimally affect acid-base equilibrium, as compared to the commonly reported 0.9% NaCl-related hyperchloremic metabolic acidosis. Recently, the term "balanced" solution has been also employed to indicate intravenous fluids with low chloride content, being the concentration of this electrolyte the most altered in 0.9% NaCl as compared to plasma, and based upon a suggested detrimental alteration of renal function associated with hyperchloremia. Despite efforts made towards its identification, the ideal balanced solution, with minimal effects on acid-base status, low chloride content, and adequate tonicity, is not yet available. After the accumulation of pre-clinical and clinical physiologic data, in the last three years, several clinical trials, mostly observational and retrospective, have addressed the question of whether the use of balanced solutions has beneficial effects as compared to the standard of care, sometimes even suggesting an improvement in survival. Nonetheless, the first large randomized controlled trial comparing the effects of a balanced vs. unbalanced solutions on renal function in critically-ill patients (SPLIT trial, the 0.9% saline vs. Plasma-Lyte 148 for Intensive Care Unit Fluid Therapy), just recently published, showed identical equipoise between the two treatments. In the present review, we offer a comprehensive and updated summary on this issue, firstly, by providing a full physiological background of balanced solutions; secondly, by summarizing their potential pathophysiologic effects; and lastly, by presenting the clinical evidence available to support their use at the present time.

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Section: The Importance Of Chloride Content and Its Pathophysiologic mentioning

confidence: 99%

Intravenous balanced solutions: from physiology to clinical evidence

Länger

Santini

Scotti

et al. 2015

Anaesthesiol Intensive Ther

View full text Add to dashboard Cite

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“…6,7 Of note is the role of chloride currents in the regulation of sodium/water homeostasis. 8 Aldosterone increases reabsorption of sodium by increasing the expression of sodium/chloride cotransporter in the luminal membranes of cells lining collective ducts, and low chloride was found to act on the The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.…”

Section: Putative Pathophysiologic Backgroundmentioning

confidence: 99%

“…8 Of the currently known several subtypes of chloride channels, 3 stand out, namely the phosphokinase-A-related chloride channel, stretch-activated chloride channel (similar or identical to the product of ClC-3 gene), and calciumdependent chloride channel. 6 These channels were found, with highly varied distribution and density, in most studied species and in most types of cells to be found in the heart, including the sinoatrial node, His-Purkinje system, and atrial and ventricular myocytes.…”

Section: Hypertensionmentioning

confidence: 99%

There Is More to Salt Than Just a Pinch of Sodium

Gąsowski

Cwynar

2013

Hypertension

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Much of what human life is about is water (60% of body mass) and a handful of solutes. Of the latter, main cations include sodium, potassium, calcium, and magnesium, and the anions include chloride, bicarbonate, phosphate and organic anions, and proteins. The concentrations of sodium (135-145 mmol/L) and chloride (95-106 mmol/L) predominate in serum and constitute the bulk of serum's osmolarity. In the course of evolution, complex regulatory mechanisms developed to keep the osmolarity (≈280 mosm/L) and thus amount of water at desired level. With it came the role of main solutes and their regulatory mechanisms (ie, renin-angiotensin-aldosterone system [RAAS]) in the regulation of blood pressure. Numerous studies demonstrated the role of sodium-based mechanisms in water homeostasis and blood pressure regulation. Recently, several well-designed studies showed that the level of ingested sodium correlated with the level of blood pressure or cardiovascular risk, and that the relationship is likely to assume a J-curve shape in population of patients with cardiovascular involvement or diabetes mellitus. 1 Studies Documenting Importance of ChlorideHowever, experimental studies performed over several decades pointed to the possibility that the form of ingested or infused sodium is of importance. Both in animal models and in human studies, Kurtz and Morris 2 and then Luft et al 3 were among those who showed that blood pressure elevated when sodium chloride was ingested or infused, but not when the salt used was sodium bicarbonate or sodium citrate. These and other similar studies led to the consideration of chloride as a possible factor in the regulation of blood pressure.Paradoxically, different picture arose when researchers related the concentration of chloride in serum to cardiovascular outcome. The major population-based study to investigate that was Belgian Interuniversity Research on Nutrition and Health. The main finding of this study was that the level of chloride ≤100 mmol/L as compared with higher levels was independently related to all-cause, cardiovascular, and noncardiovascular mortality. 4 In the current issue of Hypertension, McCallum et al 5 provide a robust confirmation of findings of De Bacquer et al, this time in treated patients with hypertension. The authors analyzed data of 12 968 patients with hypertension followed up at the Glasgow Blood Pressure Clinic. The accumulated followup amounted to 197 101 person-years. They found that patients in the lowest quintile of serum Cl − (<100 mmol/L), compared with all other patients, had a 20% higher mortality (all-cause, cardiovascular, and noncardiovascular). A 1-mmol/L increase in serum Cl − was associated with a 1.5% (hazard ratio, 0.985; 95% confidence interval, 0.98-0.99) reduction in all-cause mortality. However, the level of chloride was not longitudinally associated with the level of blood pressure. The relationships were independent of sodium, potassium, and bicarbonate levels and blood pressure values, and they held after adjustment for treatment wit...

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“…[54][55][56] In some of the earliest preclinical work in this field, Wilcox exposed 48 canines to intrarenal infusions of 1 of 6 hypertonic solutions, 2 of which contained chloride (NaCl and NH 4 Cl) and 4 of which did not (NaHCO 3 , Na Acetate, Dextrose, NH 4 Acetate). After 30 minutes of infusing chloride-containing fluids, renal blood flow, glomerular filtration rate, and urine output significantly declined.…”

Section: Concerns About Chloridementioning

confidence: 99%

Key Controversies in Colloid and Crystalloid Fluid Utilization

2015

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Nearly 2 centuries have passed since the use of intravenous fluid became a foundational component of clinical practice. Despite a steady stream of published investigations on the topic, questions surrounding the choice, dose, timing, targets, and cost-effectiveness of various fluid options remain insufficiently answered. In recent years, 2 of the most debated topics reference the role of albumin in acute care and the safety of normal saline. Although albumin has a place in therapy for specific patient populations, its high cost relative to other fluids makes it a less desirable option for hospitals and health systems with escalating formulary scrutiny. Pharmacists bear responsibility for reconciling this disparity and supporting the rational use of albumin in acute care through a careful evaluation of recently published literature. In parallel, it has become clear that crystalloids should no longer be considered a homogenous class of fluids. The past reliance on normal saline has been questioned due to recent findings of renal dysfunction attributable to the solution's supraphysiologic chloride concentration. These safety concerns with 0.9% sodium chloride may result in a practice shift toward more routine use of "balanced crystalloids," such as lactated Ringer's or Plasma-Lyte, that mimic the composition of extracellular fluid. The purpose of this review is to summarize the evidence regarding these 2 important fluid controversies that are likely to affect hospital pharmacists in the coming decades -the evidence-based use of human albumin and the rising role of balanced salt solutions in clinical practice.

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Chloride: The queen of electrolytes?

Cited by 254 publications

References 67 publications

Intravenous balanced solutions: from physiology to clinical evidence

Intravenous balanced solutions: from physiology to clinical evidence

There Is More to Salt Than Just a Pinch of Sodium

Key Controversies in Colloid and Crystalloid Fluid Utilization

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