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Tas N, Mengen E, Alacakır N, Goncu S, Boluk O, Ucakturk A. Is there a relationship between hyperchloremia status and the risk of developing acute kidney injury in pediatric patients with diabetic ketoacidosis? Eur J Pediatr 2024; 183:4319-4327. [PMID: 39080001 DOI: 10.1007/s00431-024-05697-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 07/16/2024] [Accepted: 07/18/2024] [Indexed: 09/20/2024]
Abstract
Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus (T1DM). Prerenal acute kidney injury (AKI) is associated with profound hypovolemia and reduced renal perfusion. Results regarding hyperchloremia-associated AKI in patients with DKA are conflicting; we therefore investigated the potential relationship between hyperchloremia status and the risk of developing AKI. This single-center cohort study included 113 newly diagnosed T1DM patients with DKA admitted to the pediatric intensive care unit. Laboratory parameters, including Na, K, urea, creatinine, and chloride levels, were retrospectively reviewed at the time of presentation and at 12, 24 and 36 h. AKI was defined using the eGFR according to the pediatric RIFLE classification criteria. Twenty-two (19.5%) of the 113 patients were in the AKI group. Two-way repeated-measures ANOVA showed significant (P values ≤ 0.01) time interaction effects within the groups based on the eGFR and the serum chloride, hyperchloremia, and phosphate levels. Serum chloride levels did not differ between the groups during the first 12 h (p > 0.05) but were significantly greater in the AKI group than in the non-AKI group at 24 h and 36 h (p < 0.01). The final DKA resolution time was significantly greater in the AKI group than in the non-AKI group [22.2 (9.5) vs. 17.0 (12.0) h, respectively; p = 0.03]. However, the groups had similar lengths of hospital stay [13.0 (8.0) days vs. 12.0 (4.0) days, respectively; p = 0.17].Conclusions: Hyperchloremia may be iatrogenic rather than causative during treatment. This may worsen renal failure and prolong the recovery and treatment time for DKA patients. What is Known? • Acute kidney injury resulting from severe volume depletion is a common occurrence in diabetic ketoacidosis and typically requires significant volume replacement therapy. • In recent years, hyperchloremia has been associated with increased risks of AKI, morbidity, and mortality in some conditions, such as diabetic ketoacidosis. What is New? • The incidence of hyperchloremia increases over time during the treatment of diabetic ketoacidosis. • Hyperchloremia may be an iatrogenic element rather than a cause of acute kidney injury during the treatment of diabetic ketoacidosis.
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Affiliation(s)
- Nesrin Tas
- Department of Pediatric Nephrology, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey.
- Ankara Eğitim Ve Araştırma Hastanesi Hacettepe, Mh. Ulucanlar Cd. No:89 Altındağ, Ankara, 06230, Turkey.
| | - Eda Mengen
- Department of Pediatric Endocrinology, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Nuri Alacakır
- Department of Pediatric Intensive Care Unit, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Sultan Goncu
- Department of Pediatric Intensive Care Unit, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - Oguz Boluk
- Department of General Pediatrics, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
- Ankara Eğitim Ve Araştırma Hastanesi Hacettepe, Mh. Ulucanlar Cd. No:89 Altındağ, Ankara, 06230, Turkey
| | - Ahmet Ucakturk
- Department of Pediatric Endocrinology, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
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Yıldırımçakar D, Öcal M, Altıncık SA, Özhan B. Hyperchloremia and Prolonged Acidosis During Treatment for Pediatric Diabetic Ketoacidosis. Pediatr Emerg Care 2024:00006565-990000000-00528. [PMID: 39348721 DOI: 10.1097/pec.0000000000003280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/02/2024]
Abstract
OBJECTIVES Diabetic ketoacidosis (DKA) is characterized by metabolic acidosis with a high anion gap secondary to ketonemia. Intravenous hydration fluids used in treatment can cause chloride overload, leading to hyperchloremic metabolic acidosis (HMA). The development of HMA can lead to the persistence of acidosis despite the resolution of ketonemia. METHODS A total of 178 DKA episodes in 153 patients treated between January 2013 and October 2023 were included in the study. Creatine-based glomerular filtration rate and HbA1c value at admission and venous blood gas parameters (pH, actual bicarbonate, base deficit), anion gap, chloride-corrected bicarbonate, nonchloride base deficit, and sodium and chloride measured at 0, 2, 4, 6, 9, 12, 18 and 24 hours were evaluated. RESULTS Hyperchloremia was detected in 69.3% of participants and developed at a mean of 6.3 (±4.3) hours of treatment. The incidence of hyperchloremia increased with the duration of treatment; the rates were 8.4%, 51.3%, 65%, 76.2%, 75.5%, and 80% at 0, 6, 9, 12, 18, and 24 hours of treatment, respectively. The group with hyperchloremia had more severe acidosis, a higher HbA1c value, and a longer resolution time. At the 12th hour of treatment, acidosis continued based on pH and HCO3 levels, whereas the hyperchloremia group exhibited a low anion gap (mean 12.8). At the 6th hour of treatment, the resolution rates were significantly lower in the hyperchloremia group based on the pH and HCO3 levels but increased when assessed by chloride-corrected HCO3 and anion gap. CONCLUSIONS During treatment of DKA, monitoring anion gap, blood ketones, and Cl-/Na+ ratio or using regression equations in addition to routine acid-base parameters may help differentiate DKA from HMA and prevent prolonged intravenous treatment.
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Affiliation(s)
- Didem Yıldırımçakar
- From the Department of Pediatric Endocrinology, Pamukkale University, Denizli, Turkey
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Zhang Q, Li Y, Liu L, Hu Z, Huo Y. Intrarenal venous flow patterns - Guiding fluid management in sepsis with AKI: A case report. Medicine (Baltimore) 2024; 103:e39280. [PMID: 39121256 PMCID: PMC11315495 DOI: 10.1097/md.0000000000039280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 07/23/2024] [Indexed: 08/11/2024] Open
Abstract
INTRODUCTION Sepsis often leads to acute kidney injury (AKI), presenting significant challenges in fluid management. This study explores the potential of analyzing intrarenal venous flow (IRVF) patterns to guide tailored fluid therapy, aiming to improve patient outcomes. PATIENT CONCERNS A patient was admitted to the intensive care unit with symptoms of septic shock, including fever, severe hypotension, and altered mental status, secondary to a perforated ascending colon adenocarcinoma. DIAGNOSIS The patient was diagnosed with perforated ascending colon adenocarcinoma, septic shock, and AKI. Clinical findings included elevated inflammatory markers and impaired renal function. INTERVENTIONS The primary therapeutic interventions included surgical resection of the perforated colon, administration of broad-spectrum antibiotics, and fluid resuscitation. Fluid management was guided by continuous monitoring of IRVF, which facilitated precise adjustments to optimize fluid balance and renal perfusion. OUTCOMES By utilizing IRVF patterns to guide fluid therapy, the patient's circulatory status and renal function significantly improved. The individualized fluid management approach contributed to better stabilization of the patient's condition. LESSONS This case underscores the potential utility of IRVF patterns in guiding fluid management strategies for patients with sepsis and AKI. The main is the benefit of IRVF-guided fluid therapy in improving patient outcomes. Further research is warranted to validate the efficacy and safety of this approach, with the aim of enhancing clinical outcomes in critically ill patients.
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Affiliation(s)
- Qian Zhang
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yi Li
- Department of Anesthesiology, Hebei General Hospital, Shijiazhuang, China
| | - Lixia Liu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhenjie Hu
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Huo
- Department of Intensive Care Unit, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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Gan Y, Nie S, Pang M, Huang R, Xu H, Liu B, Weng J, Chunbo C, Liu H, Li H, Kong Y, Li G, Wan Q, Zha Y, Hu Y, Xu G, Shi Y, Zhou Y, Su G, Tang Y, Gong M, Hou FF, Yang Q. Inverse association between serum chloride levels and the risk of atrial fibrillation in chronic kidney disease patients. Clin Kidney J 2024; 17:sfae137. [PMID: 39131078 PMCID: PMC11316397 DOI: 10.1093/ckj/sfae137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Indexed: 08/13/2024] Open
Abstract
Background Electrolyte abnormalities are common symptoms of chronic kidney disease (CKD), but previous studies have mainly focussed on serum potassium and sodium levels. Chloride is an important biomarker for the prognosis of various diseases. However, the relationship between serum chloride levels and atrial fibrillation (AF) in CKD patients is unclear. Objective In this study, we sought to determine the association between serum chloride homeostasis and AF in CKD patients. Methods In this retrospective cohort study, we included patients who met the diagnostic criteria for CKD in China between 2000 and 2021. Competing risk regression for AF was performed. The associations of the baseline serum chloride concentration with heart failure (HF) and stroke incidence were also calculated by competing risk regression. The association of baseline serum chloride levels with all-cause death was determined by a Cox regression model. Results The study cohort comprised 20 550 participants. During a median follow-up of 350 days (interquartile range, 123-730 days), 211 of the 20 550 CKD patients developed AF. After multivariable adjustment, every decrease in the standard deviation of serum chloride (5.02 mmol/l) was associated with a high risk for AF [sub-hazard ratio (sHR) 0.78, 95% confidence interval (CI) 0.65-0.94, P = .008]. These results were also consistent with those of the stratified and sensitivity analyses. According to the fully adjusted models, the serum chloride concentration was also associated with a high risk for incident HF (sHR 0.85, 95% CI 0.80-0.91, P < .001), a high risk for incident stroke (sHR 0.87, 95% CI 0.81-0.94, P < .001), and a high risk for all-cause death [hazard ratio (HR) 0.82, 95% CI 0.73-0.91, P < .001]. Conclusion In this CKD population, serum chloride levels were independently and inversely associated with the incidence of AF. Lower serum chloride levels were also associated with an increased risk of incident HF, stroke, and all-cause death.
