Trimatch comparison of the prognosis of hypochloremia, normolchloremia and hyperchloremia in patients with septic shock

BACKGROUND

Septic shock is a lethal disease, and identifying high-risk patients through noninvasive and widely available biomarkers can help improve global outcomes. While the clinical impact of chloride levels on critically ill patients remains unclear, this study aims to investigate the association between hypochloremia and mortality following ICU admission among septic shock patients.

METHODS

This is an analysis of data stored in the databases of Medical Information Mart for Intensive Care IV (MIMIC-IV). The initial chloride levels were classified ashypochloremia, normal chloraemia, and hyperchloraemia. A multivariate logistic regression model was applied, adjusting for age, lactate, pH, PO2, urine volume, RDW, creatinine, and liver disease, to assess the association between the three categories of chloride levels and mortality.

RESULTS

Of 3726 patients included in the study, 470 patients (12.6%) had hypochloremia on ICU admission. During the follow-up period, 1120 (33.5%) patients died. Hypochloremia was significantly associated with increased mortality and the incidence of AKI after adjusting for several variables.

CONCLUSIONS

Hypochloremia is independently associated with higher hospital mortality, AKI incidence among septic shock patients. However, further high-quality research is necessary to establish the precise relationship between hypochloremia and septic shock prognosis.

Impact of hypochloremia as a prognostic factor in patients with heart failure, a retrospective cohort study

BACKGROUND

some studies suggest that hypochloremia is a risk factor in the prognosis of heart failure (HF) in patients with recent decompensation.

MATERIALS AND METHODS

retrospective cohort study of patients discharged due to HF decompensation who began follow-up in a specialized clinic. Two groups are defined: patients with hypochloremia (chloride < 98 mmol/L) and normochloremic patients (chloride > 98 mmol/L) in the initial assessment within the first month after discharge. The rate of intravenous diuretic rescue, emergency department visits, readmission for HF and cardiovascular (CV) death are compared using a Cox proportional hazards model.

RESULTS

165 patients were included (59% women, mean age 85 years), with 60 (36%) having hypochloremia. Both groups were comparable in terms of baseline characteristics, except for female sex, presence of peripheral artery disease, moderate-to-severe liver disease (more prevalent in the hypochloremia group), PROFUND index, and baseline furosemide dose (higher in patients with hypochloremia). The incidence of the primary event was higher in subjects with hypochloremia than in normochloremic subjects (HR: 1.59, 95% CI 0.97-2.62), mainly due to the need for intravenous diuretic rescue (HR: 1.86, 95% CI 1.07-3.24).

CONCLUSIONS

hypochloremia following admission for HF decompensation is associated with a greater need for intravenous diuretic rescue therapy and probably worse overall prognosis across the spectrum of the disease, regardless of left ventricular ejection fraction (LVEF).

Serum chloride as a marker of cardiovascular and all-cause mortality in chronic hemodialysis patients: 5-Year follow-up study

BACKGROUND

Hypochloremia has been associated with increased mortality in patients with hypertension, heart failure, sepsis, and chronic kidney disease (CKD). The pathophysiological mechanisms of this finding are not clear. There are no studies describing an association between serum chloride levels (Cl-) and mortality in incident chronic hemodialysis (HD) patients.

METHOD

Retrospective cohort study of the incident population in our chronic outpatient hemodialysis program between January 1, 2016, and January 1, 2021 (N=374). Survival time was collected in all patients and analyzed using the Kaplan-Meyer method. A multivariate Cox regression model was performed to predict the probability of survival, applying a stepwise procedure.

RESULTS

During the median follow-up period of 20 months, 83 patients died. The 5-year overall survival rate for our patients was 45%. Both natremia and chloremia had no significant differences when compared by sex, vascular access, or etiology. There was an inverse correlation between Cl- and interdialytic weight gain (r=-0.15) (p=0.0038). Patients belonging to the quartile with lower Cl- levels had less probability of survival than patients in the quartile with higher Cl- levels (27% and 68%, respectively, p=0.019). On the other hand, in the multivariate Cox regression model, variables significantly associated with higher mortality were being older, having higher baseline comorbidity by modified Charlson index, not taking diuretics and having lower albumin and chloride levels. Particularly, higher Cl- levels was independently associated with both lower all-cause mortality (adjusted hazard ratio [HR]=0.84; 95% confidence interval [CI], 0.77-0.92; p=0.0001) and cardiovascular mortality (HR 0.9; 95% CI, 0.83-0.97; p<0.0057).

CONCLUSIONS

Lower Cl- levels were associated with higher all-cause and cardiovascular mortality in incident patients on chronic hemodialysis in our health area.

