The relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock

Guirgis, Faheem W.; Williams, Deborah; Hale, Matthew; Bajwa, Abubakr; Shujaat, Adil; Patel, Nisha R.; Kalynych, Colleen; Jones, Alan E.; Wears, Robert L.; Dodani, Sunita

doi:10.1016/j.ajem.2014.12.013

Cited by 8 publications

(4 citation statements)

References 32 publications

(41 reference statements)

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“…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%

“…In addition, unfortunately, methodology, terminology, amount of total volume applied, and triggers for RRT differed considerably between trials. Overall, it appears that trials with lower total amount of Cl − infusion (i.e., 1–2 L/24 h) found unaffected AKI rates [ 37 , 59 ], whereas trials with higher infusion rates showed an increased AKI incidence and RRT need [ 4 , 35 , 46 , 57 ] suggesting a dose-dependent effect. Despite the enormous heterogeneity in the available literature which makes it almost incomparable, a recently published meta-analysis [ 33 ] included randomized and non-randomized trials concluded that use of chloride-rich fluids is associated with a higher AKI risk.…”

Section: Reviewmentioning

confidence: 99%

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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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Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Serum chloride levels in critical illness—the hidden story

Pfortmueller

Uehlinger

Haehling

et al. 2018

ICMx

108

View full text Add to dashboard Cite

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“…Additionally, in animals and humans, it was shown that infusion of normal saline is associated with markedly decreased renal perfusion pressures [11,12,61,68]; however, with respect to patientcentered outcomes, such as occurrence of acute kidney injury (AKI) and the need for renal replacement therapy (RRT), the discussion remains controversial [5,12,26,29,62,70,[82][83][84][85][86][87]. Whereas some trials did not observe a change in creatinine or an increased rate of AKI under chloride-rich infusates in both general intensive care unit (ICU) patients and in patients with sepsis [5,83,86], others demonstrated a markedly increased incidence of AKI and need for RRT under infusion of normal saline [12,26,29,82,87]. This effect remained significant after adjusting for confounders such as illness severity, operative status, mechanical ventilation, and type of admission [26,29,82].…”

Section: Renal Functionmentioning

confidence: 99%

Crystalloid fluid choice in the critically ill

Pfortmueller

Kabon

Schefold

et al. 2018

Wien Klin Wochenschr

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Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.

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“…Demographic data (age, gender) Haemodynamic parameters (cardiac index [10], central venous pressure [10,11], blood pressure [10,12,17], heart rate, central/mixed venous oxygen saturation = ScvO2/SvO2, pulmonary capillary occlusion pressure (PAOP) [10]) Use of inotropic [18,19] and vasoactive [19] drugs (epinephrine, norepinephrine, milrinone, dobutamine and levosimendan) Laboratory parameters (blood gas analysis including lactate [19][20][21][22], HCO 3 − , sodium [23], potassium, blood sugar concentration [24] and need for insulin therapy [25] with respect to need for immunosuppressive therapy [26]) Parameters of renal function (creatinine, creatinine clearance, blood urea nitrogen, cystatine C, urine output, potassium, urinary protein/albumin, urinary sediment analysis, sodium excretion fraction, need for renal replacement therapy) [17,[27][28][29][30][31][32][33][34][35][36] Creatinine Trial measurements…”

Section: Established Parametersmentioning

confidence: 99%

Impact of amount of fluid for circulatory resuscitation on renal function in patients in shock: evaluating the influence of intra-abdominal pressure, renal resistive index, sublingual microcirculation and total body water measured by bio-impedance analysis on haemodynamic parameters for guidance of volume resuscitation in shock therapy: a protocol for the VoluKid pilot study–an observational clinical trial

et al. 2018

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Background: All forms of shock, particularly septic shock, that involve insufficient blood supply to tissues to meet metabolic demands are main causes of morbidity and mortality worldwide and develop in one third of patients admitted to the intensive care unit (ICU). This alarmingly high incidence underlines the importance of further research in this field. Uncertainty remains about the undeceiving parameters for guidance of fluid resuscitation to avoid acute kidney injury (AKI) and renal replacement therapy. However, there are consequences of fluid overload (e.g. organ oedema and high interstitial pressures). This proposed study aims to establish a new framework of parameters for the guidance of fluid resuscitation in shock therapy focusing on the first 72 h, amending the currently used parameters (i.e. cardiac output, heart rate, blood pressure, central venous pressure) with an array of additional measurements including assessment of total body water (TBW), renal vascular resistance (renal resistive index (RRI)), intra-abdominal pressure (IAP) and microcirculatory blood flow (MBF).

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The relationship of intravenous fluid chloride content to kidney function in patients with severe sepsis or septic shock

Cited by 8 publications

References 32 publications

Serum chloride levels in critical illness—the hidden story

Serum chloride levels in critical illness—the hidden story

Crystalloid fluid choice in the critically ill

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