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Affiliation(s)
- Yangang Gan
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Sheng Nie
- Division of Nephrology, Nanfang Hospital, Southern Medical University; National Clinical Research Center for Kidney Disease; State Key Laboratory of Organ Failure Research; Guangdong Provincial Institute of Nephrology; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, China
| | - Mingzhen Pang
- Division of Nephrology, Nanfang Hospital, Southern Medical University; National Clinical Research Center for Kidney Disease; State Key Laboratory of Organ Failure Research; Guangdong Provincial Institute of Nephrology; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, China
| | - Rong Huang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Hong Xu
- Children's Hospital of Fudan University, Shanghai, China
| | - Bicheng Liu
- Institute of Nephrology, Zhongda Hospital, Southeast University School of Medicine, Nanjing, China
| | - Jianping Weng
- Department of Endocrinology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Chen Chunbo
- Department of Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Huafeng Liu
- Key Laboratory of Prevention and Management of Chronic Kidney Disease of Zhanjiang City, Institute of Nephrology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Hua Li
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaozhong Kong
- Department of Nephrology, the First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Guisen Li
- Renal Department and Institute of Nephrology, Sichuan Provincial People's Hospital, School of Medicine, University of Electronic Science and Technology of China, Sichuan Clinical Research Center for Kidney Diseases, Chengdu, China
| | - Qijun Wan
- The Second People's Hospital of Shenzhen, Shenzhen University, Shenzhen, China
| | - Yan Zha
- Guizhou Provincial People's Hospital, Guizhou University, Guiyang, China
| | - Ying Hu
- The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Gang Xu
- Division of Nephrology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yongjun Shi
- Huizhou Municipal Central Hospital, Sun Yat-Sen University, Huizhou, China
| | - Yilun Zhou
- Department of Nephrology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guobin Su
- Department of Nephrology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital, The Second Clinical College, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ying Tang
- The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Mengchun Gong
- Institute of Health Management, Southern Medical University, Guangzhou, China
- Digital Health China Technologies Co. Ltd., Beijing, China
| | - Fan Fan Hou
- Division of Nephrology, Nanfang Hospital, Southern Medical University; National Clinical Research Center for Kidney Disease; State Key Laboratory of Organ Failure Research; Guangdong Provincial Institute of Nephrology; Guangdong Provincial Key Laboratory of Renal Failure Research, Guangzhou, China
| | - Qiongqiong Yang
- Department of Nephrology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
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Takahashi K, Uenishi N, Sanui M, Uchino S, Yonezawa N, Takei T, Nishioka N, Kobayashi H, Otaka S, Yamamoto K, Yasuda H, Kosaka S, Tokunaga H, Fujiwara N, Kondo T, Ishida T, Komatsu T, Endo K, Moriyama T, Oyasu T, Hayakawa M, Hoshino A, Matsuyama T, Miyamoto Y, Yanagisawa A, Wakabayashi T, Ueda T, Komuro T, Sugimoto T, Sasabuchi Y. High versus low chloride load in adult hyperglycemic emergencies with acute kidney injury: a multicenter retrospective cohort study. Intern Emerg Med 2024; 19:959-970. [PMID: 38488997 DOI: 10.1007/s11739-024-03556-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/04/2024] [Indexed: 03/17/2024]
Abstract
Hyperglycemic emergencies frequently lead to acute kidney injury (AKI) and require treatment with large amount of intravenous fluids. However, the effects of chloride loading on this population have not yet been investigated. We conducted a multicenter, retrospective, cohort study in 21 acute-care hospitals in Japan. The study included hospitalized adult patients with diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) who had AKI upon arrival. The patients were classified into high and low chloride groups based on the amount of chloride administered within the first 48 h of their arrival. The primary outcome was recovery from AKI; secondary outcome was major adverse kidney events within 30 days (MAKE30), including mortality and prolonged renal failure. A total of 390 patients with AKI, including 268 (69%) with DKA and 122 (31%) with HHS, were included in the study. Using the criteria of Kidney Disease Improving Global Outcomes, the severity of AKI in the patients was Stage 1 (n = 159, 41%), Stage 2 (n = 121, 31%), and Stage 3 (n = 110, 28%). The analysis showed no significant difference between the two groups in recovery from AKI (adjusted hazard ratio, 0.96; 95% CI 0.72-1.28; P = 0.78) and in MAKE30 (adjusted odds ratio, 0.91; 95% CI 0.45-1.76; P = 0.80). Chloride loading with fluid administration had no significant impact on recovery from AKI in patients with hyperglycemic emergencies.Trial Registration This study was registered in the UMIN clinical trial registration system (UMIN000025393, registered December 23, 2016).
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Affiliation(s)
- Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan.
- Department of Anesthesiology and Critical Care Medicine, Kawasaki Municipal Hospital, Kawasaki, Kanagawa, Japan.
| | - Norimichi Uenishi
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Naoki Yonezawa
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, Japan
- Division of Nephrology, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
| | - Hirotada Kobayashi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Shunichi Otaka
- Department of Emergency Medicine, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan
- Department of Emergency Medicine, Kumamoto Red Cross Hospital, Higashi, Kumamoto, Japan
| | - Kotaro Yamamoto
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
| | - Hideto Yasuda
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Omiya, Saitama, Japan
| | - Shintaro Kosaka
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Hidehiko Tokunaga
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Naoki Fujiwara
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
- Department of Medicine, Taito Municipal Taito Hospital, Taito, Tokyo, Japan
| | - Takashiro Kondo
- Department of Emergency and Critical Care Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| | - Tomoki Ishida
- Nanohana Clinic, Ikuno, Osaka, Japan
- Department of Emergency Medicine, Yodogawa Christian Hospital, Higashi Yodogawa, Osaka, Japan
| | - Takayuki Komatsu
- Department of Sports Medicine, Faculty of Medicine, Juntendo University, Bunkyo, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima, Tokyo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Sakyo, Kyoto, Japan
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Tottori, Japan
| | - Taiki Moriyama
- Department of Emergency Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
- Department of Emergency Medicine, Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Takayoshi Oyasu
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Atsumi Hoshino
- Department of Critical Care Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
- Department of Emergency and Critical Care Medicine, Toyooka Public Hospital, Toyooka, Hyogo, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Akihiro Yanagisawa
- Department of Anesthesia, Gyoda General Hospital, Gyoda, Saitama, Japan
- Department of Anesthesiology and Intensive Care, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Tadamasa Wakabayashi
- Department of Medicine, Suwa Central Hospital, Chino, Nagano, Japan
- Department of Cardiology, Suwa Central Hospital, Chino, Nagano, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Nakagyo, Kyoto, Japan
| | - Tetsuya Komuro
- Department of Medicine, TMG Muneoka Central Hospital, Shiki, Saitama, Japan
- Department of Critical Care, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
- Department of Medicine, National Hospital Organization Higashiohmi General Medical Center, Higashiohmi, Shiga, Japan
| | - Yusuke Sasabuchi
- Department of Real-World Evidence, Graduate School of Medicine, The University of Tokyo, Bunkyo City, Tokyo, Japan
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Zhang J, Liu F, Wu Z, Jiang J, Wang B, Qian Y, Suo J, Li Y, Peng Z. ACETATE RINGER'S SOLUTION VERSUS NORMAL SALINE SOLUTION IN SEPSIS: A RANDOMIZED, CONTROLLED TRIAL. Shock 2024; 61:520-526. [PMID: 38369528 DOI: 10.1097/shk.0000000000002324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
ABSTRACT Background: Normal saline solution (NSS) and Ringer's acetate solution (RAS) are commonly given to critically ill patients as a fundamental fluid therapy. However, the effect of RAS and NSS on sepsis patient outcomes remains unknown. Methods: We conducted a single-center prospective open-label parallel controlled trial to enroll adult patients (>18 years old) diagnosed with sepsis. Participants received either RAS or NSS for intravenous infusion for 5 days. The primary outcome was the incidence of major adverse kidney events within 28 days (MAKE28). Secondary outcomes included 30-/90-day mortality, acute kidney injury, and hyperchloremia. The patients were then reclassified as NSS-only, RAS-only, and RAS + NSS groups according to the type of fluid they had received before enrollment. Thereafter, a secondary post hoc analysis was performed. Results: Two hundred fifty-five septic patients were screened, and 143 patients (51.0% in RAS group and 49.0% in NSS group) were enrolled in the study. Each group received a median of 2 L of fluid administration during five interventional days. Of the patients, 39.3% had received 500 mL (500-1,000 mL) of balanced salt solutions (BSSs) before intensive care unit (ICU) admission. There was no statistical difference among the RAS and NSS group on the primary outcome MAKE28 in the initial analysis (23.3% vs. 20.0%; OR, 1.2 [0.6 to 2.2]; P = 0.69). MAKE28 was observed in 23.3% of RAS-only versus 27.3% of NSS-only group patients (0.82 [0.35-1.94], P = 0.65) in the secondary post hoc analysis. The patients in the NSS-only group had a longer invasive mechanical ventilation days and a trend toward the accumulation of serum chloride. Conclusion: This study observed no statistically significant difference on MAKE28 and secondary outcomes among sepsis patients receiving RAS and NSS. However, it is unclear whether the large amount of fluid resuscitation before ICU admission and carrier NSS narrowed the difference between BSSs and NSSs.
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Affiliation(s)
| | | | | | | | - Bingqing Wang
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
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Taka H, Douguchi T, Miyamoto A, Shimizu K, Kimura S, Iwasaki T, Kanazawa T, Morimatsu H. Modified del Nido cardioplegia is associated with low incidence of low main strong ion difference and hyperchloremia in pediatric patients after cardiac surgery. J Anesth 2024; 38:244-253. [PMID: 38358399 DOI: 10.1007/s00540-023-03306-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 12/26/2023] [Indexed: 02/16/2024]
Abstract
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.
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Affiliation(s)
- Hiroshi Taka
- Department of Clinical Engineering Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Takuma Douguchi
- Department of Clinical Engineering Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Ayako Miyamoto
- Department of Clinical Engineering Center, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Kazuyoshi Shimizu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan.
| | - Satoshi Kimura
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Tatsuo Iwasaki
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Tomoyuki Kanazawa
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
| | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1, Shikata-Cho, Kita-Ku, Okayama, 700-8558, Japan
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Hou X, Xu W, Zhang C, Song Z, Zhu M, Guo Q, Wang J. L-Shaped Association of Serum Chloride Level With All-Cause and Cause-Specific Mortality in American Adults: Population-Based Prospective Cohort Study. JMIR Public Health Surveill 2023; 9:e49291. [PMID: 37955964 PMCID: PMC10682926 DOI: 10.2196/49291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/31/2023] [Accepted: 10/17/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Chloride is the most abundant anion in the human extracellular fluid and plays a crucial role in maintaining homeostasis. Previous studies have demonstrated that hypochloremia can act as an independent risk factor for adverse outcomes in various clinical settings. However, the association of variances of serum chloride with long-term mortality risk in general populations has been rarely investigated. OBJECTIVE This study aims to assess the association of serum chloride with all-cause and cause-specific mortality in the general American adult population. METHODS Data were collected from 10 survey cycles (1999-2018) of the National Health and Nutrition Examination Survey. All-cause mortality, cardiovascular disease (CVD) mortality, cancer mortality, and respiratory disease mortality data were obtained by linkage to the National Death Index through December 31, 2019. After adjusting for demographic factors and relevant lifestyle, laboratory items, and comorbid factors, weighted Cox proportional risk models were constructed to estimate hazard ratios and 95% CIs for all-cause and cause-specific mortality. RESULTS A total of 51,060 adult participants were included, and during a median follow-up of 111 months, 7582 deaths were documented, 2388 of CVD, 1639 of cancer, and 567 of respiratory disease. The weighted Kaplan-Meier survival analyses showed consistent highest mortality risk in individuals with the lowest quartiles of serum chloride. The multivariate-adjusted hazard ratios from lowest to highest quartiles of serum chloride (≤101.2, 101.3-103.2, 103.2-105.0, and ≥105.1 mmol/L) were 1.00 (95% CI reference), 0.77 (95% CI 0.67-0.89), 0.72 (95% CI 0.63-0.82), and 0.77 (95% CI 0.65-0.90), respectively, for all-cause mortality (P for linear trend<.001); 1.00 (95% CI reference), 0.63 (95% CI 0.51-0.79), 0.56 (95% CI 0.43-0.73), and 0.67 (95% CI 0.50-0.89) for CVD mortality (P for linear trend=.004); 1.00 (95% CI reference), 0.67 (95% CI 0.54-0.84), 0.65 (95% CI 0.50-0.85), and 0.65 (95% CI 0.48-0.87) for cancer mortality (P for linear trend=.004); and 1.00 (95% CI reference), 0.68 (95% CI 0.41-1.13), 0.59 (95% CI 0.40-0.88), and 0.51 (95% CI 0.31-0.84) for respiratory disease mortality (P for linear trend=.004). The restricted cubic spline analyses revealed the nonlinear and L-shaped associations of serum chloride with all-cause and cause-specific mortality (all P for nonlinearity<.05), in which lower serum chloride was prominently associated with higher mortality risk. The associations of serum chloride with mortality risk were robust, and no significant additional interaction effect was detected for all-cause mortality and CVD mortality (P for interaction>.05). CONCLUSIONS In American adults, decreased serum chloride concentrations were independently associated with increased all-cause mortality, CVD mortality, cancer mortality, and respiratory disease mortality. Our findings suggested that serum chloride may serve as a promising cost-effective health indicator in the general adult population. Further studies are warranted to explore the potential pathophysiological mechanisms underlying the association between serum chloride and mortality.
