Sodium-Chloride Difference as a Simple Parameter for Acid-Base Status Assessment

The role of serum chloride ion in the prognosis of COPD

BACKGROUND

As exacerbations of chronic obstructive pulmonary disease (COPD) are one of the leading causes of hospitalization and are associated with significant mortality, it is particularly important to accurately assess the risk of exacerbations in COPD. Most of the current clinical biomarkers are related to inflammation and few consider how ion levels affect COPD. Chloride ion, the second most abundant serum electrolyte, has been shown to be associated with poor prognoses in several diseases, but their relationship with COPD remains unclear.

METHODS

In total, 105 patients with acute exacerbations of COPD were recruited. Data on clinical characteristics, lung function, blood count, blood biochemistry, relevant scales including the Clinical COPD Questionnaire (CCQ), BODE (BMI, airflow obstruction, dyspnea, exercise capacity) index and the St. George's Respiratory Questionnaire (SGRQ) were collected from all patients for statistical analysis.

RESULT

There were significant differences in lung function indicators and disease severity in the low chloride ion subgroup compared with the high chloride ion subgroup. On multiple logistic regression analysis, chloride ion was an independent factor affecting lung function in COPD patients (OR=0.808, 95% CI: 0.708 - 0.922, p=0.002). The sensitivity of chloride ion in predicting COPD severity was 78%, the specificity was 63%, and the area under the curve was 0.734 (p<0.001). Subgroup analysis showed that chloride ion was a stronger predictor in male and smoking patients.

CONCLUSIONS

Chloride ion was a novel prognostic biomarker for COPD, and low levels of chloride ion were independently associated with exacerbations in COPD patients.

Modified del Nido cardioplegia is associated with low incidence of low main strong ion difference and hyperchloremia in pediatric patients after cardiac surgery

PURPOSE

The aims of this study were (1) to determine the associations of cardioplegic solutions with postoperative main strong ion difference (mSID), which is the difference between sodium ion concentration and chloride ion concentration ([Cl-]) and (2) to determine the associations of cardioplegic solutions with markers of organ dysfunction.

METHODS

In this retrospective cohort study, patients aged <5 years who underwent cardiac surgery in a tertiary teaching hospital were included. Patients were classified on the basis of the type of cardioplegic solution: modified del Nido cardioplegia (mDNC) and conventional cardioplegia (CC). The effects of mDNC on postoperative mSID and markers of organ functions were examined using propensity-matched analysis.

RESULTS

A total of 500 cases were included. mDNC solution was used in 163 patients (32.6%). After propensity score matching, patients in the mDNC group (n = 152) had significantly higher minimum mSID [28 (26, 30) mEq/L vs. 27 (25, 29) mEq/L, p = 0.02] and lower maximum [Cl-] [112 (109, 114) mEq/L vs. 113 (111, 117) mEq/L, p < 0.001] than patients in the CC group (n = 304). The incidences of low mSID and hyperchloremia in the mDNC group were significantly lower than those in the CC group (63.8 vs. 75.7%, p = 0.01 and 63.2 vs. 79.3%, p < 0.001, respectively). There was no significant difference in the incidence of postoperative acute kidney injury and B-type natriuretic peptide level between the two groups.

CONCLUSION

The use of modified del Nido cardioplegia may reduce the incidence of abnormal mSID and hyperchloremia compared with the use of a chloride-rich cardioplegic solution.

Compared effectiveness of sodium zirconium cyclosilicate and calcium polystyrene sulfonate on hyperkalemia in patients with chronic kidney disease

Hyperkalemia is a well-recognized electrolyte abnormality in patients with chronic kidney disease (CKD). Potassium binders are often used to prevent and treat hyperkalemia. However, few studies have evaluated the difference in serum potassium (K⁺) level-lowering effect during the post-acute phase between the novel potassium binder, sodium zirconium cyclosilicate (ZSC), and conventional agents. This retrospective study included patients who received potassium binders (either ZSC or calcium polystyrene sulfonate [CPS]) in our hospital between May 2020 and July 2022. The patients were divided into the ZSC and CPS groups. After propensity score matching, we compared changes from baseline to the first follow-up point, at least 4 weeks after initiating potassium binders, in electrolytes including K⁺ level between the two groups. Of the 132 patients, ZSC and CPS were administered in 48 and 84 patients, respectively. After matching, 38 patients were allocated to each group. The ZSC group showed greater reduction in K⁺ levels than did the CPS group (P < 0.05). Moreover, a significant increase in serum sodium minus chloride levels, a surrogate marker for metabolic acidosis, was observed in the ZSC group (P < 0.05). Our results demonstrated that ZSC could potentially improve hyperkalemia and metabolic acidosis in patients with CKD.

