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

Abstract

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.

Hypochloremia as a novel adverse prognostic factor in acute liver failure

“…Accumulating evidence has shed light on the prognostic implications of altered serum chloride levels in multiple conditions, including decompensated cirrhosis, congestive heart failure, chronic kidney disease, hypertension and pulmonary hypertension. [9][10][11][12][13][14][15][16]22,23 that serum chloride provides more robust prognostic information in this population than serum sodium. Indeed, although sodium is a widely known mortality predictor in cirrhosis, it has limited prognostic value in ALF demonstrated by multiple previous studies.…”

“…It is, however, generally considered as a counterpart of serum sodium and has previously received little attention for its potential pathological roles. Accumulating evidence has shed light on the prognostic implications of altered serum chloride levels in multiple conditions, including decompensated cirrhosis, congestive heart failure, chronic kidney disease, hypertension and pulmonary hypertension 9–16,22,23 . Whether chloride plays a role in the prognosis and disease severity of ALF was previously unknown.…”

“…Emerging evidence has identified hypochloremia as a predictor for mortality in patients with congestive heart failure and chronic kidney disease 9–12 . More recently, hypochloremia was demonstrated to be an adverse prognostic factor independent of serum sodium in patients with decompensated cirrhosis 13–16 . Electrolyte derangements are frequently observed in the ALF population, with previous studies focused on hypophosphatemia and hyponatremia 17–19 .…”

“…[9][10][11][12] More recently, hypochloremia was demonstrated to be an adverse prognostic factor independent of serum sodium in patients with decompensated cirrhosis. [13][14][15][16] Electrolyte derangements are frequently observed in the ALF population, with previous studies focused on hypophosphatemia and hyponatremia. [17][18][19] However, very little is known about the prognostic value and clinical relevance of chloride perturbations in ALF patients.…”

Review of Chloride Ion Detection Technology in Water

“…[18][19][20]. A severely reduced Cl − intake can have negative impacts such as chronic heart failure, chronic kidney disease, liver cirrhosis, and so on [21][22][23][24]. (4) Construction and building trades: Very elevated Cl − levels in cement raw materials will reduce the strength of concrete, corrode steel bars, affect the durability of the whole building, and severely affect project quality [25][26][27].…”