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Affiliation(s)
- Xinran Hou
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Wei Xu
- Department of Anesthesiology, Hunan Provincial Maternal and Child Health Care Hospital, University of South China, Changsha, China
| | - Chengliang Zhang
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
- Department of Cardiovascular Surgery, Xiangya Hospital, Central South University, Changsha, China
| | - Zongbin Song
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Maoen Zhu
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Qulian Guo
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Wang
- Department of Anesthesiology, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Zhou D, Jiang J, Zhang J, Cao F, Peng Z. INCREASE IN CHLORIDE IS ASSOCIATED WITH MAJOR ADVERSE KIDNEY EVENTS IN CRITICALLY ILL PATIENTS. Shock 2023; 59:338-343. [PMID: 36455261 DOI: 10.1097/shk.0000000000002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
ABSTRACT Purpose: This study aimed to identify the association between hyperchloremia at intensive care unit (ICU) admission and/or the increase of blood chloride levels and the incidence of major adverse kidney events within 30 days (MAKE30) in critically ill adults. Methods: We conducted a retrospective study to analyze the data of all adult patients admitted to the ICU of a tertiary academic hospital in China between April 2020 and April 2022. Patients were categorized based on their admission chloride levels (hyperchloremia ≥110 mmol/L and nonhyperchloremia <110 mmol/L) and stratified on the increased chloride levels 48 h after ICU admission (∆Cl ≥5 mmol/L and ∆Cl <5 mmol/L). The primary outcome was the MAKE30 incidence, including in-hospital death, new receipt of renal replacement therapy (RRT), and persistent renal dysfunction (PRD). Association between hyperchloremia at ICU admission and/or the increase of chloride and the incidence of MAKE30 were assessed using logistic regression. Result: A total of 2,024 patients with a median age of 67 years (interquartile range [IQR], 55-76 years) and a median Acute Physiology and Chronic Health Evaluation II score of 22 (IQR, 17-28) were included. Hyperchloremia occurred in 30.9% (n = 625), and ΔCl ≥5 mmol/L occurred in 18.5% (n = 375) of all ICU patients. The overall MAKE30 incidence was 33.6% (n = 680), including a 10.9% of 30-day hospital mortality (n = 220; as well as overall in-hospital mortality, 11.8% [n = 238]), a 20.2% (n = 408) of PRD, and a 18.0% (n = 365) of new RRT. After adjusted for confounders, it was found that ΔCl ≥5 mmol/L (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.096-1.93; P = 0.010), but not hyperchloremia (OR, 0.99; 95% CI, 0.77-1.28; P = 0.947), was associated with increased incidence of MAKE30. Conclusion: An increased chloride level in the first 48 h of ICU admission was an independent risk factor for MAKE30, whereas hyperchloremia at ICU admission was not associated with an increased incidence of MAKE30. Large-scale prospective studies are needed to verify our findings.
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Affiliation(s)
| | | | | | - Fengsheng Cao
- Department of Emergency and Intensive Care, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei Province, China
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10
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Stanski NL, Gist KM, Pickett K, Brinton JT, Sadlowski J, Wong HR, Mourani P, Soranno DE, Kendrick J, Stenson EK. Electrolyte derangements in critically ill children receiving balanced versus unbalanced crystalloid fluid resuscitation. BMC Nephrol 2022; 23:388. [PMID: 36474179 PMCID: PMC9727874 DOI: 10.1186/s12882-022-03009-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/15/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adult studies have demonstrated potential harm from resuscitation with 0.9% sodium chloride (0.9%NaCl), resulting in increased utilization of balanced crystalloids like lactated ringers (LR). The sodium and potassium content of LR has resulted in theoretical safety concerns, although limited data exists in pediatrics. We hypothesized that use of LR for resuscitation would not be associated with increased electrolyte derangements compared to 0.9%NaCl. METHODS A prospective, observational cohort study of critically ill children who received ≥ 20 ml/kg of fluid resuscitation and were admitted to two pediatric intensive care units from November 2017 to February 2020. Fluid groups included patients who received > 75% of fluids from 0.9%NaCl, > 75% of fluids from LR, and a mixed group. The primary outcome was incidence of electrolyte derangements (sodium, chloride, potassium) and acidosis. RESULTS Among 559 patients, 297 (53%) received predominantly 0.9%NaCl, 74 (13%) received predominantly LR, and 188 (34%) received a mixture. Extreme hyperkalemia (potassium ≥ 6 mmol/L) was more common in 0.9%NaCl group (5.8%) compared to LR group (0%), p 0.05. Extreme acidosis (pH > 7.1) was more common in 0.9%NaCl group (11%) compared to LR group (1.6%), p 0.016. CONCLUSIONS LR is associated with fewer electrolyte derangements compared to 0.9%NaCl. Prospective interventional trials are needed to validate these findings.
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Affiliation(s)
- Natalja L. Stanski
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Katja M. Gist
- grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA ,grid.239573.90000 0000 9025 8099Division of Cardiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Kaci Pickett
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - John T. Brinton
- grid.430503.10000 0001 0703 675XDepartment of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA
| | - Jennifer Sadlowski
- grid.413957.d0000 0001 0690 7621Research Informatics, Children’s Hospital Colorado, Aurora, CO USA
| | - Hector R. Wong
- grid.239573.90000 0000 9025 8099Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA ,grid.24827.3b0000 0001 2179 9593Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH USA
| | - Peter Mourani
- grid.241054.60000 0004 4687 1637Department of Pediatrics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR USA ,grid.239305.e0000 0001 2157 2081Division of Critical Care Medicine, Arkansas Children’s Hospital, Little Rock, AR USA
| | - Danielle E. Soranno
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Nephrology, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO USA ,grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Jessica Kendrick
- grid.430503.10000 0001 0703 675XDivision of Renal Disease and Hypertension, University of Colorado Anschutz Medical Campus, Aurora, CO USA
| | - Erin K. Stenson
- grid.430503.10000 0001 0703 675XDepartment of Pediatrics, University of Colorado School of Medicine, Aurora, CO USA ,grid.430503.10000 0001 0703 675XSection of Critical Care, University of Colorado School of Medicine and Children’s Hospital Colorado, 13121 E 17th Avenue, MS8414, Aurora, CO 80045 USA
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11
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Hyperchloremia and association with acute kidney injury in critically ill children. Pediatr Nephrol 2022:10.1007/s00467-022-05823-8. [PMID: 36409366 DOI: 10.1007/s00467-022-05823-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 10/30/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Hyperchloremia has been associated with acute kidney injury (AKI) in critically ill adult patients. Data is limited in pediatric patients. Our study sought to determine if an association exists between hyperchloremia and AKI in pediatric patients admitted to the intensive care unit (PICU). METHODS This is a single-center retrospective cohort study of pediatric patients admitted to the PICU for greater than 24 h and who received intravenous fluids. Patients were excluded if they had a diagnosis of kidney disease or required kidney replacement therapy (KRT) within 6 h of admission. Exposures were hyperchloremia (serum chloride ≥ 110 mmol/L) within the first 7 days of PICU admission. The primary outcome was the development of AKI using the Kidney Disease Improving Global Outcomes (KDIGO) criteria. Secondary outcomes included time on mechanical ventilation, new KRT, PICU length of stay, and mortality. Outcomes were analyzed using multivariate logistic regression. RESULTS There were 407 patients included in the study, 209 in the hyperchloremic group and 198 in the non-hyperchloremic group. Univariate analysis demonstrated 108 (51.7%) patients in the hyperchloremic group vs. 54 (27.3%) in the non-hyperchloremic group (p = < .001) with AKI. On multivariate analysis, the odds ratio of AKI with hyperchloremia was 2.24 (95% CI 1.39-3.61) (p = .001). Hyperchloremia was not associated with increased odds of mortality, need for KRT, time on mechanical ventilation, or length of stay. CONCLUSION Hyperchloremia was associated with AKI in critically ill pediatric patients. Further pediatric clinical trials are needed to determine the benefit of a chloride restrictive vs. liberal fluid strategy. A higher resolution version of the Graphical abstract is available as Supplementary information.
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12
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Moriwaki M, Kito K, Nakagawa R, Tominaga E, Kapoor MP, Matsumiya Y, Fukuhara T, Yamagata H, Katsumata T, Minegawa K. Mutagenic, Acute, and Subchronic Toxicity Studies of the Hesperetin-7-Glucoside-β-Cyclodextrin Inclusion Complex. Int J Toxicol 2022; 42:50-62. [PMID: 36280476 PMCID: PMC9841476 DOI: 10.1177/10915818221134022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Hesperetin glucosides such as hesperidin and hesperetin-7-glucoside are abundantly present in citrus fruits and have various pharmacological properties. However, the potential toxicity of hesperetin glucosides remains unclear. An initial assessment of the safety of hesperetin-7-glucoside-β-cyclodextrin inclusion complex (HPTGCD) as a functional food ingredient was undertaken to assess toxicity and mutagenic potential. A bacterial reverse mutation assay (Ames test) using Salmonella typhimurium (strains TA98, TA1535, TA100, and TA1537) and Escherichia coli (strain WP2 uvrA) with HPTGCD (up to 5000 µg/plate) in the absence and presence of metabolic activation was negative. In a single oral (gavage) toxicity study in male and female rats, HPTGCD at dose up to 2000 mg/kg did not produce mortality nor clinical signs of toxicity or change in body weight. In a subchronic oral (dietary admix) toxicity study in rats receiving 0, 1.5, 3, and 5% HPTGCD for 13 weeks, no adverse effects were noted and the no-observed-adverse-effect level (NOAEL) was 5% in the diet (equivalent to 3267.7 mg/kg/day for males and to 3652.4 mg/kg/day for females). These results provide initial evidence of the safety of HPTGCD.
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Affiliation(s)
- Masamitsu Moriwaki
- Taiyo Kagaku Co. Ltd., Nutrition
Division, Mie, Japan,Masamitsu Moriwaki, Taiyo Kagaku Co. Ltd.,
Nutrition Division, 1-3 Takaramachi, Yokkaichi, Mie 510-0844, Japan.
| | - Kento Kito
- Taiyo Kagaku Co. Ltd., Nutrition
Division, Mie, Japan
| | - Ryo Nakagawa
- Taiyo Kagaku Co. Ltd., Nutrition
Division, Mie, Japan
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13
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Sakuraya M, Yoshihiro S, Onozuka K, Takaba A, Yasuda H, Shime N, Kotani Y, Kishihara Y, Kondo N, Sekine K, Morikane K. A burden of fluid, sodium, and chloride due to intravenous fluid therapy in patients with respiratory support: a post-hoc analysis of a multicenter cohort study. Ann Intensive Care 2022; 12:100. [PMID: 36272034 PMCID: PMC9588139 DOI: 10.1186/s13613-022-01073-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 10/11/2022] [Indexed: 11/12/2022] Open
Abstract
Background Fluid creep, including fluids administered as drug diluents and for the maintenance of catheter patency, is the major source of fluid intake in critically ill patients. Although hypoxemia may lead to fluid restriction, the epidemiology of fluid creep in patients with hypoxemia is unclear. This study aimed to address the burden due to fluid creep among patients with respiratory support according to oxygenation status. Methods We conducted a post-hoc analysis of a prospective multicenter cohort study conducted in 23 intensive care units (ICUs) in Japan from January to March 2018. Consecutive adult patients who underwent invasive or noninvasive ventilation upon ICU admission and stayed in the ICU for more than 24 h were included. We excluded the following patients when no fluids were administered within 24 h of ICU admission and no records of the ratio of arterial oxygen partial pressure to fractional inspired oxygen. We investigated fluid therapy until 7 days after ICU admission according to oxygenation status. Fluid creep was defined as the fluids administered as drug diluents and for the maintenance of catheter patency when administered at ≤ 20 mL/h. Results Among the 588 included patients, the median fluid creep within 24 h of ICU admission was 661 mL (25.2% of the total intravenous-fluid volume), and the proportion of fluid creep gradually increased throughout the ICU stay. Fluid creep tended to decrease throughout ICU days in patients without hypoxemia and in those with mild hypoxemia (p < 0.001 in both patients), but no significant trend was observed in those with severe hypoxemia (p = 0.159). Similar trends have been observed in the proportions of sodium and chloride caused by fluid creep. Conclusions Fluid creep was the major source of fluid intake among patients with respiratory support, and the burden due to fluid creep was prolonged in those with severe hypoxemia. However, these findings may not be conclusive as this was an observational study. Interventional studies are, therefore, warranted to assess the feasibility of fluid creep restriction. Trial registration UMIN-CTR, the Japanese clinical trial registry (registration number: UMIN 000028019, July 1, 2017). Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01073-x.
