Baseline Chloride Levels are Associated with the Incidence of Contrast-Associated Acute Kidney Injury

Prognosis value of serum chloride on 1-year mortality in cirrhotic patients receiving transjugular intrahepatic portosystemic shunt

BACKGROUND AND PURPOSE

Emerging researches have regarded serum chloride as a capable predictor of mortality in liver cirrhosis. We aim to investigate the clinical role of admission chloride in cirrhotic patients with esophagogastric varices receiving transjugular intrahepatic portosystemic shunt (TIPS), which is unclear.

METHODS

We retrospectively analyzed data of cirrhotic patients with esophagogastric varices undergoing TIPS in Zhongnan Hospital of Wuhan University. Mortality outcome was obtained by following up for 1-year after TIPS. Univariate and multivariate Cox regression were used to identify independent predictors of 1-year mortality post-TIPS. The receiver operating characteristic (ROC) curves were adopted to assess the predictive ability of the predictors. In addition, log-rank test and Kaplan-Meier (KM) analyses were employed to evaluate the prognostic value of predictors in the survival probability.

RESULTS

A total of 182 patients were included ultimately. Age, fever symptom, platelet-to lymphocyte-ratio (PLR), lymphocyte-to-monocyte ratio (LMR), total bilirubin, serum sodium, chloride, and Child-Pugh score were related to 1-year follow-up mortality. In multivariate Cox regression analysis, serum chloride (HR = 0.823, 95%CI = 0.757-0.894, p < 0.001) and Child-Pugh score (HR = 1.401, 95%CI = 1.151-1.704, p = 0.001) were identified as independent predictors of 1-year mortality. Patients with serum chloride <107.35 mmol/L showed worse survival probability than those with serum chloride ≥107.35 mmol/L no matter with or without ascites (p < 0.05).

CONCLUSION

Admission hypochloremia and increasing Child-Pugh score are independent predictors of 1-year mortality in cirrhotic patients with esophagogastric varices receiving TIPS.

Admission electrolyte and osmotic pressure levels are associated with the incidence of contrast-associated acute kidney injury

This retrospective study aimed to explore the relationships between electrolytes and osmotic pressure homeostasis with contrast-associated acute kidney injury (CA-AKI) risk in patients with percutaneous coronary intervention or coronary angiography. We totally enrolled 4386 hospitalized patients, who were categorized into five groups based on the predetermined cutoff values of electrolytes and osmotic pressure. CA-AKI was defined as an increase in serum creatine by 0.5 mg/dL (44.2 mol/L) or a 25% increase of the highest level post-operation compared to baseline. Multivariable logistic analysis was used to examine the association of CA-AKI incidence with electrolytes and osmotic pressure levels. Piecewise linear regression models and restricted cubic spline analysis were further utilized to determine the nonlinear relationship. The results showed U-shaped relationships between sodium, chloride, magnesium, and osmotic pressure levels and CA-AKI incidence. The lowest incidence was observed in the categories of 139–141.9 mmol/L, 107.0–109.9 mmol/L, 0.91–1.07 mmol/L, and 290.0–299.9 mOsm/kg, respectively. J-shaped associations were observed for potassium and phosphate levels and CA-AKI incidence, with the lowest incidence in the categories of 3.50–4.09 mmol/L and 0.96–1.28 mmol/L, respectively. A negative correlation was observed between calcium level and CA-AKI incidence, with the lowest CA-AKI risk in the category of ≥ 2.58 mmol/L. In conclusion, abnormally higher or lower sodium, chloride, magnesium, phosphate, and osmotic pressure levels on admission were associated with increased risks of CA-AKI. While for potassium and calcium, the status of hyperkalemia and hypocalcemia on admission showed more susceptibility for CA-AKI.

Visual Analytics for Predicting Disease Outcomes Using Laboratory Test Results

Laboratory tests play an essential role in the early and accurate diagnosis of diseases. In this paper, we propose SUNRISE, a visual analytics system that allows the user to interactively explore the relationships between laboratory test results and a disease outcome. SUNRISE integrates frequent itemset mining (i.e., Eclat algorithm) with extreme gradient boosting (XGBoost) to develop more specialized and accurate prediction models. It also includes interactive visualizations to allow the user to interact with the model and track the decision process. SUNRISE helps the user probe the prediction model by generating input examples and observing how the model responds. Furthermore, it improves the user’s confidence in the generated predictions and provides them the means to validate the model’s response by illustrating the underlying working mechanism of the prediction models through visualization representations. SUNRISE offers a balanced distribution of processing load through the seamless integration of analytical methods with interactive visual representations to support the user’s cognitive tasks. We demonstrate the usefulness of SUNRISE through a usage scenario of exploring the association between laboratory test results and acute kidney injury, using large provincial healthcare databases from Ontario, Canada.