An optimal dietary sodium chloride supplemental level of broiler chicks fed a corn-soybean meal diet from 1 to 21 days of age

Sodium chloride (NaCl) is usually added to diets to meet the Na and Cl requirements of broilers in the Chinese poultry industry, but the optimal dietary NaCl supplemental level was not well-established. The present study was conducted to estimate the optimal dietary NaCl supplemental level of broilers fed a corn-soybean meal diet from 1 to 21 days of age. A total of 490, 1-day-old Arbor Acres male broilers were fed a NaCl-unsupplemented corn-soybean meal basal diet (control) and the basal diet supplemented with 0.10, 0.20, 0.30, 0.40, 0.50 or 0.60% NaCl for 21 days. Regression analysis was conducted to evaluate the optimal dietary NaCl level using the best fitted broken-line or asymptotic models. As dietary supplemental NaCl levels increased, average daily gain (ADG), average daily feed intake (ADFI), blood partial pressure of CO₂, total CO₂, base excess and anion gap, blood concentrations of HCO₃, Na and Cl, serum Na concentration, jejunal villus height (VH) and tibia ash content increased linearly and quadratically (P < 0.05), while feed/gain ratio, relative weights of heart, liver and kidney, blood K concentration, serum concentrations of K, uric acid and glucose, and osmotic pressure decreased linearly and quadratically (P < 0.05). The estimates of optimal dietary NaCl levels were 0.20-0.22% based on the best fitted broken-line or asymptotic models (P < 0.0001) of ADG, ADFI and feed/gain ratio, and 0.08-0.24% based on the best fitted broken-line or asymptotic models (P < 0.0001) of blood gas indices, serum parameters, jejunal VH, tibia ash content and organ indices. These results suggested that the optimal dietary NaCl supplemental level would be 0.24% for broilers fed the corn-soybean meal diet from 1 to 21 days of age, which is lower than the current dietary NaCl supplemental level (0.30%) in the Chinese broiler production.

Predicting oxygen requirements in patients with coronavirus disease 2019 using an artificial intelligence-clinician model based on local non-image data

BACKGROUND

When facing unprecedented emergencies such as the coronavirus disease 2019 (COVID-19) pandemic, a predictive artificial intelligence (AI) model with real-time customized designs can be helpful for clinical decision-making support in constantly changing environments. We created models and compared the performance of AI in collaboration with a clinician and that of AI alone to predict the need for supplemental oxygen based on local, non-image data of patients with COVID-19.

MATERIALS AND METHODS

We enrolled 30 patients with COVID-19 who were aged >60 years on admission and not treated with oxygen therapy between December 1, 2020 and January 4, 2021 in this 50-bed, single-center retrospective cohort study. The outcome was requirement for oxygen after admission.

RESULTS

The model performance to predict the need for oxygen by AI in collaboration with a clinician was better than that by AI alone. Sodium chloride difference >33.5 emerged as a novel indicator to predict the need for oxygen in patients with COVID-19. To prevent severe COVID-19 in older patients, dehydration compensation may be considered in pre-hospitalization care.

CONCLUSION

In clinical practice, our approach enables the building of a better predictive model with prompt clinician feedback even in new scenarios. These can be applied not only to current and future pandemic situations but also to other diseases within the healthcare system.

Effect of high-dose sulfamethoxazole/trimethoprim and glucocorticoid use on hyperkalemic event: A retrospective observational study

INTRODUCTION

Sulfamethoxazole/trimethoprim causes hyperkalemia; however, the effect of sulfamethoxazole/trimethoprim dose and co-administered glucocorticoids on hyperkalemia has not been clarified.