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Affiliation(s)
- Masaaki Sakuraya
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hiroshima, JA, 738-8503, Japan.
| | - Shodai Yoshihiro
- Department of Pharmacy, Onomichi General Hospital, Hiroshima, Japan
| | - Kazuto Onozuka
- Pharmaceutical Department, JA Hiroshima General Hospital, Hiroshima, JA, Japan
| | - Akihiro Takaba
- Department of Emergency and Intensive Care Medicine, JA Hiroshima General Hospital, Jigozen 1-3-3, Hiroshima, JA, 738-8503, Japan
| | - Hideto Yasuda
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan.,Department of Clinical Research Education and Training Unit, Keio University Hospital Clinical and Translational Research Center (CTR), Tokyo, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuki Kotani
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Yuki Kishihara
- Department of Emergency and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Natsuki Kondo
- Department of Intensive Care Medicine, Chiba Emergency Medical Center, Chiba, Japan
| | - Kosuke Sekine
- Department of Medical Engineer, Kameda Medical Center, Chiba, Japan
| | - Keita Morikane
- Division of Clinical Laboratory and Infection Control, Yamagata University Hospital, Yamagata, Japan
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Hernández-Leiva E, Hernández-Huertas F. The use of inotropes and not hyperchloremia is an independent risk factor for acute kidney injury during the postoperative period of cardiac surgery. A prospective cohort-study. INTERNATIONAL JOURNAL OF SURGERY OPEN 2022. [DOI: 10.1016/j.ijso.2022.100507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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15
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Beran A, Altorok N, Srour O, Malhas SE, Khokher W, Mhanna M, Ayesh H, Aladamat N, Abuhelwa Z, Srour K, Mahmood A, Altorok N, Taleb M, Assaly R. Balanced Crystalloids versus Normal Saline in Adults with Sepsis: A Comprehensive Systematic Review and Meta-Analysis. J Clin Med 2022; 11:1971. [PMID: 35407578 PMCID: PMC8999853 DOI: 10.3390/jcm11071971] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/26/2022] [Accepted: 03/28/2022] [Indexed: 02/08/2023] Open
Abstract
The crystalloid fluid of choice in sepsis remains debatable. We aimed to perform a comprehensive meta-analysis to compare the effect of balanced crystalloids (BC) vs. normal saline (NS) in adults with sepsis. A systematic search of PubMed, EMBASE, and Web of Sciences databases through 22 January 2022, was performed for studies that compared BC vs. NS in adults with sepsis. Our outcomes included mortality and acute kidney injury (AKI), need for renal replacement therapy (RRT), and ICU length of stay (LOS). Pooled risk ratio (RR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were obtained using a random-effect model. Fifteen studies involving 20,329 patients were included. Overall, BC showed a significant reduction in the overall mortality (RR 0.88, 95% CI 0.81-0.96), 28/30-day mortality (RR 0.87, 95% CI 0.79-0.95), and AKI (RR 0.85, 95% CI 0.77-0.93) but similar 90-day mortality (RR 0.96, 95% CI 0.90-1.03), need for RRT (RR 0.91, 95% CI 0.76-1.08), and ICU LOS (MD -0.25 days, 95% CI -3.44, 2.95), were observed between the two groups. However, subgroup analysis of randomized controlled trials (RCTs) showed no statistically significant differences in overall mortality (RR 0.92, 95% CI 0.82-1.02), AKI (RR 0.71, 95% CI 0.47-1.06), and need for RRT (RR 0.71, 95% CI 0.36-1.41). Our meta-analysis demonstrates that overall BC was associated with reduced mortality and AKI in sepsis compared to NS among patients with sepsis. However, subgroup analysis of RCTs showed no significant differences in both overall mortality and AKI between the groups. There was no significant difference in the need for RRT or ICU LOS between BC and NS. Pending further data, our study supports using BC over NS for fluid resuscitation in adults with sepsis. Further large-scale RCTs are necessary to validate our findings.
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Affiliation(s)
- Azizullah Beran
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nehaya Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Omar Srour
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Saif-Eddin Malhas
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Waleed Khokher
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Hazem Ayesh
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo, Toledo, OH 43606, USA;
| | - Ziad Abuhelwa
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Khaled Srour
- Department of Critical Care Medicine, Henry Ford Health System, Detroit, MI 48202, USA;
| | - Asif Mahmood
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
| | - Nezam Altorok
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Rheumatology, University of Toledo, Toledo, OH 43606, USA
| | - Mohammad Taleb
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
| | - Ragheb Assaly
- Department of Internal Medicine, University of Toledo, Toledo, OH 43606, USA; (N.A.); (O.S.); (S.-E.M.); (W.K.); (M.M.); (H.A.); (Z.A.); (A.M.); (N.A.); (R.A.)
- Department of Pulmonary and Critical Care Medicine, University of Toledo, Toledo, OH 43606, USA;
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Nalimu F, Oloro J, Peter EL, Ogwang PE. Acute and sub-acute oral toxicity of aqueous whole leaf and green rind extracts of Aloe vera in Wistar rats. BMC Complement Med Ther 2022; 22:16. [PMID: 35031035 PMCID: PMC8760731 DOI: 10.1186/s12906-021-03470-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several local communities in Central, Western, Eastern, and Northern regions of Uganda have been using the whole leaf extracts of Aloe vera (L.) Burm. f. (Asphodelaceae) in the treatment of various ailments. Also, several commercial companies sell A. vera as soft drinks in Uganda. However, there are inadequate reports on the toxicities of such preparations. This paper reports the acute and sub-acute oral toxicity of aqueous extracts of whole leaf and green rind of A. vera in Wistar rats. METHODS Acute oral toxicity test was carried out in female Wistar rats at doses of 175, 550, 1750, and 5000 mg/kg, p.o. The animals were observed for signs of toxicity for 14 days. Similarly, a sub-acute oral toxicity test was performed in both sexes of rats at doses of 200, 400, and 800 mg/kg, p.o. daily for 28 days. All the groups of animals were monitored for behavioral, morphological, biochemical, and physiological changes, including mortality and compared with respective controls. Body weights were measured weekly while the animals' relative organ weights, hematological, biochemical, gross, and microscopic pathology were examined on day 29. RESULTS There was no mortality or apparent behavioral changes at the doses tested in acute and sub-acute oral toxicity tests. Thus, the Median Lethal Dose (LD50) of green rind and whole leaf aqueous extracts was above 5000 mg/kg. Gross anatomy revealed that the rats' relative spleen weight in green rind extract at 200 mg/kg significantly decreased compared to the control group. The creatinine levels in female rats that received green rind extract and the chloride ion levels in male rats administered whole leaf extract were significantly elevated. Conversely, Mean Corpuscular Hemoglobin Concentration (MCHC) levels significantly decreased at lower doses of the green rind extract compared to the control. Histopathology of the kidney revealed the renal interstitium's inflammation at doses of 200 and 800 mg/kg of the whole leaf extract. CONCLUSION The findings demonstrated that A. vera green rind and whole leaf extracts are non-toxic at relatively high doses when used for a short duration. Prolonged use of the aqueous whole leaf extract might be associated with kidney toxicity.
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Affiliation(s)
- Florence Nalimu
- Department of Pharmaceutical Sciences, Faculty of Medicine, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda.
| | - Joseph Oloro
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Emanuel L Peter
- Department of Innovation, Technology Transfer & Commercialization, National Institute for Medical Research, Dar es Salaam, Tanzania.,Department of Pharmacy, Faculty of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
| | - Patrick Engeu Ogwang
- Department of Pharmacy, Faculty of Medicine, Mbarara University of Science and Technology, P.O Box 1410, Mbarara, Uganda
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Carrillo AR, Elwood K, Werth C, Mitchell J, Sarangarm P. Balanced Crystalloid Versus Normal Saline as Resuscitative Fluid in Diabetic Ketoacidosis. Ann Pharmacother 2022; 56:998-1006. [DOI: 10.1177/10600280211063651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Large volume resuscitation with normal saline (NS) may be associated with iatrogenic hyperchloremia and renal injury. Objective: The purpose of this study was to assess clinical outcomes associated with the use of Lactated Ringer’s (LR) compared to NS as resuscitative fluid in diabetic ketoacidosis (DKA). Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was to evaluate the incidence of iatrogenic hyperchloremia associated with fluid resuscitation using balanced crystalloid compared to NS. Results Iatrogenic hyperchloremia occurred more frequently in the NS group compared to the LR group (74.4% vs 64.2%; P = 0.05). Mean maximum serum chloride was higher in the NS group (115.7 mmol/L vs 113.7 mmol/L; P = 0.004). Incidence of hypernatremia was higher in the NS group (18.3% vs 9.3%; P = 0.02). There was no significant difference in the incidence of AKI; however, mean change in serum creatinine at 48 hours showed a significantly greater decrease in the LR group (-0.15 mg/dL vs -0.04 mg/dL; P = 0.002). No significant differences were found in intensive care unit (ICU) length of stay or total hospital length of stay. Conclusion and Relevance This study found a statistically significant reduction in the incidence of iatrogenic hyperchloremia with the use of LR compared to NS as fluid resuscitation in DKA. Serum creatinine was more improved in the LR group versus NS group at 48 hours. Preferential use of balanced crystalloid for fluid resuscitation in DKA may reduce incidence of hyperchloremia and support renal recovery in this population.