Patterns of Calcium- and Chloride-Ion Disorders and Predictors among Obese Outpatient Adults in Southern Ethiopia

BACKGROUND

Obesity is a condition characterized by abnormal or excess accumulation of fat in body tissue, which may impair health and result in electrolyte derangement. Hypercalcemia and hypochloremia are significant problems in obese patients, and can cause substantial morbidity and mortality. Determination of patterns of calcium and chloride may play a major role in the management of obese patients. Therefore, this study aimed to determine calcium and chloride disorders and their predictors among obese adults in the outpatient department at Wolkite University Specialized Hospital, southern Ethiopia from May to August 2020.

METHODS

This institution-based cross-sectional study was conducted on 250 obese adults attending the outpatient department from May to August 2020. Structured questionnaires through face-to-face interviews and participants' medical records were used to collect information on determinants related to calcium- and chloride-ion disturbances. Levels of serum calcium and chloride were measured using an ion-selective electrode analyzer. Bivariate and multivariate logistic regression analyses were done to identify determinants associated with calcium and chloride disorders. Using ORs and 95% CIs,P<0.05 was considered significant.

RESULTS

Among the 250 patients, 18% (95% CI 53.02-111) and 17.6% (95% CI 0.78-12) of study participants were hypochloremic and hypercalcemic, respectively. Age ≥50 years (AOR 3.58, 95% CI 2.57-11.10), diuretic use (AOR 2.35, 95% CI 1.31-4.23), and obesity (AOR, 6.82, 95% CI 2.26-14.62) were independent predictors of hypochloremia on multivariate logistic regression, and obesity (AOR 9.21, 95% CI 2.50-14.81), overweight (AOR 8.32, 95% CI 1.61-10.20) and physical inactivity (AOR 4.28, 95% CI 1.71-10.44) were predictors of hypercalcemia.

CONCLUSION

High burdens of hypochloremia (18%) and hypercalcemia (17.6%) were observed in these patients. Increased age, diuretic use, being overweight, and physical inactivity were predictors of electrolyte disorders. The findings of this study should be taken into consideration to implement preventive interventions on these predictors in obese patients. Promoting sufficient fruit and vegetable consumption and physical exercise and determination of serum-chloride and -calcium levels in adult overweight/obese patients are recommended to minimize the emergence of electrolyte disorders.

Usefulness of chloride levels for fluid resuscitation in patients undergoing targeted temperature management after out-of-hospital cardiac arrest

OBJECTIVE

Chloride is an important electrolyte in the body. In this study, we aimed to evaluate the associations between chloride levels on emergency department (ED) admission and neurologic outcomes by stratifying patients undergoing targeted temperature management (TTM) after out-of-hospital cardiac arrest (OHCA) into three groups (hyper/normo/hypochloremia); we also assessed the effect of changes in chloride levels from baseline over time on outcomes.

METHODS

This retrospective, observational cohort study of 346 patients was conducted between 2011 and 2019. The chloride levels were categorized as hypochloremia, normochloremia, and hyperchloremia by predetermined definitions. The primary endpoint was poor neurologic outcomes after hospital discharge. We evaluated the associations between chloride levels on ED admission and neurologic outcomes and assess the effect of changes in chloride levels over time on clinical outcomes.

RESULTS

On ED admission, compared with normochloremia, hypochloremia was significantly associated with unfavorable neurologic outcomes (OR, 2.668; 95% CI, 1.217-5.850, P = 0.014). Over time, unfavorable neurologic outcomes were significantly associated with increases in chloride levels in the hyperchloremia and normochloremia groups after ED admission. The rates of poor neurologic outcomes in the hyperchloremia and normochloremia groups were increased by 14.2% at Time-12, 20.1% at Time-24, and 9.3% at Time-48 with a 1-mEq/L increase in chloride levels.

CONCLUSION

In clinical practice, chloride levels can be routinely and serially measured cost-effectively. Thus, baseline chloride levels may be a promising tool for rapid risk stratification of patients after OHCA. For fluid resuscitation after cardiac arrest, a chloride-restricted solution may be an early therapeutic strategy.

