Hyperchloremic Metabolic Acidosis Following Resuscitation of Shock

Gheorghe, Cristina Mihaela; Dadu, Ramona; Blot, Cristina; Barrantes, Fidel; Vázquez, Rodrigo; Berianu, Florentina; Feng, Yan; Feintzig, Irwin; Amoateng-Adjepong, Yaw; Manthous, Constantine A.

doi:10.1378/chest.10-1458

Cited by 18 publications

(5 citation statements)

References 6 publications

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“…Despite growing evidence, 0.9% NaCl is still one of the most widely used crystalloids [ 12 , 30 – 36 ]; however, its use is widely debated [ 37 – 43 ]. Importantly, the ICU physician should note that albumin-based replacement fluids may contain rather large quantities of chloride also [ 44 , 45 ]. Furthermore cases of hyperchloremia on the ICU may result from infusion of HCl, acetazolamide, and/or triamterene therapy, or specific cortisone derivates resulting in NaCl retention [ 1 ].…”

Section: Reviewmentioning

confidence: 99%

Serum chloride levels in critical illness—the hidden story

Pfortmueller

Uehlinger

Haehling

et al. 2018

ICMx

103

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Chloride is the principal anion of the extracellular fluid and vital for both serum electroneutrality and acid-base homeostasis. The aim of this review is to investigate the relevance of dyschloremia in the critically ill.An extensive literature research was conducted on www.pubmed.org. In addition, the references of included articles were searched for further possible investigation regarding chloride.Articles investigating the relevance of dyschloremia in the critically ill were included.All articles were screened in regard to dyschloremia in the critically ill.Chloride is essential for blood pressure control, decarboxylation/gas transport, renal function, and gastrointestinal homeostasis. “Dyschloremia,” i.e., serum chloride levels not within the limits of normal, may commonly be observed on ICUs and appear mainly induced by iatrogenic measures (i.e., infusion of chloride-rich fluids). Hypo- and hyperchloremia appear linked to increased mortality in defined ICU populations, but evidence is sparse. Data show that hyperchloremia may not only be linked to hyperchloremic metabolic acidosis, but also to increased hemodynamic instability and vasopressor need (e.g., in patients after major surgery). Nevertheless, it is currently unknown whether such effects would be directly or indirectly mediated. Moreover, recent evidence points to an increased incidence of acute kidney injury and need for renal replacement therapy in patients with advanced hyperchloremia.Current knowledge on chloride is largely limited by heterogeneous trial design and mostly abundant data on specific fluid replacement strategies. The aim of this review is to summarize key consequences of chloride in critical illness and to discuss implications for daily clinical practice and future research.

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Section: Reviewmentioning

confidence: 99%

Serum chloride levels in critical illness—the hidden story

Pfortmueller

Uehlinger

Haehling

et al. 2018

ICMx

103

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“…Thirdly, animals were fluid resuscitated with normal saline, a chloride rich crystalloid solution. Despite the observed microcirculatory benefits, recent findings suggest that hyperchloremic resuscitation may be associated with worse outcomes, particularly in patients with septic shock [64,65]. Since we did not intend to compare different choices of resuscitation fluids, we may only suggest that fluid resuscitation with normal saline is better than no resuscitation.…”

Section: Discussionmentioning

confidence: 95%

Fluid resuscitation therapy in endotoxemic hamsters improves survival and attenuates capillary perfusion deficits and inflammatory responses by a mechanism related to nitric oxide