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Affiliation(s)
- Adriana R. Carrillo
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Kirsten Elwood
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Chris Werth
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Jessica Mitchell
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM, USA
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, NM, USA
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18
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Choi JS, Yun D, Kim DK, Oh KH, Joo KW, Kim YS, Na KY, Han SS. Hyperchloremia is associated with poor renal outcome after coronary artery bypass grafting. BMC Nephrol 2021; 22:343. [PMID: 34657614 PMCID: PMC8522137 DOI: 10.1186/s12882-021-02554-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 10/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Hyperchloremia is associated with the risks of several morbidities and mortality. However, its relationship with acute kidney injury (AKI) and end-stage renal disease (ESRD) in patients undergoing coronary artery bypass grafting (CABG) remains unresolved. Methods A total of 2977 patients undergoing CABG between 2003 and 2015 were retrospectively reviewed from two tertiary hospitals. Patients were categorized by serum chloride levels into normochloremia (95–105 mmol/L), mild hyperchloremia (106–110 mmol/L), and severe hyperchloremia (> 110 mmol/L). The odds ratios (ORs) for AKI and hazard ratios (HRs) for ESRD were calculated after adjustment for multiple covariates. The death-adjusted risk of ESRD was additionally evaluated. Results Postoperative AKI occurred in 798 patients (26.5%). The hyperchloremia group had a higher risk of AKI than the normochloremia group, wherein the risk was incremental depending on the severity of hyperchloremia, as follows: ORs were 1.26 (1.06–1.51) and 1.95 (1.52–2.51) in the mild and severe hyperchloremia groups, respectively. During a median period of 7 years (maximum 15 years), 70 patients (2.3%) had ESRD. The severe hyperchloremia group was at an elevated risk of ESRD compared with the normochloremia group, with an HR of 2.43 (1.28–4.63). Even after adjusting for the competing risk of death, hyperchloremia was associated with the risk of ESRD. Conclusions Preoperative hyperchloremia is associated with poor renal outcomes such as AKI and ESRD after CABG. Accordingly, serum chloride should be monitored in patients undergoing CABG.
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Affiliation(s)
- Jae Shin Choi
- Department of Internal Medicine, Pyeongtaek St. Mary's Hospital, Gyeonggi-do, Korea
| | - Donghwan Yun
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Ki Kim
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Kwon Wook Joo
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Yon Su Kim
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea.,Department of Internal Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, 103 Daehakro, Jongno-gu, Seoul, 03080, Korea.
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Subtyping Hyperchloremia among Hospitalized Patients by Machine Learning Consensus Clustering. MEDICINA-LITHUANIA 2021; 57:medicina57090903. [PMID: 34577826 PMCID: PMC8465989 DOI: 10.3390/medicina57090903] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/26/2021] [Accepted: 08/26/2021] [Indexed: 01/20/2023]
Abstract
Background and Objectives: Despite the association between hyperchloremia and adverse outcomes, mortality risks among patients with hyperchloremia have not consistently been observed among all studies with different patient populations with hyperchloremia. The objective of this study was to characterize hyperchloremic patients at hospital admission into clusters using an unsupervised machine learning approach and to evaluate the mortality risk among these distinct clusters. Materials and Methods: We performed consensus cluster analysis based on demographic information, principal diagnoses, comorbidities, and laboratory data among 11,394 hospitalized adult patients with admission serum chloride of >108 mEq/L. We calculated the standardized mean difference of each variable to identify each cluster's key features. We assessed the association of each hyperchloremia cluster with hospital and one-year mortality. Results: There were three distinct clusters of patients with admission hyperchloremia: 3237 (28%), 4059 (36%), and 4098 (36%) patients in clusters 1 through 3, respectively. Cluster 1 was characterized by higher serum chloride but lower serum sodium, bicarbonate, hemoglobin, and albumin. Cluster 2 was characterized by younger age, lower comorbidity score, lower serum chloride, and higher estimated glomerular filtration (eGFR), hemoglobin, and albumin. Cluster 3 was characterized by older age, higher comorbidity score, higher serum sodium, potassium, and lower eGFR. Compared with cluster 2, odds ratios for hospital mortality were 3.60 (95% CI 2.33-5.56) for cluster 1, and 4.83 (95% CI 3.21-7.28) for cluster 3, whereas hazard ratios for one-year mortality were 4.49 (95% CI 3.53-5.70) for cluster 1 and 6.96 (95% CI 5.56-8.72) for cluster 3. Conclusions: Our cluster analysis identified three clinically distinct phenotypes with differing mortality risks in hospitalized patients with admission hyperchloremia.
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20
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Barhight MF, Nelson D, Moran T, Christiano J, Sanchez-Pinto LN. Association between the use of balanced fluids and outcomes in critically ill children: a before and after study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:266. [PMID: 34325729 PMCID: PMC8319885 DOI: 10.1186/s13054-021-03705-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 07/24/2021] [Indexed: 12/29/2022]
Abstract
Background Hyperchloremia and chloride load have been associated with worse clinical outcomes in critically ill patients. We sought to evaluate the electrolyte profile and clinical outcomes associated with a unit-wide transition from saline to balanced fluids for resuscitation and maintenance fluids in a pediatric intensive care unit (PICU). Methods A before and after analysis of all patients admitted to the PICU in a large, urban, academic hospital between August 2018 and March 2020. The transition from the use of saline to the use of balanced fluids for both resuscitation and maintenance fluid as standard care occurred in June 2019. The primary outcome was day 3 acute kidney injury (AKI). The secondary outcomes included mortality, ventilator-free days (VFDs), need for renal replacement therapy (RRT), hospital length of stay (LOS), and electrolyte abnormalities. Results Overall, 2863 patients (47% female) with a day 3 AKI rate of 12.9% (n = 130) and a mortality rate of 2.8% (n = 79) were included. After adjusting for confounders (age, PRISM III, mechanical ventilation, and immunocompromised state, septic shock), there were no significant differences in the odds of day 3 AKI (pre 13%, post 12.5%; adjusted odds ratio [aOR] 0.96, 95%CI 0.65–1.42). There were no differences in the secondary outcomes. The post-intervention period had fewer patients with hyperchloremia (pre 15.5% vs. post 10.4%, p = < 0.0001) and hyperkalemia (pre 3.2% vs. post 1.4%, p = 0.02) and more patients with hypochloremia (pre 9.5% vs. post 14.4%, p = < 0.0001) and hypokalemia (pre 38.2% vs. post 47.2%, p = < 0.0001). In reference to the normochloremic cohort, the hypochloremic cohort had an increase in day 3 AKI, need for RRT, hyperchloremia, and hyperkalemia, and a decrease in hypokalemia; and the hyperchloremic cohort had an increase in VFD and a decrease in hospital LOS. Conclusions Following a unit-wide implementation of balanced fluids as standard care, there were no differences in rates of day 3 AKI or other clinical outcomes. However, there were lower rates of hyperkalemia and hyperchloremia and higher rates of hypokalemia and hypochloremia. Further evaluation of the effect of balanced fluids and the clinical significance of electrolyte abnormalities in critically ill children is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03705-3.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA. .,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Delphine Nelson
- Division of Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Thomas Moran
- Department of Pharmacy, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jessica Christiano
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - L Nelson Sanchez-Pinto
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave., Chicago, IL, 60611, USA.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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21
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Molinari L, Sakhuja A, Kellum JA. Perioperative Renoprotection: General Mechanisms and Treatment Approaches. Anesth Analg 2020; 131:1679-1692. [PMID: 33186157 DOI: 10.1213/ane.0000000000005107] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In the perioperative setting, acute kidney injury (AKI) is a frequent complication, and AKI itself is associated with adverse outcomes such as higher risk of chronic kidney disease and mortality. Various risk factors are associated with perioperative AKI, and identifying them is crucial to early interventions addressing modifiable risk and increasing monitoring for nonmodifiable risk. Different mechanisms are involved in the development of postoperative AKI, frequently picturing a multifactorial etiology. For these reasons, no single renoprotective strategy will be effective for all surgical patients, and efforts have been attempted to prevent kidney injury in different ways. Some renoprotective strategies and treatments have proven to be useful, some are no longer recommended because they are ineffective or even harmful, and some strategies are still under investigation to identify the best timing, setting, and patients for whom they could be beneficial. With this review, we aim to provide an overview of recent findings from studies examining epidemiology, risk factors, and mechanisms of perioperative AKI, as well as different renoprotective strategies and treatments presented in the literature.
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Affiliation(s)
- Luca Molinari
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Ankit Sakhuja
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania.,Division of Cardiovascular Critical Care, Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, West Virginia
| | - John A Kellum
- From the Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
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22
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Association of Chloride Ion and Sodium-Chloride Difference With Acute Kidney Injury and Mortality in Critically Ill Patients. Crit Care Explor 2020; 2:e0247. [PMID: 33251513 PMCID: PMC7688253 DOI: 10.1097/cce.0000000000000247] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
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.
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23
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Dyschloremia is associated with failure to restore renal function in survivors with acute kidney injury: an observation retrospective study. Sci Rep 2020; 10:19623. [PMID: 33184400 PMCID: PMC7661702 DOI: 10.1038/s41598-020-76798-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/23/2020] [Indexed: 01/30/2023] Open
Abstract
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.
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Magboul SM, Osman B, Elnour AA. The incidence, risk factors, and outcomes of acute kidney injury in the intensive care unit in Sudan. Int J Clin Pharm 2020; 42:1447-1455. [PMID: 32951181 PMCID: PMC7502153 DOI: 10.1007/s11096-020-01147-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 09/05/2020] [Indexed: 12/31/2022]
Abstract
Background There is a paucity of studies in acute kidney injury in the intensive care unit, particularly in Sudan. Objectives The current study has estimated the incidence; risk factors and outcomes of subjects with acute kidney injury developed during admission to the intensive care unit at Fedail Hospital, Khartoum, Sudan. Methodology This was a cross-sectional study conducted in the intensive care unit during the period from July 2018 to June 2019. The data was collected from the clinical profiles of all adult subjects' who have met the published criteria for acute kidney injury. Analysis of association (Chi square test χ2) and multivariate logistic regression were used to analyze data. Main outcome measure The development of acute kidney injury during the subjects' stay in the intensive care unit, length of hospital stay and death. Results From a total of 187 subjects admitted to the intensive care unit; only (105, 56.2%) have met the inclusion criteria (mean age was 61 ± 3.5 years). The main finding of the study was the high incidence of acute kidney injury 39%. The major significant predictors for the development of acute kidney injury with respective odds ratio (OR) were: sepsis (OR 7.5 [95% CI 3-19.7]; P .001); hypovolemia (OR 5.1 [95% CI 2-15.7]; P .001); chronic cardiovascular diseases (OR 3.4 [95% CI 1.2-9.4]; P .017); age > 60 years (OR 2.7 [95% CI 1.2-6.3]; P .018); diabetes mellitus (OR 2.6 [95% CI 1.2-6]; P .02); hypertension (OR 2.4 [95% CI 1.2-5.4]; P .028); and renal replacement therapy (OR 0.2 [95% CI 0.15-0.3]; P .001). The length of hospital stay within the AKI cohort was (6.7 ± 3.8; [range 2-17]) and the mortality rate was (36, 87.8%). Conclusion The major significant predictors for the development of acute kidney injury in the intensive care unit were: sepsis; hypovolemia; chronic cardiovascular diseases; age > 60 years; diabetes mellitus; hypertension; and renal replacement therapy. Sepsis and hypovolemia were common etiologies for acute kidney injury post-admission to the intensive care unit. Acute kidney injury was associated with increased length of hospital stay and a very high absolute mortality rate.
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Affiliation(s)
| | - Bashier Osman
- Department of Pharmacology, Faculty of Pharmacy, University of Khartoum, Khartoum, Sudan
| | - Asim Ahmed Elnour
- Clinical Pharmacy Program, College of Pharmacy, Al Ain University (AAU), Abu Dhabi, UAE.