Quantitative Analysis of Microperfusion in Contrast-Induced Nephropathy Using Contrast-Enhanced Ultrasound: An Animal Study

OBJECTIVE

To investigate imaging biomarkers of microperfusion in contrast-induced nephropathy (CIN) using contrast-enhanced ultrasound (CEUS).

MATERIALS AND METHODS

The CIN model was fabricated by administering indomethacin (10 mg/kg), L-NAME (15 mg/kg), and iopamidol (10 mL/kg) to Sprague-Dawley rats. After 24 hours, CEUS was performed on CIN (n = 6) and control (n = 6) rats with sulphur hexafluoride microbubbles (SonoVue). From time-intensity curves obtained from the kidney arriving time (AT), acceleration time (AC), time to peak (TTP), and peak enhancement (PE) were measured and compared between the groups. After CEUS, the rats were sacrificed, and cell apoptosis markers were evaluated to confirm the development of CIN.

RESULTS

Among CEUS parameters, AT (7.8 ± 1.6 vs. 4.2 ± 0.5 s, p = 0.002), AC (4.7 ± 1.4 vs. 2.0 ± 0.4 s, p = 0.002), and TTP (12.5 ± 2.9 vs. 6.2 ± 0.6 s, p = 0.002) were significantly prolonged in the CIN group compared to controls. PE was significantly higher in the control group than in the CIN group (17.1 ± 1.9 vs. 12.2 ± 2.0 dB, p = 0.004). In kidney tissue, mRNA and protein levels of the apoptotic makers were significantly higher in the CIN group than in the control group (p = 0.003 and p = 0.002).

CONCLUSION

CEUS parameters can be used as imaging biomarkers for microperfusion in CIN. In rats with CIN, AT, AC, and TTP were significantly prolonged, while PE was significantly lower compared to controls.

Association of Chloride Ion and Sodium-Chloride Difference With Acute Kidney Injury and Mortality in Critically Ill Patients

Objectives

Derangements of chloride ion concentration ([Cl^-]) have been shown to be associated with acute kidney injury and other adverse outcomes. For a physicochemical approach, however, chloride ion concentration should be considered with sodium ion concentration. This study aimed to examine the association of chloride ion concentration and the main strong ion difference (difference between sodium ion concentration and chloride ion concentration) during the first 24 hours after admission into ICU with the development of acute kidney injury and mortality.

Design

Retrospective analyses using the eICU Collaborative Research Database.

Setting

ICUs in 208 hospitals across the United States between 2014 and 2015.

Patients

Critically ill patients who were admitted into the ICU.

Interventions

None.

Measurements and Main Results

A total of 34,801 patients records were analyzed. A multivariable logistic regression analysis for the development of acute kidney injury within 7 days of ICU admission shows that, compared with main strong iron difference 32-34 mEq/as a reference, there were significantly high odds for the development of acute kidney injury in nearly all groups with main strong iron difference more than 34 mEq/L (main strong iron difference = 34-36 mEq/L, odds ratio = 1.17, p = 0.02; main strong iron difference = 38-40 mEq/L, odds ratio = 1.40, p < 0.001; main strong iron difference = 40-42 mEq/L, odds ratio = 1.46, p = 0.001; main strong iron difference > 42 mEq/L, odds ratio = 1.56, p < 0.001). With chloride ion concentration 104-106 mEq/L as a reference, the odds for acute kidney injury were significantly higher only in chloride ion concentration less than or equal to 94 mEq/L and chloride ion concentration 98-100 mEq/L groups. Analyses conducted using inverse probability weighting showed significantly greater odds for ICU mortality in all groups with main strong iron difference greater than 34mEq/L other than the 36-38mEq/L group, as well as in the less than 26-mEq/L group.

Conclusions

Main strong iron difference measured on ICU presentation to the ICU predicts acute kidney injury within 7 days, with low and, in particular, high values representing increased risk. The association between the chloride levels and acute kidney injury is statistically insignificant in models incorporating main strong iron difference, suggesting main strong iron difference is a better predictive marker than chloride on ICU admission.

