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Chloride-liberal vs. chloride-restrictive intravenous fluid administration and acute kidney injury: an extended analysis

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Abstract

Purpose

In a previous study, restricting intravenous chloride administration in ICU patients decreased the incidence of acute kidney injury (AKI). To test the robustness of this finding, we extended our observation period to 12 months.

Methods

The study extension included a 1-year control period (18 August 2007 to 17 August 2008) and a 1-year intervention period (18 February 2009 to 17 February 2010). During the extended control period, patients received standard intravenous fluids. During the extended intervention period, we continued to restrict all chloride-rich fluids. We used the Kidney Disease: Improving Global Outcomes (KDIGO) staging to define AKI.

Results

We studied 1,476 control and 1,518 intervention patients. Stages 2 and 3 of KDIGO defined AKI decreased from 302 (20.5 %; 95 % CI, 18.5–22.6 %) to 238 (15.7 %; 95 % CI, 13.9–17.6 %) (P < 0.001) and the use of RRT from 144 (9.8 %; 95 % CI, 8.3–11.4 %) to 103 (6.8 %; 95 % CI, 5.6–8.2 %) (P = 0.003). After adjustment for relevant covariates, liberal chloride therapy remained associated with a greater risk of KDIGO stages 2 and 3 [hazard ratio 1.32 (95 % CI 1.11–1.58); P = 0.002] and use of RRT [hazard ratio 1.44 (95 % CI 1.10–1.88); P = 0.006]. However, on sensitivity assessment of each 6-month period, KDIGO stages 2 and 3 increased in the new extended intervention period compared with the original intervention period.

Conclusions

On extended assessment, the overall impact of restricting chloride-rich fluids on AKI remained. However, sensitivity analysis suggested that other unidentified confounders may have also contributed to fluctuations in the incidence of AKI.

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References

  1. Myburgh JA, Mythen MG (2013) Resuscitation fluids. N Engl J Med 369:1243–1251

    Article  CAS  PubMed  Google Scholar 

  2. Chowdhury AH, Cox EF, Francis ST, Lobo DN (2012) A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9 % saline and Plasma-Lyte 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers. Ann Surg 256:18–24

    Article  PubMed  Google Scholar 

  3. Chowdhury AH, Cox EF, Francis ST, Lobo DN (2014) A randomized, controlled, double-blind crossover study on the effects of 1-L infusions of 6 % hydroxyethyl starch suspended in 0.9 % saline (Voluven) and a balanced solution (Plasma Volume Redibag) on blood volume, renal blood flow velocity, and renal cortical tissue perfusion in healthy volunteers. Ann Surg 259:881–887

    Article  PubMed  Google Scholar 

  4. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M (2012) Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 308:1566–1572

    Article  CAS  PubMed  Google Scholar 

  5. Waikar SS, Winkelmayer WC (2012) Saving the kidneys by sparing intravenous chloride? JAMA 308:1583–1585

    Article  CAS  PubMed  Google Scholar 

  6. Yunos NM, Kim IB, Bellomo R, Bailey M, Ho L, Story D, Gutteridge GA, Hart GK (2011) The biochemical effects of restricting chloride-rich fluids in intensive care. Crit Care Med 39:2419–2424

    Article  CAS  PubMed  Google Scholar 

  7. RENAL Study Investigators (2008) Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units: a practice survey. Crit Care Resusc 10:225–230

    Google Scholar 

  8. Bellomo R, Cass A, Cole L, Cass A, Finfer S, Gallagher M, Lo S, McArthur C, McGuinness S, Myburgh J, Norton R, Scheinkestel C, Su S, RENAL Replacement Therapy Study Investigators (2009) Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 361:1627–1638

    Article  PubMed  Google Scholar 

  9. The KDIGO Acute Kidney Injury Work Group (2012) KDIGO Clinical Practice Guideline for Acute Kidney Injury. Kidney Int 2(Suppl):1–138

  10. Závada J, Hoste E, Cartin-Ceba R, Calzavacca P, Gajic O, Clermont G, Bellomo R, Kellum JA, AKI6 investigators (2010) A comparison of three methods to estimate baseline creatinine for RIFLE classification. Nephrol Dial Transpl 25:3911–3918