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25
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McIlroy DR, Murphy D, Shotwell MS, Bhatia D. Peak Serum Chloride and Hyperchloremia in Patients Undergoing Cardiac Surgery Is Not Explained by Chloride-Rich Intravenous Fluid Alone: A Post-Hoc Analysis of the LICRA Trial. J Cardiothorac Vasc Anesth 2020; 35:1321-1331. [PMID: 32863142 DOI: 10.1053/j.jvca.2020.07.085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 07/30/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES With the exception of 0.9% saline, little is known about factors that may contribute to increased serum chloride concentration (SCl-) in patients undergoing cardiac surgery. For the present study, the authors sought to characterize the association between administered chloride load from intravenous fluid and other perioperative variables, with peak perioperative SCl-. DESIGN Secondary analysis of data from a previously published controlled clinical trial in which patients were assigned to a chloride-rich or chloride-limited perioperative fluid strategy (NCT02020538). SETTING Academic medical center. PARTICIPANTS The study comprised 1,056 adult patients with normal preoperative SCl- undergoing cardiac surgery. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Peak perioperative SCl- and hyperchloremia, defined as peak SCl- >110 mmol/L, were selected as co-primary endpoints. Regression modeling identified factors independently associated with these endpoints. Mean (standard deviation) peak perioperative SCl- was 114 (5) mmol/L, and hyperchloremia occurred in 824 (78.0%) of the cohort. In addition to administered volume of 0.9% saline, multivariate linear and logistic regression modeling consistently associated preoperative SCl- (regression coefficient 0.5; 95% confidence interval [CI] 0.4-0.6 mmol/L; odds ratio 1.60; 95% CI 1.41-1.82 per 1 mmol/L increase) and cardiopulmonary bypass duration (regression coefficient 0.1; 95% CI 0.1-0.2 mmol/L; odds ratio 1.12; 95% CI 1.06-1.19 per 10 minutes) with both co-primary outcomes. Multivariate modeling only explained approximately 50% of variability in peak SCl-. CONCLUSIONS The present study's data identified an association for both 0.9% saline administration and other nonfluid variables with peak perioperative SCl- and hyperchloremia. Stand-alone strategies to limit administration of chloride-rich intravenous fluid may have limited ability to prevent hyperchloremia in this setting.
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Affiliation(s)
- David R McIlroy
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia; Vanderbilt University Medical Center, Nashville, TN.
| | - Deirdre Murphy
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | | | - Dhiraj Bhatia
- Alfred Hospital, Monash University, Melbourne, Victoria, Australia
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26
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Libin MB, Weltman JG, Prittie J. A Preliminary Investigation into the Association of Chloride Concentration on Morbidity and Mortality in Hospitalized Canine Patients. VETERINARY MEDICINE-RESEARCH AND REPORTS 2020; 11:57-69. [PMID: 32766124 PMCID: PMC7369501 DOI: 10.2147/vmrr.s253759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/05/2020] [Indexed: 11/23/2022]
Abstract
Purpose To evaluate whole blood chloride concentration and hospital-acquired AKI in hospitalized canine patients. Secondary outcome measures included the volume-adjusted chloride load, in-hospital mortality and length of ICU stay. Patients and Methods This is a prospective, observational study. Sixty dogs admitted to the ICU and receiving IV fluid therapy for >24 hours from February 2018 to July 2019. Corrected chloride and creatinine concentrations were obtained twice daily. Total volume of IV fluid and total chloride load were recorded. Volume-adjusted chloride load (VACL) was calculated by dividing the chloride administered by the volume of fluid administered. Hospital-acquired AKI was defined as an increase in creatinine of ≥26.5 μmol/L (0.3 mg/dL) or 150% from baseline to maximum. Survival to hospital discharge or non-survival and ICU length of stay were also recorded. Results Fifteen out of 60 patients developed hospital-acquired AKI. Maximum corrected chloride was significantly different in AKI group (median 122.3 mmol/L) vs non-AKI group (median 118.1 mmol/L; p=0.0002). Six out of 60 patients developed hyperchloremia. Hyperchloremic patients were significantly more likely to develop in-hospital AKI (p=0.03). Patients hospitalized ≥2 days had a significantly higher [Cl−]max compared to those with shorter ICU stay (121.8 ± 5.9 mmol/L vs 117.5 ± 4.3 mmol/L; p=0.002). Eight out of 60 patients were non-survivors. Maximum corrected chloride and creatinine concentrations were not significantly different between survivors and non-survivors. VACL was not significantly different between AKI or mortality groups. Conclusion Maximum corrected chloride concentration was significantly higher in dogs with hospital-acquired AKI, even amongst dogs without hyperchloremia. Additionally, maximum corrected chloride concentrations were significantly higher in dogs hospitalized in the ICU longer compared to those hospitalized for fewer than two days. There was no significant difference in VACL in any of the outcome groups. Results from this study suggest alterations in chloride may be observed alongside the development of acute kidney injuries. Future studies in critically ill dogs are warranted.
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Affiliation(s)
- Madeline B Libin
- Department of Emergency and Critical Care, Animal Medical Center, New York, NY, USA
| | - Joel G Weltman
- Department of Emergency and Critical Care, Animal Medical Center, New York, NY, USA
| | - Jennifer Prittie
- Department of Emergency and Critical Care, Animal Medical Center, New York, NY, USA
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Thongprayoon C, Cheungpasitporn W, Petnak T, Mao MA, Chewcharat A, Qureshi F, Medaura J, Bathini T, Vallabhajosyula S, Kashani KB. Hospital-Acquired Serum Chloride Derangements and Associated In-Hospital Mortality. MEDICINES 2020; 7:medicines7070038. [PMID: 32610534 PMCID: PMC7400070 DOI: 10.3390/medicines7070038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 06/27/2020] [Accepted: 06/28/2020] [Indexed: 01/28/2023]
Abstract
Background: We aimed to describe the incidence of hospital-acquired dyschloremia and its association with in-hospital mortality in general hospitalized patients. Methods: All hospitalized patients from 2009 to 2013 who had normal admission serum chloride and at least two serum chloride measurements in the hospital were studied. The normal range of serum chloride was defined as 100–108 mmol/L. Hospital serum chloride levels were grouped based on the occurrence of hospital-acquired hypochloremia and hyperchloremia. The association of hospital-acquired hypochloremia and hyperchloremia with in-hospital mortality was analyzed using logistic regression. Results: Among the total of 39,298 hospitalized patients, 59% had persistently normal hospital serum chloride levels, 21% had hospital-acquired hypochloremia only, 15% had hospital-acquired hyperchloremia only, and 5% had both hypochloremia and hyperchloremia. Compared with patients with persistently normal hospital serum chloride levels, hospital-acquired hyperchloremia only (odds ratio or OR 2.84; p < 0.001) and both hospital-acquired hypochloremia and hyperchloremia (OR 1.72; p = 0.004) were associated with increased in-hospital mortality, whereas hospital-acquired hypochloremia only was not (OR 0.91; p = 0.54). Conclusions: Approximately 40% of hospitalized patients developed serum chloride derangements. Hospital-acquired hyperchloremia, but not hypochloremia, was associated with increased in-hospital mortality.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (A.C.); (F.Q.); (K.B.K.)
- Correspondence: (C.T.); (W.C.)
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
- Correspondence: (C.T.); (W.C.)
| | - Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand;
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Michael A. Mao
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, FL 32224, USA;
| | - Api Chewcharat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (A.C.); (F.Q.); (K.B.K.)
| | - Fawad Qureshi
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (A.C.); (F.Q.); (K.B.K.)
| | - Juan Medaura
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85719, USA;
| | | | - Kianoush B. Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA; (A.C.); (F.Q.); (K.B.K.)
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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The causal link between hyperchloremia and acute kidney injury is yet to be conclusively established: we are not sure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:271. [PMID: 32466768 PMCID: PMC7257179 DOI: 10.1186/s13054-020-02966-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/11/2020] [Indexed: 02/03/2023]
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Petnak T, Thongprayoon C, Cheungpasitporn W, Bathini T, Vallabhajosyula S, Chewcharat A, Kashani K. Serum Chloride Levels at Hospital Discharge and One-Year Mortality among Hospitalized Patients. ACTA ACUST UNITED AC 2020; 8:medsci8020022. [PMID: 32438557 PMCID: PMC7353470 DOI: 10.3390/medsci8020022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/11/2020] [Accepted: 05/14/2020] [Indexed: 01/02/2023]
Abstract
This study aimed to assess the one-year mortality risk based on discharge serum chloride among the hospital survivors. We analyzed a cohort of adult hospital survivors at a tertiary referral hospital from 2011 through 2013. We categorized discharge serum chloride; ≤96, 97–99, 100–102, 103–105, 106–108, and ≥109 mmoL/L. We performed Cox proportional hazard analysis to assess the association of discharge serum chloride with one-year mortality after hospital discharge, using discharge serum chloride of 103–105 mmoL/L as the reference group. Of 56,907 eligible patients, 9%, 14%, 26%, 28%, 16%, and 7% of patients had discharge serum chloride of ≤96, 97–99, 100–102, 103–105, 106–108, and ≥109 mmoL/L, respectively. We observed a U-shaped association of discharge serum chloride with one-year mortality, with nadir mortality associated with discharge serum chloride of 103–105 mmoL/L. When adjusting for potential confounders, including discharge serum sodium, discharge serum bicarbonate, and admission serum chloride, one-year mortality was significantly higher in both discharge serum chloride ≤99 hazard ratio (HR): 1.45 and 1.94 for discharge serum chloride of 97–99 and ≤96 mmoL/L, respectively; p < 0.001) and ≥109 mmoL/L (HR: 1.41; p < 0.001), compared with discharge serum chloride of 103–105 mmoL/L. The mortality risk did not differ when discharge serum chloride ranged from 100 to 108 mmoL/L. Of note, there was a significant interaction between admission and discharge serum chloride on one-year mortality. Serum chloride at hospital discharge in the optimal range of 100–108 mmoL/L predicted the favorable survival outcome. Both hypochloremia and hyperchloremia at discharge were associated with increased risk of one-year mortality, independent of admission serum chloride, discharge serum sodium, and serum bicarbonate.
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Affiliation(s)
- Tananchai Petnak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA;
- Division of Pulmonary and Critical Care Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 10100, Thailand
| | - Charat Thongprayoon
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
- Correspondence: (C.T.); (W.C.); (K.K.)
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Internal Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA
- Correspondence: (C.T.); (W.C.); (K.K.)
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85721, USA;
| | | | - Api Chewcharat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Kianoush Kashani
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN 55902, USA;
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
- Correspondence: (C.T.); (W.C.); (K.K.)
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Khatri M, Zitovsky J, Lee D, Nayyar K, Fazzari M, Grant C. The association between serum chloride levels and chronic kidney disease progression: a cohort study. BMC Nephrol 2020; 21:165. [PMID: 32375681 PMCID: PMC7203999 DOI: 10.1186/s12882-020-01828-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
Background Limited data suggest serum chloride levels associate with mortality in heart failure, chronic kidney disease (CKD), and pulmonary arterial hypertension. Randomized trials have also shown that administration of crystalloid intravenous fluids with lower chloride concentration may have better renal outcomes. However, chloride has not been studied longitudinally for CKD progression. Methods We used a prospective cohort of subjects with stage 3 and 4 CKD recruited from a nephrology clinic at a single medical center. Linear regression, linear regression with generalized estimating equations, and Cox proportional hazards models were created for outcomes of overall change in estimated glomerular filtration rate (eGFR), longitudinal changes in eGFR, and time to > 30% decline in eGFR, respectively. Baseline chloride was modeled continuously and categorically, and models were adjusted for potential confounders. Results Median follow-up was 1.7 years. Baseline median age was 72 years and median eGFR was 35.7 mL/min/1.73m2. In multivariable analysis, higher serum chloride associated with worsened eGFR decline. Every 1 mEq/L increase in chloride associated with an overall eGFR decline of 0.32 mL/min/1.73m2 (p = 0.003), while the difference in eGFR decline in the highest quartile of chloride was 3.4 mL/min/1.73m2 compared to the lowest quartile (p = 0.004). No association between serum chloride and time to 30% decline in eGFR was observed in multivariable analysis (hazard ratio 1.05 per 1 mEq/L increase in serum chloride, p = 0.103). Conclusions In CKD patients, higher serum chloride associated with a modestly steeper rate of eGFR decline, and may be a useful biomarker to predict CKD progression. Further studies are needed to determine causality.