Trajectory of serum chloride levels during decongestive therapy in acute heart failure

BACKGROUND

Hypochloremia is a risk factor for poor outcomes in patients with acute heart failure (AHF). However, the changes in serum chloride levels during decongestion therapy and their impact on prognosis remain unknown.

METHODS

In total, 2798 patients with AHF were retrospectively studied and divided into four groups according to their admission and discharge serum chloride levels: (1) normochloremia (n=2,192, 78%); (2) treatment-associated hypochloremia, defined as admission normochloremia with a subsequent decrease (<98 mEq/L) during hospitalization (n=335, 12%); (3) resolved hypochloremia, defined as admission hypochloremia that disappeared at discharge (n=128, 5%); (4) persistent hypochloremia, defined as chloride <98 mEq/L at admission and discharge (n = 143, 5%). The primary outcome was all-cause death, and the secondary outcomes were cardiovascular death and a composite of cardiovascular death and rehospitalization for heart failure after discharge.

RESULTS

The mean age was 76 ± 12 years and 1584 (57%) patients were men. The mean left ventricular ejection fraction was 46 ± 16%. During a median follow-up period of 365 days, persistent hypochloremia was associated with an increased risk of all-cause death (adjusted hazard ratio [95% confidence interval]: 2.27 [1.53-3.37], p < 0.001), cardiovascular death (2.38 [1.46-3.87], p < 0.001), and a composite of cardiovascular death and heart failure rehospitalization (1.47 [1.06-2.06], p = 0.022). However, the outcomes were comparable between patients with resolved hypochloremia and normochloremia.

CONCLUSIONS

Persistent hypochloremia was associated with worse clinical outcomes, while resolved hypochloremia and normochloremia showed a comparable prognosis. Changes in serum chloride levels can help identify patients with poor prognoses and can be used to determine subsequent treatment strategies.

Association of hypochloremia with mortality among patients requiring continuous renal replacement therapy

BACKGROUND

Serum chloride derangement is common in critically ill patients requiring continuous renal replacement therapy (CRRT). We aimed to assess the association between serum chloride levels before and during CRRT with mortality.

METHODS

This is a retrospective cohort study of critically ill patients receiving CRRT for acute kidney injury from December 2006 through November 2015 in a tertiary referral hospital in the United States. We used logistic regression to assess serum chloride before and mean serum chloride during CRRT as predictors for 90 days mortality after CRRT initiation. The normal reference range for serum chloride was 99-108 mmol/L.

RESULTS

Of 1282 eligible patients, 25%, 50%, and 25% had hypochloremia, normochloremia, and hyperchloremia, respectively. The adjusted odds ratio for 90 days mortality in patients with hypochloremia before CRRT was 1.82 (95% CI 1.29-2.55). During CRRT, 4%, 70%, 26% of patients had mean serum chloride in the hypochloremia, normochloremia, and hyperchloremia range, respectively. The adjusted odds ratio for 90 days mortality in patients with mean serum chloride during CRRT in the hypochloremia range was 2.96 (95% CI 1.43-6.12). Hyperchloremia before and during CRRT was not associated with mortality. The greater serum chloride range during CRRT was associated with increased mortality (OR 1.29; 95% CI 1.13-1.47 per 5 mmol/L increase).

CONCLUSION

Hypochloremia before and during CRRT is associated with higher mortality.

Clinical, haemato-biochemical, and ultrasonographic findings of abomasal impaction and abomasal ulcers in buffaloes

The current study evaluated the clinical, ruminal, haemato-biochemical, and ultrasonographic findings of abomasal disorders' affected buffaloes grouped as abomasal impaction (n = 18) and abomasal ulcers (n = 15). The abomasal disorders' screening was based on clinical examination and confirmed by ultrasonography. The most common clinical findings of the buffaloes affected with abomasal disorders include depressed demeanour (96.97%), absence of rumination (87.88%), abdominal guarding (87.88%), sunken eye balls (81.82%), tachycardia (78.79%), tachypnea (72.73%), and kyphosis (63.64%). The average rumen motility, respiratory rate, and pulse rate for abomasal impaction and abomasal ulcers were 0.28, 33.37, and 83.44, and 0.33, 35.87, and 92.60, respectively. The faecal occult blood test (benzidine test) revealed the presence of melena in all the buffaloes diagnosed with abomasal ulcers (100%). The ultrasonographic examination of the abomasal impaction group revealed increased abomasal size with no movement of the abomasal contents. The ultrasonographic imaging of abomasal ulcer-affected buffaloes showed irregularity in the abomasal wall-outline with moderately echogenic abomasal contents and a layer of fibrin at the affected area. Nine buffaloes had ultrasonographic evidence of peritonitis. The abomasal contents of buffaloes with positive benzidine test (n = 15) were screened for Clostridium perfringens by a polymerase chain reaction and were found positive for cpa toxin yielding 900-bp length. The rumen protozoal count was higher in healthy buffaloes, while the sedimentation test, (time) methylene blue reduction test, (time) and chloride levels were higher (P < 0.01) in the buffaloes affected with abomasal disorders. Haematological findings revealed a higher haematocrit, total leucocyte count, neutrophils, and eosinophil proportion and lower haemoglobin, total erythrocyte count, and lymphocyte proportion without affecting the fractions of monocytes and basophils. Furthermore, the buffaloes affected with abomasal disorders showed lower albumin, phosphorus, and potassium and higher aspartate transaminase, blood urea nitrogen, creatinine kinase, creatinine, and chloride concentrations. The present study projects clinical signs, ruminal parameters, and haemato-biochemical parameters as better indicators of abomasal disorders; however, ultrasonography is the sole diagnostic aid for the confirmation of abomasal disorders in buffaloes.

