Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients

Suetrong, Bandarn; Pisitsak, Chawika; Boyd, John H.; Russell, James A.; Walley, Keith R.

doi:10.1186/s13054-016-1499-7

Cited by 146 publications

(149 citation statements)

References 46 publications

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“…The different fluid types have difference effects on different diseases, populations and genders. For example, patients with sepsis may more sensitive to metabolic acidosis and may suffer more AKI or increased mortality [22,23]. The patients included in this analysis come from different sources, but with the limited studies included in this meta-analysis, we could not perform more subgroup or sensitivity analyses.…”

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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“…While the debate of the previous decades focused on hypotonic versus isotonic maintenance fluids, 3,4 the current debate centers around balanced versus unbalanced salt solutions fueled by emerging evidence suggesting an association between hyperchloremia and adverse patient outcomes. [14][15][16][17][18] It is currently unclear whether the incidence of hyperchloremia and HCMA in critically ill children is rising over time, as previous studies focused primarily on sodium concentration and fluid tonicity. [2][3][4][5] The primary source of hyperchloremia in critically ill children therefore has not been well established.…”

Section: Discussionmentioning

confidence: 99%

“…These adverse events were chosen as they are reported in the literature to be associated with HCMA. [14][15][16][17][18] Hyperchloremia was defined as a serum chloride of >107 mmol/L. 19,20 HCMA was defined as hyperchloremia associated with a metabolic acidemia (serum pH of <7.35 and bicarbonate of <23 mmol/L and/ or a base deficit of >5 mEq/L).…”

Section: Outcomes Measuresmentioning

confidence: 99%

Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia?

Bulfon

Alomani

Anton

et al. 2019

J Pediatr Intensive Care

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Our objective is to evaluate intravenous (IV) fluid prescription practice patterns in critically ill children in the first 72 hours of pediatric intensive care unit (PICU) admission and to evaluate the incidence and predictors of hyperchloremic metabolic acidemia (HCMA) and the association between HCMA and adverse outcomes. This retrospective cohort study was conducted in two tertiary-care Canadian PICUs. Children aged 0 to 18 years admitted to the PICU between January 2015 and January 2016 who received at least 50% of their calculated maintenance fluid requirements parenterally during the first 24 hours of admission were included. Children with known preexisting conditions associated with HCMA, such as renal tubular acidosis and gastrointestinal bicarbonate losses, were excluded. Of the 771 children screened, 543 met eligibility criteria and were included. The commonest prescribed maintenance fluid was 0.9% NaCl (72.9%) followed by lactated Ringer's solution (19.6%) and hypotonic solutions (4.6%). Balanced salt solutions (i.e., lactated Ringer's and Plasma-Lyte) were as commonly administered as unbalanced solutions (0.9% NaCl) for volume expansion (49.6 vs. 48.5%, respectively). Medications contributed to a significant proportion of total daily intake, in excess of bolus fluids. The incidence of hyperchloremia and HCMA was 94.9% (95% confidence interval [CI]: 93.2–96.9; 470/495) and 38.9% (95% CI: 34.6–43.2; 196/504), respectively. Predictors of HCMA were increasing combined bolus and maintenance 0.9% NaCl intake (odds ratio: 1.13; 95% CI: 1.04–1.23) and increasing severity of illness. HCMA was not associated with an increased risk of acute kidney injury, feeding intolerance, or PICU-acquired weakness. Isotonic fluids, specifically 0.9% NaCl, were the most commonly administered maintenance IV fluid in critically ill children. Sources of chloride load are not isolated to resuscitation fluids as previously suggested. Maintenance fluids and fluids administered with medications and IV flushes (fluid creep) are under-recognized significant sources of fluid and electrolyte intake in critically ill children. HCMA is common, and further prospective research is required to determine whether HCMA is indeed harmful in children. However, all significant sources of fluid should be accounted for in the design of future trials comparing balanced and unbalanced salt solutions.

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“…The finding that hyperchloremic acidosis was associated with worse outcome is also notable because this form of acidosis is not clearly as hazardous from a clinical perspective [ 20 ] although animal studies have shown deleterious effect of hyperchloremia in experimental sepsis [ 21 , 22 ] and in agreement of this recent studies in human reported similar findings. [ 18 , 23 – 25 ]…”

Section: Discussionmentioning

confidence: 99%

Acid base variables predict survival early in the course of treatment with continuous venovenous hemodiafiltration

Passos

Caldas²,

Ramos³

et al. 2018

Medicine

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Metabolic acid–base disorders, especially metabolic acidosis, are common in critically ill patients who require renal replacement therapy. Continuous veno-venous hemodiafiltration (CVVHDF) achieves profound changes in acid–base status, but metabolic acidosis can remain unchanged or even deteriorate in some patients. The objective of this study is to understand the changes of acid–base variables in critically ill patients with septic associated acute kidney injury (SA-AKI) during CVVHDF and to determine how they relate to clinical outcome.Observational study of 200 subjects with SA-AKI treated with CVVHDF for at least 72 hours. Arterial blood gases and electrolytes and other relevant acid–base variables were analyzed using quantitative acid–base chemistry.Survivors and nonsurvivors had similar demographic characteristics and acid–base variables on day one of CVVHDF. However, during the next 48 hours, the resolution of acidosis was significantly different between the 2 groups, with an area under the ROC curve for standard base excess (SBE) and mortality of 0.62 (0.54–0.70), this was better than APACHE II score prediction power. Quantitative physicochemical analysis revealed that the majority of the change in SBE was due to changes in Cl and Na concentrations.Survivors of SA-AKI treated with CVVHDF recover hyperchloremic metabolic acidosis more rapidly than nonsurvivors. Further study is needed to determine if survival can be improved by measures to correct acidosis more rapidly.

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Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients

Cited by 146 publications

References 46 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

Intravenous Fluid Prescription Practices in Critically Ill Children: A Shift in Focus from Natremia to Chloremia?

Acid base variables predict survival early in the course of treatment with continuous venovenous hemodiafiltration

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