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Affiliation(s)
- Minesh Khatri
- Division of Nephrology, Department of Medicine, NYU Winthrop Hospital, 200 Old Country Rd, Ste 135, Mineola, NY, 11501, USA.
| | - Joshua Zitovsky
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA
| | - Dale Lee
- Department of Medicine, NYU Winthrop Hospital, Mineola, NY, USA
| | - Kamal Nayyar
- Division of Nephrology, Department of Medicine, NYU Winthrop Hospital, 200 Old Country Rd, Ste 135, Mineola, NY, 11501, USA
| | - Melissa Fazzari
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Candace Grant
- Division of Nephrology, Department of Medicine, NYU Winthrop Hospital, 200 Old Country Rd, Ste 135, Mineola, NY, 11501, USA
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Li Z, Xing C, Li T, Du L, Wang N. Hypochloremia is associated with increased risk of all-cause mortality in patients in the coronary care unit: A cohort study. J Int Med Res 2020; 48:300060520911500. [PMID: 32338101 PMCID: PMC7218470 DOI: 10.1177/0300060520911500] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/11/2020] [Indexed: 11/16/2022] Open
Abstract
Objective Serum chloride disorders have been gaining increased attention. We aimed to assess the impact of serum chloride on all-cause mortality in critically ill patients in coronary care units (CCUs). Methods We extracted clinical data from the Multiparameter Intelligent Monitoring in Intensive Care III database. We used data for the first CCU admission of each patient; baseline data were extracted within 24 hours after CCU admission. Statistical methods included the Lowess smoothing technique, Cox proportional hazards model, and subgroup analyses. Results A total 5616 patients who met the inclusion criteria were included. We observed a U-shaped relationship between admission chloride levels and 30-day all-cause mortality. In multivariate analysis adjusted for age, ethnicity, and sex, both hyper- and hypochloremia were significant predictors of risk of 30-day, 90-day, and 365-day all-cause mortality. After adjusting additional clinical characteristics, hypochloremia remained a significant predictor of risk of 30-day all-cause mortality (hazard ratio, 1.47; 95% confidence interval, 1.19–1.83). For 90-day and 365-day all-cause mortality, similar significant robust associations were found. Conclusions We observed a U-shaped relationship between admission chloride levels and 30-day all-cause mortality among patients in the CCU. Hypochloremia was associated with increased risk of all-cause mortality in these patients.
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Affiliation(s)
- Zongying Li
- Department of Cardiology, Zhoukou Central Hospital, Zhoukou, Henan, China
| | - Cheng Xing
- Department of Cardiology, Zhoukou Central Hospital, Zhoukou, Henan, China
| | - Tingting Li
- Department of Cardiology, Zhoukou Central Hospital, Zhoukou, Henan, China
| | - Linxiang Du
- Department of Cardiology, Zhoukou Central Hospital, Zhoukou, Henan, China
| | - Na Wang
- Department of Cardiology, Zhoukou Central Hospital, Zhoukou, Henan, China
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Lombardi G, Ferraro PM, Bargagli M, Naticchia A, D'Alonzo S, Gambaro G. Hyperchloremia and acute kidney injury: a retrospective observational cohort study on a general mixed medical-surgical not ICU-hospitalized population. Intern Emerg Med 2020; 15:273-280. [PMID: 31388894 DOI: 10.1007/s11739-019-02165-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 07/27/2019] [Indexed: 01/30/2023]
Abstract
The aim of this observational retrospective cohort study was to analyze the association between hyperchloremia and serum chloride variation with in-hospital acute kidney injury (AKI) and mortality in a general, no-ICU hospitalized population. We performed a retrospective study on inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 2010 and December 2014 with inclusion of adult patients with at least two values available for chloride, sodium and creatinine. Hyperchloremia was defined as serum chloride concentration ≥ 108 mmol/L (moderate hyperchloremia: chloremia between 108-110 mmol/L, severe hyperchloremia: chloremia > 110 mmol/L). According to the time of onset of the electrolyte disturbance, hyperchloremia was then classified as hospital acquired (HA) and community acquired (CA). In patients with HA-hyperchloremia, chloride variation (ΔCl) was calculated. In-hospital AKI was defined according to creatinine kinetics criteria occurring 48 h after hospital admission. Logistic regression analysis was used to evaluate the association between the exposures of interest and in-hospital AKI and mortality. A total of 24,912 hospital admissions met the inclusion criteria. Regression analyses showed that only severe HA-hyperchloremia was associated with increased risk of in-hospital AKI [odds ratio (OR) 2.60, 95% confidence interval (CI) 1.58, 4.30, p value < 0.001] and death (OR 3.89, 95% CI 2.11, 7.18, p value < 0.001). With increasing ΔCl, the OR of in-hospital AKI increased progressively (p value for trend = 0.005). In conclusion, severe hyperchloremia is an independent predictor for in-hospital AKI and mortality; HA-hyperchloremia is more detrimental for patient outcome; higher ΔCl from hospital admission is associated with increased risk of AKI.
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Affiliation(s)
- Gianmarco Lombardi
- Nefrologia, Dipartimento di Medicina, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italia
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Pietro Manuel Ferraro
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia.
- Università Cattolica del Sacro Cuore, Roma, Italia.
| | - Matteo Bargagli
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Alessandro Naticchia
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Silvia D'Alonzo
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
| | - Giovanni Gambaro
- Nefrologia, Dipartimento di Medicina, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italia
- U.O.C Nefrologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via G. Moscati 31, 00168, Roma, Italia
- Università Cattolica del Sacro Cuore, Roma, Italia
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Regolisti G, Maggiore U, Rossi GM, Cabassi A, Fiaccadori E. Hyperchloremia and acute kidney injury: a spurious association or a worrisome reality? Intern Emerg Med 2020; 15:187-189. [PMID: 31650432 DOI: 10.1007/s11739-019-02213-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/03/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Giuseppe Regolisti
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy.
| | - Umberto Maggiore
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Giovanni Maria Rossi
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Aderville Cabassi
- UO Clinica e Terapia Medica, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria di Parma and Dipartimento di Medicina e Chirurgia, Università degli Studi di Parma, Parma, Italy
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Dos Santos RP, Carvalho ARDS, Peres LAB. Incidence and risk factors of acute kidney injury in critically ill patients from a single centre in Brazil: a retrospective cohort analysis. Sci Rep 2019; 9:18141. [PMID: 31792326 PMCID: PMC6889393 DOI: 10.1038/s41598-019-54674-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 11/18/2019] [Indexed: 12/15/2022] Open
Abstract
Studies with a comprehensive analysis of the epidemiology of acute kidney injury (AKI) in intensive care units (ICUs) are still limited in developing countries. The aim of this study is to identify the incidence and risk factors of AKI in critically ill patients from a Brazilian ICU. We performed a retrospective analysis of the records of patients admitted to a single-centre adult ICU in Brazil between 1 January 2011 and 31 December 2016. The KDIGO criteria were used to define AKI. Univariate and multivariate data analyses were carried out. We included 1,500 patients. The incidence of AKI was 40.5%, and the AKI dialysis rate was 13%. The predictors of AKI at ICU admission included hypertension [odds ratio (OR) = 1.44, p 0.017], high serum creatinine concentration [OR = 3.54; p < 0.001], low serum albumin concentration [OR = 1.42, p 0.015], high APACHE II score [OR = 2.10; p < 0.001] and high SAPS 3 [OR = 1.75; p < 0.001]. The incidence of AKI was high, and we identified the predictors of AKI among critically ill Brazilian patients. The results of this study may contribute to the implementation of targeted therapies.
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Affiliation(s)
| | - Ariana Rodrigues da Silva Carvalho
- Postgraduate Program in Biosciences and Health, Western Parana State University, Cascavel, Brazil.,Department of Nursing, Western Parana State University, Cascavel, Brazil
| | - Luis Alberto Batista Peres
- Postgraduate Program in Biosciences and Health, Western Parana State University, Cascavel, Brazil.,Department of Medicine, Nephrology Division, Western Parana State University, Cascavel, Brazil
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35
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Affiliation(s)
- Hans-Joachim Priebe
- Department of Anesthesia and Critical Care, University Hospital Freiburg, Freiburg, Germany,
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36
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Liu N, Zhang Z, Hong Y, Li B, Cai H, Zhao H, Dai J, Liu L, Qian X, Jin Q. Protocol for a prospective observational study on the association of variables obtained by contrast-enhanced ultrasonography and sepsis-associated acute kidney injury. BMJ Open 2019; 9:e023981. [PMID: 31362958 PMCID: PMC6677954 DOI: 10.1136/bmjopen-2018-023981] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Sepsis commonly results in acute kidney injury (AKI), whereas about 50% of AKI cases are due to sepsis. Sepsis-associated acute kidney injury (SA-AKI) increases morbidity and mortality especially among critically ill patients. This study aims to monitor renal microcirculation perfusion during sepsis using contrast-enhanced ultrasonography (CEUS), and to explore whether CEUS is useful for predicting the development of SA-AKI. METHODS AND ANALYSIS This prospective observational study will enrol patients who were diagnosed with sepsis-3 definition. The total of septic or septic shock patients were stratified into AKI (including stages 1, 2 and 3) and non-AKI groups according to Kidney Disease Improving Global Outcomes criteria on days 0, 1, 2 and 7 after admission to the emergency intensive care unit, meanwhile, the CEUS technique will be performed to monitor renal microcirculation perfusion. A multivariable model including all CEUS variables were expected to create for predicting the development of AKI during sepsis. Ultrasonography results, demographic information, therapeutic interventions, survival outcomes, laboratory and other clinical datas will also be collected for further analysis. ETHICS AND DISSEMINATION The study protocol was approved on 2 August 2017 by the Ethics Committee of Sir Run Run Shaw Hospital (Zhejiang University Medical College) (approval number: 2016C91401). The results will be published in a peer-reviewed journal and shared with the worldwide medical community within 2 years after the start of the recruitment. TRIAL REGISTRATION NUMBER ISRCTN14728986.