Dyschloremia is associated with failure to restore renal function in survivors with acute kidney injury: an observation retrospective study

Dyschloremia is common in critically ill patients. However, little is known about the effects of dyschloremia on renal function in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). A total of 483 patients who received CRRT for AKI were selected and divided into three groups according to their serum chloride concentrations at the time of CRRT initiation. At 90 days after initiating CRRT, renal outcome, i.e., non-complete renal recovery, or renal failure, was assessed in the three groups. The hypochloremia group (serum chloride concentrations < 96 mEq/L, n = 60), the normochloremia group (serum chloride concentrations, 96–111 mEq/L, n = 345), and the hyperchloremia group (serum chloride concentrations > 111 mEq/L, n = 78) were classified. The simplified acute physiology score III was higher in the hyperchloremia and hypochloremia groups than in the normochloremia group. Multivariate logistic regression analyses showed that hypochloremia (odds ratio, 5.12; 95% confidence interval [CI], 2.56–10.23; P < 0.001) and hyperchloremia (odds ratio, 2.53; 95% CI, 1.25–5.13; P = 0.01) were significantly associated with non-complete renal recovery. Similar trends were observed for renal failure. This study showed that dyschloremia was independently associated with failure in restoring renal function following AKI.

Is there association between statin usage and contrast-associated acute kidney injury after intravenous administration of iodine-based contrast media in enhanced computed tomography?

OBJECTIVES

Contrast-induced acute kidney injury (CI-AKI) is one of the leading causes of new-onset renal failure in hospitalized patients. Statin has been evaluated for its protective effect against CI-AKI but rarely in patients receiving intravenous (IV) administrations of iodine-based contrast media for enhanced computed tomography (CT).

METHODS

In total, 12,371 patients who underwent contrast-enhanced abdominopelvic CT were retrospectively reviewed and stratified into statin users and statin nonusers. Subgroup analyses comparing high-intensity statins with low- to moderate-intensity statins were conducted within statin users and similar comparisons were performed within statin users stratified based on baseline eGFR.

RESULTS

Overall, CI-AKI events did not occur less in statin users compared with non-statin users (p = 0.342). Within statin users, CI-AKI events did not decrease in high-intensity statin users compared with low- to moderate-intensity statin users (p = 0.355). Moreover, no significant difference in CI-AKI events was found between high-intensity statin users and low- to moderate-intensity statin users even after stratifying the patients with baseline eGFR.

CONCLUSIONS

Collectively, statin was not significantly associated with the risk of CI-AKI events in patients undergoing contrast-enhanced abdominopelvic CT and high-intensity statins did not show significant association with CI-AKI over low- to moderate-intensity statins in the subgroup analysis.

KEY POINTS

• Statin is not associated with risk of CI-AKI events in patients undergoing intravenous administration of contrast-enhanced CT. • CI-AKI incidence among high-intensity statin users was not significantly different from that of low- to moderate-intensity statin users.

Predictive Modeling of the Risk of Acute Kidney Injury in Critical Care: A Systematic Investigation of The Class Imbalance Problem

Acute Kidney Injury (AKI) in critical care is often a quickly-evolving clinical event with high morbidity and mortality. Early prediction of AKI risk in critical care setting can facilitate early interventions that are likely to provide ben- efit. Recently there have been some research on AKI prediction with patient Electronic Health Records (EHR). The class imbalance problem is encountered in such prediction setting where the number of AKI cases is usually much smaller than the controls. This study systematically investigates the impact of class imbalance on the performance of AKI prediction. We systematically investigate several class-balancing strategies to address class imbalance, includ- ing traditional statistical approaches and the proposed methods (case-control matching approach and individualized prediction approach). Our results show that the proposed class-balancing strategies can effectively improve the AKI prediction performance. Additionally, some important predictors (e.g., creatinine, chloride, and urine) for AKI can be found based on the proposed methods.

"I don't get no respect": the role of chloride in acute kidney injury

Acute kidney injury (AKI) is a major public health problem that complicates 10-40% of hospital admissions. Importantly, AKI is independently associated with increased risk of progression to chronic kidney disease, end-stage renal disease, cardiovascular events, and increased risk of in-hospital and long-term mortality. The chloride content of intravenous fluid has garnered much attention over the last decade, as well as its association with excess use and adverse outcomes, including AKI. Numerous studies show that changes in serum chloride concentration, independent of serum sodium and bicarbonate, are associated with increased risk of AKI, morbidity, and mortality. This comprehensive review details the complex renal physiology regarding the role of chloride in regulating renal blood flow, glomerular filtration rate, tubuloglomerular feedback, and tubular injury, as well as the findings of clinical research related to the chloride content of intravenous fluids, changes in serum chloride concentration, and AKI. Chloride is underappreciated in both physiology and pathophysiology. Although the exact mechanism is debated, avoidance of excessive chloride administration is a reasonable treatment option for all patients and especially in those at risk for AKI. Therefore, high-risk patients and those with "incipient" AKI should receive balanced solutions rather than normal saline to minimize the risk of AKI.