Lower serum chloride concentrations are associated with increased risk of mortality in critically ill cirrhotic patients: an analysis of the MIMIC-III database

Background

Cirrhosis can be complicated by electrolyte abnormalities, but the major focus has been concentrated on the clinical significance of serum sodium levels. Emerging studies have identified hypochloremia as an independent prognostic marker in patients with chronic heart failure and chronic kidney disease. The aim of this study was to investigate whether serum chloride levels were associated with mortality of critically ill cirrhotic patients.

Methods

Critically ill cirrhotic patients were identified from the Multi-parameter Intelligent Monitoring in Intensive Care III Database. The primary outcome was ICU mortality. Logistic regression was used to explore the association between serum chloride levels and ICU mortality. The area under the receiver operating characteristic curves (AUC) was used to assess the performance of serum chloride levels for predicting ICU mortality.

Results

A total of 1216 critically ill cirrhotic patients were enrolled in this study. The overall ICU mortality rate was 18.8%. Patients with hypochloremia had a higher ICU mortality than those with non-hypochloremia (34.2% vs. 15.8%; p < 0.001). After multivariable risk adjustment for age, gender, ethnicity, chloride, sodium, Model for End-stage Liver Disease score, Sequential Organ Failure Assessment score, Elixhauser comorbidity index, mechanical ventilation, vasopressors, renal replacement therapy, acute kidney injury, hemoglobin, platelet, and white blood cell, serum chloride levels remained independently associated with ICU mortality (OR 0.94; 95% CI 0.91–0.98; p = 0.002) in contrast to serum sodium levels, which were no longer significant (OR 1.03; 95% CI 0.99–1.08; p = 0.119). The AUC of serum chloride levels (AUC, 0.600; 95% CI 0.556–0.643) for ICU mortality was statistically higher than that of serum sodium levels (AUC, 0.544; 95% CI 0.499–0.590) (p < 0.001).

Conclusions

In critically ill cirrhotic patients, serum chloride levels are independently and inversely associated with ICU mortality, thus highlighting the prognostic role of serum chloride levels which are largely overlooked.

Hypocalcemia, hypochloremia, and eosinopenia as clinical predictors of leptospirosis: A retrospective study

BACKGROUND

Underestimation of leptospirosis cases is happening in many countries. The most common factor of underreporting is misdiagnosis. Considering the limitations of direct detection of pathogen and serological diagnosis for leptospirosis, clinical features and blood tests though non-specific are usually referred in making presumptive diagnosis to decide disease management.

METHODS

In this single-centre retrospective study, comparative analysis on clinical presentations and laboratory findings was performed between confirmed leptospirosis versus non-leptospirosis cases.

RESULTS

In multivariate logistic regression evidenced by a Hosmer-Lemeshow significance value of 0.979 and Nagelkerke R square of 0.426, the predictors of a leptospirosis case are hypocalcemia (calcium <2.10mmol/L), hypochloremia (chloride <98mmol/L), and eosinopenia (absolute eosinophil count <0.040×10⁹/L). The proposed diagnostic scoring model has a discriminatory power with area under the curve (AUC) 0.761 (p<0.001). A score value of 6 reflected a sensitivity of 0.762, specificity of 0.655, a positive predictive value of 0.38, negative predictive value of 0.91, a positive likelihood ratios of 2.21, and a negative likelihood ratios of 0.36.

CONCLUSION

With further validation in clinical settings, implementation of this diagnostic scoring model is helpful to manage presumed leptospirosis especially in the absence of leptospirosis confirmatory tests.