METHODS

This single-center, retrospective, observational cohort, chart review study involving patients (>20 years) who were treated with sulfamethoxazole/trimethoprim was conducted at Tokyo Women's Medical University, Medical Center East from June 2015 to May 2019. Multivariate Cox proportional hazard model was used to identify risk factors for hyperkalemia (serum potassium level > 5.5 mEq/L). Additionally, Kaplan-Meier curve analyzed the cumulative incidence of hyperkalemia focusing on sulfamethoxazole/trimethoprim dose and concomitant use of glucocorticoids with mineralocorticoid activity.

RESULTS

Among 333 patients, 44 (13%) patients developed hyperkalemia associated with sulfamethoxazole/trimethoprim use for over 49 (interquartile range; 17-233) days. We found associations between the time to hyperkalemia development and sulfamethoxazole/trimethoprim dose (hazard ratio 1.238, 95% confidence interval 1.147-1.338, p < 0.001) and glucocorticoid use (hazard ratio 0.678, 95% confidence interval 0.524-0.877, p = 0.003). Interestingly, the Kaplan-Meier curves revealed that the concomitant use of glucocorticoids did not attenuate the risk of hyperkalemia in patients receiving high-dose sulfamethoxazole/trimethoprim (p = 0.747), whereas concomitant use of glucocorticoids significantly reduced the risk of hyperkalemia in patients receiving non-high dose sulfamethoxazole/trimethoprim (p < 0.001).

CONCLUSIONS

High-dose sulfamethoxazole/trimethoprim is a significant predictor of hyperkalemia. The effect of glucocorticoids on hyperkalemia varies depending on the sulfamethoxazole/trimethoprim dose.

Prevalences of hyperuricemia and electrolyte abnormalities in patients with chronic kidney disease in Japan: A nationwide, cross-sectional cohort study using data from the Japan Chronic Kidney Disease Database (J-CKD-DB)

BACKGROUND

The Japan Chronic Kidney Disease Database (J-CKD-DB) is a nationwide clinical database of patients with chronic kidney disease (CKD) based on electronic health records. The objective of this study was to assess the prevalences of hyperuricemia and electrolyte abnormalities in Japanese patients with CKD.

METHODS

In total, 35,508 adult outpatients with estimated glomerular filtration rates of 5-60 ml/min/1.73 m2 in seven university hospitals were included this analysis. The proportions of patients with CKD stages G3b, G4, and G5 were 23.5%, 7.6%, and 3.1%, respectively.

RESULTS

Logistic regression analysis showed that prevalence of hyperuricemia was associated with CKD stages G3b (adjusted odds ratio [95% confidence interval]: 2.12 [1.90-2.37]), G4 (4.57 [3.92-5.32]), and G5 (2.25 [1.80-2.80]). The respective prevalences of hyponatremia, hypercalcemia, hyperphosphatemia, and narrower difference between serum sodium and chloride concentrations were elevated in patients with CKD stages G3b, G4, and G5, compared with those prevalences in patients with CKD stage G3a. The prevalences of hyperkalemia were 8.3% and 11.6% in patients with CKD stages G4 and G5, respectively. In patients with CKD stage G5, the proportions of patients with optimal ranges of serum uric acid, potassium, corrected calcium, and phosphate were 49.6%, 73.5%, 81.9%, and 56.1%, respectively.

CONCLUSIONS

We determined the prevalences of hyperuricemia and electrolyte abnormalities in Japanese patients with CKD using data from a nationwide cohort study.

Non-lactate strong ion difference and cardiovascular, cancer and all-cause mortality

Objectives

Non-lactate strong ion difference (SID) has been shown to be associated with predictors of mortality in intensive care unit. However, the existence of any association between non-lactate SID (nlSID) and all cause, cardiovascular and cancer mortality has not been explored before in community dwelling US adults.

Methods

In a nationally representative cross-sectional survey of the US non-institutionalized population, all adult participants (≥20 years of age) using National Health and Nutrition Examination Survey data (1999-2010) combined with National Death Index for mortality status through December 2011. Cox proportional hazard models were built to estimate the hazard ratios for cardiovascular, cancer, and all-cause mortality for each unit increase in non-lactate SID. The models were adjusted for demographic and confounder variables.

