Predictors of Acute Kidney Injury in Neurocritical Care Patients Receiving Continuous Hypertonic Saline

Abstract

Background and Purpose: Continuous intravenous 3% hypertonic saline (HTS) infusions are commonly used for the management of cerebral edema following severe neurologic injuries. Despite widespread use, data regarding the incidence and predictors of nephrotoxicity are lacking. The purpose of this study was to describe the incidence and identify predictors of acute kidney injury (AKI) in neurocritical care patients administered continuous infusion HTS. Methods: This was an institutional review board-approved, multicenter, retrospective cohort study of patients receiving HTS infusions at 2 academic medical centers. A univariate analysis and multivariable logistic regression were used to identify predictors of AKI. Data regarding AKI were evaluated during treatment with HTS and up to 24 hours after discontinuation. Results: A total of 329 patients were included in our analysis, with 54 (16%) developing AKI. Those who developed AKI experienced significantly longer stays in the intensive care unit (14.8 vs 11.5 days; P ¼ .006) and higher mortality (48.1% vs 21.9%; P < .001). We identified past medical history of chronic kidney disease (odds ratio [OR]: 9.7, 95% confidence interval [CI]: 1.9-50.6; P ¼ .007), serum sodium greater than 155 mmol/L (OR: 4.1, 95% CI: 2.1-8.0; P < .001), concomitant administration of piperacillin/tazobactam (OR: 3.9, 95% CI: 1.7-9.3; P ¼ .002), male gender (OR: 3.2, 95% CI: 1.5-6.6; P ¼ .002), and African American race (OR: 2.6, 95% CI: 1.3-5.2; P ¼ .007) as independent predictors of AKI. Conclusion: Acute kidney injury is relatively common in patients receiving continuous HTS and may significantly impact clinical outcomes.

Higher incidence of acute kidney injury in patients treated with piperacillin/tazobactam than in patients treated with cefepime: a single-center retrospective cohort study

“…In this study, PIPC/TAZ was identified as a significant risk factor of AKI in multivariate analysis. Erdman and colleagues reported that PIPC/TAZ was an independent risk factor of AKI in neurocritical care patients receiving continuous infusion of hypertonic saline [15]. Our results also showed that PIPC/TAZ increases the risk of AKI.…”

Role of continuous hypertonic saline in acute ischemic infarcts: a systematic literature review

“…However, of these studies, only five involved continuous administration of hypertonic saline and were thus included for data synthesis (Fig. 1, Table 1) [10][11][12][13][14]. The overall quality of the studies as determined by the Newcastle-Ottawa scale ranged from fair to good, and most were limited by follow-up length and comparability of the study groups (Table 2) [10][11][12][13][14].…”

“…In 2017, Erdman et al [14] conducted a two-center retrospective cohort review to assess predictors of acute kidney injury in 337 patients receiving hypertonic saline infusion for severe neurological injuries-113 with ischemic strokes. Acute kidney injury occurred in 16% of patients receiving hypertonic saline.…”

Management of Acute Ischemic Stroke

“…There is no definitive data whether one hyperosmolar agent is superior to the other, and the choice can be guided by their individual side effects. Potential complications of HTS use are fluid overload, pulmonary edema, hypokalemia, cardiac arrhythmias, hyperchloremic metabolic acidosis, acute kidney injury, and dilutional coagulopathy ( 63 , 64 ). To avoid rebound edema, HTS should be gradually tapered and the serum sodium level should never be allowed to drop more than 10–12 mEq/L over 24 hours ( 63 , 65 ).…”