    Article  Google Scholar 

  11. Gray R (1988) A class of K-sample tests for comparing the cumulative incidence of a competing risk. Ann Stat 16:1141–1154

    Article  Google Scholar 

  12. Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, Kellum JA (2012) Major complications, mortality, and resource utilization after open abdominal surgery: 0.9 % saline compared to Plasma-Lyte. Ann Surg 255:821–829

    Article  PubMed  Google Scholar 

  13. McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS (2013) Hyperchloremia after non-cardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg 117:412–421

    Article  PubMed  Google Scholar 

  14. Ke L, Calzavacca P, Bailey M, May CN, Li WQ, Bertolin J, Bellomo R (2014) Systemic and hemodynamic effects of fluid bolus therapy: sodium chloride versus sodium octanoate. Crit Care Resusc 16(1):29–33

    PubMed  Google Scholar 

  15. Bihari S, Peake SL, Seppelt I, Wiliams P, Wilkins B, Bersten A (2013) Sodium administration in critically ill patients in Australia and New Zealand: a multicentre point prevalence study. Crit Care Resusc 15:294–300

    PubMed  Google Scholar 

  16. Bihari S, Festa M, Peake SL, Seppelt I, Wiliams P, Wilkins B, Bersten A (2014) Sodium administration in critically ill paediatric patients in Australia and New Zealand: a multicentre point prevalence study. Crit Care Resusc 16:112–118

    PubMed  Google Scholar 

  17. Gattas D, Saxena MK (2013) Is maintenance fluid therapy in need of maintenance? Crit Care Resusc 15:255–256

    PubMed  Google Scholar 

  18. Raghunathan K, Shaw A, Nathanson B, Stürmer T, Brookhart A, Stefan MS, Setoguchi S, Beadles C, Lindenauer PK (2014) Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis. Crit Care Med 42:1585–1591

    Article  CAS  PubMed  Google Scholar 

  19. Shaw AD, Raghunathan A, Peyerl FW, Munson SH, Paluszkiewicz SM, Schermer CR (2014) Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med 40:1897–1905

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  20. Sharek PJ, Parast LM, Leong K, Coombs J, Earnest K, Sullivan J, Frankel LR, Roth SJ (2007) Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA 298:2267–2274

    Article  CAS  PubMed  Google Scholar 

  21. Chan PS, Khalid A, Longmore LS, Berg RA, Kosiborod M, Spertus JA (2008) Hospital-wide code rates and mortality before and after implementation of a rapid response team. JAMA 300:2506–2513

    Article  CAS  PubMed  Google Scholar 

  22. Cruz DN, Ricci Z, Ronco C (2009) Clinical review: RIFLE and AKIN—time for reappraisal. Crit Care 13(3):211

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

We acknowledge the Pathology Department for their kind assistance in obtaining the creatinine results required for this study and the Pharmacy Department for study fluid delivery, monitoring, and reconciliation.

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

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Authors and Affiliations

  1. Austin Health, Heidelberg, Australia

    Nor’azim Mohd Yunos, Rinaldo Bellomo, Neil Glassford, Harvey Sutcliffe, Que Lam & Michael Bailey

Authors
  1. Nor’azim Mohd Yunos
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  2. Rinaldo Bellomo
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  3. Neil Glassford
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  4. Harvey Sutcliffe
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  5. Que Lam
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  6. Michael Bailey
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Corresponding author

Correspondence to Rinaldo Bellomo.

Additional information

Take-home message:

We extended a previous study of chloride restriction and AKI to 12 months and found the renal impact remained. However, other unidentified confounders may have contributed to the findings.

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Yunos, N.M., Bellomo, R., Glassford, N. et al. Chloride-liberal vs. chloride-restrictive intravenous fluid administration and acute kidney injury: an extended analysis. Intensive Care Med 41, 257–264 (2015). https://doi.org/10.1007/s00134-014-3593-0

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  • DOI: https://doi.org/10.1007/s00134-014-3593-0

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