Results

In the study population the mean (SD) age was 49.6 (18.4) years. Of the study population, 31,475 (91.5%) were alive and 2,893 (8.4%) died during the mean (SD) follow-up period of 5.5 (3.5) years. In univariate regression model using nlSID as continuous variable, we found 2% (unadjusted hazard ratio, HR=1.02; 95% CI, 1.004-1.05) increase in all-cause but not in cardiovascular and cancer mortality (HR=1.03; 95% CI, 0.99-1.08, HR=1.01; 95% CI, 0.97-1.06). After adjusting for potential confounders, we found 7% (adjusted HR=1.07; 95% CI, 1.04-1.10), 5% (HR=1.05; 95% CI, 1.00-1.11) and 7% (HR=1.07; 95% CI, 1.02-1.12) increase in all-cause, cardiovascular, and cancer mortality.

Conclusions

A high nlSID is associated with an increase in cardiovascular, cancer and all-cause mortality and may be a prognostic indicator of mortality in general adult population. These findings may provide a point of reference for further studies.

Changes in Serum and Urinary Potassium Handling Associated with Renin-Angiotensin-Aldosterone System Inhibitors in Advanced Chronic Kidney Disease Patients

Objective This study aimed to (i) compare the extent of urinary potassium (K+) excretion in addition to the changes in serum K+ concentration: and (ii) clarify the association between changes in serum K+ concentration, urinary K+ excretion, and acid-base status with or without renin-angiotensin-aldosterone system (RAAS) inhibitors in patients with advanced chronic kidney disease (CKD) stages. Methods Six hundred and ninety-one patients with advanced CKD (CKD G3b, 161; G4, 271; G5, 259) were retrospectively evaluated. Differences in serum K+ concentration, urinary K+ excretion, and serum sodium and chloride differences (Na+-Cl-) were compared among patients with RAAS inhibitors, RAAS inhibitors and diuretic agents, and without either medication in each CKD stage. Results Serum K+ concentrations in patients with RAAS inhibitors were significantly higher than in those with RAAS inhibitors and diuretics in CKD stage G3b and the other two treatment groups in CKD stage G4. Urinary K+ excretion among the three groups did not differ significantly in each CKD stage. Serum Na+-Cl- differences in patients with RAAS inhibitors were significantly smaller than in those with RAAS inhibitors and diuretics in CKD stages G3b (p = 0.006) and the other two groups in CKD stage G4 (vs. RAAS inhibitors and diuretics, p <0.001; vs. without either medication, p = 0.008). Conclusion Our study demonstrated that RAAS inhibitor use might be associated with hyperkalemia via not decreased urinary K+ excretion but rather K+ redistribution from intracellular to extracellular fluid induced by the progression of metabolic acidosis in patients with advanced CKD, particularly stages G3b and G4.

Association between serum Na-Cl level and renal function decline in chronic kidney disease: results from the chronic kidney disease Japan cohort (CKD-JAC) study

BACKGROUND

Metabolic acidosis, which reduces serum bicarbonate levels, contributes to the progression of chronic kidney disease (CKD). The difference between sodium and chloride (Na-Cl) may theoretically predict serum bicarbonate levels. This study aimed to evaluate serum Na-Cl level as a risk factor for renal function decline among patients who participated in the chronic kidney disease Japan cohort (CKD-JAC) study.

METHODS

The association between low Na-Cl concentration (< 34 mmol/L) and composite renal function decline events (any initiation of renal replacement therapy or 50% decline in estimated glomerular filtration rate) was evaluated among 2143 patients with CKD stage G3a-4. Using Cox regression analysis, hazard ratios (HRs) were estimated after adjusting for the following covariates: age, sex, diabetes mellitus, diabetic nephropathy, cardiovascular disease, anemia, angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists, loop diuretics, cigarette smoking, body mass index, serum albumin, systolic blood pressure, urine albumin-to-creatinine ratio, and CKD stage.

RESULTS

Composite renal function decline events were observed in 405 patients (18.9%) over the 4-year follow-up period. Low serum Na-Cl level (< 34 mmol/L) was independently associated with a greater risk for composite renal function decline events (HR 1.384; 95% confidence interval [CI], 1.116-1.717). Subgroup analyses identified that the association between low Na-Cl level and composite renal function decline events was stronger among patients with CKD stage G4 and those with anemia.

CONCLUSIONS

Our investigation suggests that Na-Cl is an independent predictor of CKD progression, especially among patients with CKD stage G4 and those with anemia.