Use of Arginine Hydrochloride in the Treatment of Metabolic Alkalosis or Hypochloremia in Pediatric Patients

Abstract

Dosing of arginine for treatment of hypochloremia or metabolic alkalosis is laborious and has inherent variability in dose selection. The primary objective of this study was to determine the efficacy of arginine in the treatment of metabolic alkalosis and hypochloremia. Secondary objectives were to determine an optimal dose, route, and frequency for arginine administration in the treatment of these conditions. METHODS This single center, retrospective, descriptive study was conducted in children who received arginine for treatment of hypochloremia or metabolic alkalosis. Treatment success was assessed by measuring serum chloride and bicarbonate concentrations after arginine administration. RESULTS Of the 464 orders analyzed, 177 met inclusion criteria in 82 unique patients. Fifty percent (n = 81) of arginine administrations used to manage hypochloremia saw normalization of abnormal chloride levels, and 83% (n = 62) of arginine administrations used to treat metabolic alkalosis saw normalization of abnormal bicarbonate levels. Patients who received arginine to resolve hypochloremia were statistically significantly more likely to have their hypochloremia resolve if they used alternative dosing methods compared to established dosing methods (76 vs. 5, p = 0.001). However, this relationship was not seen for patients with metabolic alkalosis (11 vs. 51, p = 1.000). The median percentage of calculated daily dose of arginine needed for resolution of hypochloremia was 59% and was 35% for metabolic alkalosis. CONCLUSIONS Arginine is effective to improve metabolic alkalosis and hypochloremia. Established dosing methods are not more effective than other methods in resolving metabolic alkalosis or hypochloremia. Further prospective studies are warranted to validate these results.

Hypochloremia Secondary to Diuretics in Preterm Infants: Should Clinicians Pay Close Attention?

“…(3) Role of arginine chloride: Arginine chloride is an appealing option to treat hypochloremia. Sierra et al 65 reported that arginine chloride, especially the oral supplementation, was effective in resolving both hypochloremia and metabolic alkalosis in pediatric patients. Arginine chloride was the most common supplement used in one of the level IV neonatal intensive care units.…”

Diuretic Use and Subsequent Electrolyte Supplementation in a Level IV Neonatal Intensive Care Unit

“…A previous study by Sierra et al 19 also reported on arginine chloride use and found that arginine chloride was effective in resolving both hypochloremia and metabolic alkalosis in pediatric patients. In addition, oral arginine was more effective than intravenous arginine in normalizing chloride levels.…”

“…Therefore, supplemental chloride is often used to correct metabolic alkalosis, since chloride administration promotes bicarbonate secretion through chloride-bicarbonate exchange pumps in the nephron. 19,20 Overall, the decision to use arginine chloride versus sodium chloride or potassium chloride supplements at our institution is provider dependent. Sodium chloride was the second most commonly used supplement, but patients were on arginine chloride for more days while on diuretic therapy compared with sodium chloride.…”

Metabolic Alkalosis in the Pediatric Patient: Treatment Options in the Pediatric ICU or Pediatric Cardiothoracic ICU Setting

“…In a single-center study, Sierra et al retrospectively reviewed the use of 177 arginine HCl infusions to treat hypochloremia or metabolic alkalosis in a cohort of 82 pediatric patients. 38 Arginine HCl infusions successfully corrected 50% of abnormal chloride values in patients with hypochloremia and 83% of serum bicarbonate values in patients with metabolic alkalosis. The authors also noted that established dosing methods were not more effective than other methods in resolving metabolic alkalosis or hypochloremia.…”

“…However, anecdotal experience has also demonstrated its utility to treat metabolic alkalosis, using various dosing recommendations. 38,39 Martin and Matzke suggested that the dose of HCl should be calculated using the equation: 0.5 L/kg  body weight in kgs  (observed serum bicarbonate -24). 40 It is recommended that half of this dose be administered intravenously over 12 hours with ongoing assessment of acid-base status performed every four hours.…”