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Affiliation(s)
- Ning Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Bing Li
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Huabo Cai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hui Zhao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Junru Dai
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lian Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Qian
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qicheng Jin
- Department of Ultrasound Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Kimura S, Iwasaki T, Shimizu K, Kanazawa T, Kawase H, Shioji N, Kuroe Y, Matsuoka Y, Isoyama S, Morimatsu H. Hyperchloremia Is Not an Independent Risk Factor for Postoperative Acute Kidney Injury in Pediatric Cardiac Patients. J Cardiothorac Vasc Anesth 2019; 33:1939-1945. [DOI: 10.1053/j.jvca.2018.12.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Indexed: 11/11/2022]
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38
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Zhang Z. Human recombinant alkaline phosphatase: a promising, yet-to-be-tested agent for the treatment sepsis-induced acute kidney injury. ANNALS OF TRANSLATIONAL MEDICINE 2019; 6:S124. [PMID: 30740445 DOI: 10.21037/atm.2018.12.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zhongheng Zhang
- Department of emergency medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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Rein JL, Coca SG. "I don't get no respect": the role of chloride in acute kidney injury. Am J Physiol Renal Physiol 2018; 316:F587-F605. [PMID: 30539650 DOI: 10.1152/ajprenal.00130.2018] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Joshua L Rein
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Steven G Coca
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai , New York, New York
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40
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Barhight MF, Brinton J, Stidham T, Soranno DE, Faubel S, Griffin BR, Goebel J, Mourani PM, Gist KM. Increase in chloride from baseline is independently associated with mortality in critically ill children. Intensive Care Med 2018; 44:2183-2191. [PMID: 30382307 DOI: 10.1007/s00134-018-5424-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children. METHODS We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96-109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality. RESULTS A total of 1935 patients [55% female, median age 6.3 years IQR (1.9-13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03-5.21) greater odds of mortality. CONCLUSIONS An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E. Chicago Ave., Chicago, IL, 60611, USA.
| | - John Brinton
- Department of Biostatistics and Informatics, University of Colorado School of Public Health, Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy Stidham
- Division of Critical Care, Kalispell Regional Healthcare, Kalispell, MT, USA
| | - Danielle E Soranno
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Benjamin R Griffin
- Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Jens Goebel
- Sections of Nephrology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Sections of Critical Care, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
| | - Katja M Gist
- Sections of Cardiology, Department of Paediatrics, University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado, Aurora, CO, USA
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Barhight MF, Lusk J, Brinton J, Stidham T, Soranno DE, Faubel S, Goebel J, Mourani PM, Gist KM. Hyperchloremia is independently associated with mortality in critically ill children who ultimately require continuous renal replacement therapy. Pediatr Nephrol 2018; 33:1079-1085. [PMID: 29404689 DOI: 10.1007/s00467-018-3898-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/20/2017] [Accepted: 01/19/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes. METHODS This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy. RESULTS Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002). CONCLUSIONS Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes.
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Affiliation(s)
- Matthew F Barhight
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jennifer Lusk
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA
| | - John Brinton
- Department of Biostatistics and Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy Stidham
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Danielle E Soranno
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA.,Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Sarah Faubel
- Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA.,Division of Renal Disease and Hypertension, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jens Goebel
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Nephrology, Children's Hospital Colorado, Aurora, CO, USA
| | - Peter M Mourani
- Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Katja M Gist
- Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Division of Cardiology, Children's Hospital Colorado, Aurora, CO, USA. .,The Heart Institute, Children's Hospital Colorado, 13123 E. 16th Ave, Box 100, Aurora, CO, 80045-2535, USA.
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42
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de Vasconcellos K, Skinner DL. Hyperchloraemia is associated with acute kidney injury and mortality in the critically ill: A retrospective observational study in a multidisciplinary intensive care unit. J Crit Care 2018; 45:45-51. [DOI: 10.1016/j.jcrc.2018.01.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 12/15/2017] [Accepted: 01/17/2018] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW To describe recent advances in the understanding of the role of fluid composition in renal outcomes in critically ill patients. RECENT FINDINGS The debate on fluid composition is now focused in a pragmatic discussion on fluid electrolyte composition. The resurgence of this debate was propelled by several observational studies that suggested that balanced (i.e., low chloride) solutions were associated with less acute kidney injury in critically ill patients. Nevertheless, a cluster randomized trial failed to show any benefit of balanced solutions. This trial, however, may have failed to detect an effect because of low global illness severity and little fluid infused. If balanced solutions are to be associated with less acute kidney injury, it will probably be in high risk, aggressively resuscitated patients. Additionally, the causal loop involving unbalanced solution infusion, induction of hyperchloremia and acute kidney injury is yet to be closed. Other factors, such as buffer type, speed of infusion and temperature, among others, may also be important. SUMMARY Recent evidence suggests that crystalloid fluid composition matters and can influence renal outcomes in critically ill patients. Further studies should assess the impact and cost-efficiency of balanced solutions in the context of high-risk scenarios.
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44
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Santillanes G, Rose E. Evaluation and Management of Dehydration in Children. Emerg Med Clin North Am 2018; 36:259-273. [DOI: 10.1016/j.emc.2017.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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45
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Pfortmueller CA, Uehlinger D, von Haehling S, Schefold JC. Serum chloride levels in critical illness-the hidden story. Intensive Care Med Exp 2018; 6:10. [PMID: 29654387 PMCID: PMC5899079 DOI: 10.1186/s40635-018-0174-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 03/29/2018] [Indexed: 02/14/2023] Open
Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 10, 3010, Bern, Switzerland.
| | - Dominik Uehlinger
- Department of Nephrology, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 10, 3010, Bern, Switzerland
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Innovative Clinical Trials Group, University of Göttingen, Robert-Koch-Str. 10, 37099, Göttingen, Germany
| | - Joerg Christian Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstr. 10, 3010, Bern, Switzerland
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46
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Filis C, Vasileiadis I, Koutsoukou A. Hyperchloraemia in sepsis. Ann Intensive Care 2018; 8:43. [PMID: 29589205 PMCID: PMC5869346 DOI: 10.1186/s13613-018-0388-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 03/17/2018] [Indexed: 12/21/2022] Open
Abstract
Chloride represents—quantitatively—the most prevalent, negatively charged, strong plasma electrolyte. Control of chloride concentration is a probable major mechanism for regulating the body’s acid–base balance and for maintaining homeostasis of the entire internal environment. The difference between the concentrations of chloride and sodium constitutes the major contributor to the strong ion difference (SID); SID is the key pH regulator in the body, according to the physicochemical approach. Hyperchloraemia resulting from either underlying diseases or medical interventions is common in intensive care units. Recent studies have demonstrated the importance of hyperchloraemia in metabolic acidosis and in other pathophysiological disorders present in sepsis. The aim of this narrative review is to present the current knowledge about the effects of hyperchloraemia, in relation to the underlying pathophysiology, in septic patients.
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Affiliation(s)
- Christos Filis
- 3rd Department of Internal Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece
| | - Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Respiratory Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece.
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Respiratory Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, 152 Mesogion Av., 115 27, Athens, Greece
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47
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48
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Skube SJ, Katz SA, Chipman JG, Tignanelli CJ. Acute Kidney Injury and Sepsis. Surg Infect (Larchmt) 2018; 19:216-224. [DOI: 10.1089/sur.2017.261] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Steven J. Skube
- Department of Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Stephen A. Katz
- Department of Integrative Biology and Physiology, University of Minnesota, Minneapolis, Minnesota
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Oh HJ, Kim S, Park JT, Kim SJ, Han SH, Yoo TH, Ryu DR, Kang SW, Chung YE. Baseline Chloride Levels are Associated with the Incidence of Contrast-Associated Acute Kidney Injury. Sci Rep 2017; 7:17431. [PMID: 29234129 PMCID: PMC5727178 DOI: 10.1038/s41598-017-17763-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 11/30/2017] [Indexed: 01/02/2023] Open
Abstract
Although hypo- and hyperchloremia have been associated with worsening renal outcomes, there has been no study that correlates hypo- and hyperchloremia and the incidence of contrast-associated acute kidney injury (CA-AKI). A total of 13,088 patients with less than 2.0 mg/dL of serum creatinine (Cr) who underwent contrast-enhanced abdominal CT (CECT) were included. Patients were divided into 3 groups based on Cl (the hypo-, normo- and hyperchloremia groups). Patients were also classified by baseline Cr (<1.2; the ‘Normal Cr group’ and 1.2–2.0 mg/dL; the ‘Slightly increased Cr group’). Multivariate logistic regression analysis was used to reveal the association between Cl and CA-AKI. Among patients, 2,525 (19.3%) and 241 (1.8%) patients were classified in the hypo- and hyperchloremia group. The incidence of CA-AKI was significantly lower in the normochloremia group (4.0%) compared to the hypo- (5.4%) and hyperchloremia groups (9.5%). On multivariate logistic regression, hypochloremia was significantly associated with the incidence of CA-AKI compared with normochloremia (1.382, P = 0.002). Moreover, hypochloremia was still significantly associated with the incidence of CA-AKI in ‘Normal Cr group’ compared with normochloremia (1.314, P = 0.015), while hyperchloremia did not show significant association with CA-AKI incidence. In conclusion, hypochloremia might be associated with the incidence of CA-AKI even in patients who have normal-range Cr levels.
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Affiliation(s)
- Hyung Jung Oh
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Research Institute for Human Health Information, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea
| | - Sungwon Kim
- Department of Radiology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Jung Tak Park
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Sang-Joon Kim
- Ewha School of Business, Ewha Womans University, Seoul, Republic of Korea
| | - Seung Hyeok Han
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Dong-Ryeol Ryu
- Ewha Institute of Convergence Medicine, Ewha Womans University Mokdong Hospital, Seoul, Republic of Korea.,Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Republic of Korea.,Tissue Injury Defense Research Center, Ewha Womans University, Seoul, Republic of Korea
| | - Shin-Wook Kang
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea.,BK21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Eun Chung
- Department of Radiology, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea. .,BK21 PLUS Project for Medical Science, Yonsei University College of Medicine, Seoul, Republic of Korea.
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50
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Yessayan L, Neyra JA, Canepa-Escaro F, Vasquez-Rios G, Heung M, Yee J. Effect of hyperchloremia on acute kidney injury in critically ill septic patients: a retrospective cohort study. BMC Nephrol 2017; 18:346. [PMID: 29197350 PMCID: PMC5712082 DOI: 10.1186/s12882-017-0750-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 11/13/2017] [Indexed: 01/16/2023] Open
Abstract
Background Hyperchloremia is common in critically ill septic patients. The impact of hyperchloremia on the incidence of acute kidney injury (AKI) is not well studied. We investigated the association between hyperchloremia and AKI within the first 72 h of intensive care unit (ICU) admission. Methods 6490 ICU adult patients admitted with severe sepsis or septic shock were screened for eligibility. Exclusion criteria included: AKI on admission, baseline estimated glomerular filtration rate (eGFR) <15 ml/min/1.73 m2, chronic renal replacement therapy, absent baseline serum creatinine data, and absent serum chloride data on ICU admission. Results A total of 1045 patients were available for analysis following the implementation of eligibility criteria: 303 (29%) had hyperchloremia (Cl0 ≥ 110 mEq/L) on ICU admission, 561 (54%) were normochloremic (Cl0 101–109 mEq/L) and 181 (17%) were hypochloremic (Cl0 ≤ 100 mEq/L). AKI within the first 72 h of ICU stay was the dependent variable. Chloride on ICU admission (Cl0) and change in Cl by 72 h (ΔCl = Cl72 – Cl0) were the independent variables. The odds for AKI were not different in the hyperchloremic group when compared to the normochloremic group [adjusted odds ratio (OR) =0.80, 95% confidence interval [CI] (0.51–1.25); p = 0.33] after adjusting for demographics, comorbidities, baseline kidney function, drug exposure and critical illness indicators including cumulative fluid balance and base deficit. Furthermore, within the subgroup of patients with hyperchloremia on ICU admission, neither Cl0 nor ΔCl was associated with AKI or with moderate/severe AKI (KDIGO Stage ≥2). Conclusions Hyperchloremia occurs commonly among critically ill septic patients admitted to the ICU, but does not appear to be associated with an increased risk for AKI within the first 72 h of admission.
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Affiliation(s)
- Lenar Yessayan
- Division of Nephrology, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA.
| | - Javier A Neyra
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, KY, USA.,Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern, Dallas, TX, USA
| | - Fabrizio Canepa-Escaro
- Division of Hospitalist Medicine, University of Kentucky Medical Center, Lexington, KY, USA
| | - George Vasquez-Rios
- Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky Medical Center, Lexington, KY, USA
| | - Michael Heung
- Division of Nephrology, University of Michigan, 3914 Taubman Center, 1500 E. Medical Center Dr. 5364, Ann Arbor, MI, 48109-5364, USA
| | - Jerry Yee
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, MI, USA
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