The prognostic effects of hyponatremia and hyperchloremia on postoperative NSCLC patients

Electrolytic disorders are common in lung cancer patients. But the association between serum electrolytes levels and survival in patients undergoing lung cancer resections for non-small-cell lung cancer (NSCLC) has been poorly investigated. A retrospective study was conducted on consecutive postoperative NSCLC patients. Pearson's test was used to determine the association between serum sodium and chlorine levels and clinical characteristics, and cox regression and Kaplan-Meier model were applied to analyze risk factors on overall survival. We found that hyponatremia was an independent prognostic factor associated with poor prognosis in NSCLC patients undergoing complete resection (log-rank test, P = 0.004). In addition, we found that hyperchloremia predicted a poor clinical outcome in patients with non-anion-gap (log-rank test, P = 0.011), whereas it predicted a favorable clinical outcome in patients with high-anion-gap (log-rank test, P = 0.002). The serum electrolytes levels may reflect the prognosis of NSCLC patients who receive complete resection. Early detection, monitoring, and management of hyperchloremia and hyponatremia might improve patients' prognosis.

Pharmacologic Approaches to Electrolyte Abnormalities in Heart Failure

Electrolyte abnormalities are common in heart failure and can arise from a variety of etiologies. Neurohormonal activation from ventricular dysfunction, renal dysfunction, and heart failure medications can perturb electrolyte homeostasis which impact both heart failure-related morbidity and mortality. These include disturbances in serum sodium, chloride, acid-base, and potassium homeostasis. Pharmacological treatments differ for each electrolyte abnormality and vary from older, established treatments like the vaptans or acetazolamide, to experimental or theoretical treatments like hypertonic saline or urea, or to newer, novel agents like the potassium binders: patiromer and zirconium cyclosilicate. Pharmacologic approaches range from limiting electrolyte intake or directly repleting the electrolyte, to blocking or promoting their resorption, and to neurohormonal antagonism. Because of the prevalence and clinical impact of electrolyte abnormalities, understanding both the older and newer therapeutic options is and will continue to be necessity for the management of heart failure.

A Quick Reference on Metabolic Alkalosis

Metabolic alkalemia is characterized by an increase in bicarbonate concentration and base excess, an increase in pH, and a compensatory increase in carbon dioxide pressure. This article outlines indications for analysis, reference ranges, causes, and clinical signs of metabolic alkalosis. Algorithms for evaluation of patients with acid-base disorders and metabolic alkalosis are included.

Fluid therapy in mature cattle

Fluid therapy for mature cattle differs from that for calves because the common conditions that result in dehydration and the metabolic derangements that accompany these conditions are different. The veterinarian needs to know which problem exists, what to administer to correct the problem, in what quantity, by what route, and at what rate. Mature cattle more frequently suffer from alkalosis; therefore, acidifying solutions containing K(+) and Cl(-) in concentrations greater than that of plasma are frequently indicated. The rumen provides a large-capacity reservoir into which oral rehydration solutions may be administered, which can save time and money.

Association of serum chloride concentration with outcomes in postoperative critically ill patients: a retrospective observational study

Background

Although chloride is one of the major electrolytes measured routinely in dairy practice, the amount of attention chloride receives in critically ill patients is limited. There are still a few studies reporting the incidence of derangements of chloride and its association with patients' outcomes. Accordingly, we conducted a retrospective study to assess the prevalence of abnormality of serum chloride level in postoperative patients in the intensive care unit on the early phase of surgery and its association with outcome.

Methods

We conducted a single-center retrospective observational study. All adult patients who underwent elective thoracic or abdominal surgery and required postoperative intensive care for more than 48 h between 2007 and 2011 were included. Chloride levels were measured on each morning of postoperative day 1 and day 2 in the intensive care unit. We defined all-cause hospital death as the primary outcome and compared serum chloride levels on postoperative day 1 and day 2 between hospital survivors and non-survivors. Comparisons among groups were conducted using the chi-square test for equal proportion, Mann-Whitney U tests, or Kruskal-Wallis test.

Results

Among 98 patients included in this study, hypochloremia (less than 98 mmol/L) during the first 48 h occurred in 14 patients (14.3%). The mortality in hypochloremia patients was 28.6%, which is significantly higher than 6.0% in patients with normal chloride concentration (p = 0.007). Even after being adjusted for severity of illness, the incidence of hypochloremia was independently associated with the risk of hospital death (adjusted odds ratio 5.8 (1.1, 30.2), p = 0.04). Hyperchloremia (more than 112 mmol/L) occurred in one patient (1.0%), who was discharged from the hospital at day 9. There was no significant difference in the total volume of infused fluid (p = 0.30), sum of chloride administration (p = 0.33), and use of furosemide (p = 0.75) from intensive care unit admission to the morning of postoperative day 2 between survivors and non-survivors.

Conclusions

Hypochloremia observed within 48 h after surgery was not rare and was independently associated with the increased risk of hospital death. Hypochloremia might be a useful indicator of prognosis for patients in the postoperative intensive care unit.