2014

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BackgroundRelative hypovolemia is frequently found in early stages of severe sepsis and septic shock and prompt and aggressive fluid therapy has become standard of care improving tissue perfusion and patient outcome. This paper investigates the role of the nitric oxide pathway on beneficial microcirculatory effects of fluid resuscitation.MethodsAfter skinfold chamber implantation procedures and endotoxemia induction by intravenous Escherichia coli lipopolysaccharide administration (2 mg.kg−1), male golden Syrian hamsters were fluid resuscitated and then sequentially treated with L-Nω-Nitroarginine and L-Arginine hydrochloride (LPS/FR/LNNA group). Intravital microscopy of skinfold chamber preparations allowed quantitative analysis of microvascular variables including venular leukocyte rolling and adhesion. Macro-hemodynamic, biochemical and hematological parameters as well as survival rate were also evaluated. Endotoxemic hamsters treated with fluid therapy alone (LPS/FR group) and non-treated animals (LPS group) served as controls.ResultsFluid resuscitation was effective in reducing lipopolysaccharide-induced microcirculatory changes. After 3 hours of lipopolysaccharide administration, non-fluid resuscitated animals (LPS group) had the lowest functional capillary density (1% from baseline for LPS group vs. 19% for LPS/FR one; p <0.05). At the same time point, arteriolar mean internal diameter was significantly wider in LPS/FR group than in LPS one (100% vs. 50% from baseline). Fluid resuscitation also reduced leukocyte-endothelium interactions and sequestration (p <0.05 for LPS vs. LPS/FR group) and increased survival (median survival time: 2 and 5.5 days for LPS and LPS/FR groups, respectively; p <0.05). Nitric oxide synthase inhibition prevented these protective effects, while L-Arginine administration markedly restored many of them.ConclusionOur results suggest that the underlying mechanism of fluid therapy is the restoration of nitric oxide bioavailability, because inhibition of NOS prevented many of its beneficial effects. Nevertheless, further investigations are required in experimental models closer to conditions of human sepsis to confirm these results.

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“…Firstly, in clinical work, 0.9% NaCl solution is widely used, while which contains more than physiological amounts of chloride ions [35]. This can cause hyperchloremia and metabolic acidosis [36,37]. Based on the consideration of the in uence of serum chloride level on IgAN, can we replace the NaCl solution with other solutions or restrict the use of NaCl solution?…”

Section: Discussionmentioning

confidence: 99%

Elevated Serum Chloride Level Contributes to the Poor Prognosis of IgA Nephropathy

Zhai¹,

Yao²,

Qi³

et al. 2020

Preprint

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IntroductionFinding reliable prognostic factors is crucial for IgA nephropathy (IgAN). Here, we determined the relationship between prognosis of IgAN with serum chloride.MethodsPrimary IgAN diagnosed by renal biopsy from January 1, 2015 to April 1, 2019 were recruited. Patients were divided into lower group and higher group based on the best cut-off value of survival receiver operating characteristics (ROC) curves. The baseline clinicopathological characteristics were retrospectively compared. Cox proportional hazard models were used to demonstrate the prognostic value of serum chloride in IgAN. Prognosis prediction model was built by multivariate Cox regression. ResultsCompared to higher group , age、24-hour urinary protein and serum creatinine(Cr) in the lower group were significantly lower, hemoglobin(Hb)、albumin were significantly higher(all P<0.05),the degree of endothelial cell proliferation (E) and renal tubule atrophy or renal interstitial fibrosis (T) were significantly lighter (all P<0.05). Univariate and multivariate Cox analysis revealed that serum chloride ≥105.4 mmol/l was an independent risk factor for the prognosis of IgAN(P<0.05). Serum chloride, Cr, T, hypertension, and Hb were screened out as features in predictive prognosis model. The c-index of the model was 0.85、0.82 and 0.77 for 1、2 and 3 years respectively, and brier scores were 0.06 、0.09 and 0.16 respectively. ConclusionsSerum chloride ≥105.4 mmol/l was an independent risk factor for the prognosis of IgAN. A predictive prognosis model including serum chloride, Cr, T, hypertension and Hb exhibited a relatively good prediction effect.

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Hyperchloremic Metabolic Acidosis Following Resuscitation of Shock

Cited by 18 publications

References 6 publications

Serum chloride levels in critical illness—the hidden story

Serum chloride levels in critical illness—the hidden story

Fluid resuscitation therapy in endotoxemic hamsters improves survival and attenuates capillary perfusion deficits and inflammatory responses by a mechanism related to nitric oxide

Elevated Serum Chloride Level Contributes to the Poor Prognosis of IgA Nephropathy

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Hyperchloremic Metabolic Acidosis Following Resuscitation of Shock

Cited by 18 publications

References 6 publications

Serum chloride levels in critical illness—the hidden story

Serum chloride levels in critical illness—the hidden story

Fluid resuscitation therapy in endotoxemic hamsters improves survival and attenuates capillary perfusion deficits and inflammatory responses by a mechanism related to nitric oxide

Elevated Serum Chloride Level Contributes to the Poor Prognosis of IgA&nbsp;Nephropathy

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Elevated Serum Chloride Level Contributes to the Poor Prognosis of IgA Nephropathy