Log in | Register

Increase in chloride from baseline is independently associated with mortality in critically ill children

Matthew F. Barhight| John Brinton| Timothy Stidham| Danielle E. Soranno| Sarah Faubel| Benjamin R. Griffin| Jens Goebel| Peter M. Mourani| Katja M. Gist
Pediatric Original
Volume 44, Issue 12 / December , 2018

Pages 2183 - 2191

Abstract

Purpose

To determine if there is an association between mortality and admission chloride levels and/or increases in the chloride level in critically ill children.

Methods

We performed a retrospective cohort study of all patients admitted to the paediatric intensive care unit (PICU) from January 2014 to December 2015. Patients were excluded for the following reasons: (1) age < 90 days or > 18 years, (2) admission to the cardiac intensive care unit, (3) no laboratory values upon admission to the PICU, (4) history of end-stage renal disease, (5) a disorder of chloride transport, and (6) admission for diabetic ketoacidosis. The patients were stratified on the basis of admission chloride levels (hypochloraemia, < 96 mEq/L; normochloraemia, 96–109 mEq/L; and hyperchloraemia, ≥ 110 mEq/L) and dichotomised on the basis of an increase in chloride in the first day (< 5 mEq/L, ≥ 5 mEq/L). Our primary outcome was in-hospital mortality.

Results

A total of 1935 patients [55% female, median age 6.3 years IQR (1.9–13.4)] were included. The overall mortality was 4% (n = 71) and day 2 AKI occurred in 17% (n = 333. Hypochloraemia, hyperchloraemia, and an increase in serum chloride ≥ 5 mEq/L occurred in 2%, 21%, and 12%, respectively. After adjusting for confounders, increase in chloride ≥ 5 mEq/L was associated with a 2.3 (95% CI 1.03–5.21) greater odds of mortality.

Conclusions

An increase in serum chloride level in the first day of admission is common and an independent risk factor for mortality in critically ill children. Further studies are warranted to identify how chloride disturbances contribute to mortality risk in critically ill children.

Keywords

References

  1. de Vasconcellos K, Skinner DL (2018) Hyperchloraemia is associated with acute kidney injury and mortality in the critically ill: a retrospective observational study in a multidisciplinary intensive care unit. J Crit Care 45:45–51
    • View reference on publisher's website
  2. Barhight MF, Lusk J, Brinton J, Stidham T, Soranno DE, Faubel S, Goebel J, Mourani PM, Gist KM (2018) Hyperchloremia is independently associated with mortality in critically ill children who ultimately require continuous renal replacement therapy. Pediatr Nephrol 33(6):1079–1085
    • View reference on publisher's website
  3. Stenson EK, Cvijanovich NZ, Anas N, Allen GL, Thomas NJ, Bigham MT, Weiss SL, Fitzgerald JC, Checchia PA, Meyer K, Quasney M, Hall M, Gedeit R, Freishtat RJ, Nowak J, Raj SS, Gertz S, Grunwell JR, Wong HR (2018) Hyperchloremia is associated with complicated course and mortality in pediatric patients with septic shock. Pediatr Crit Care Med 19:155–160
    • View reference on publisher's website
  4. Neyra JA, Canepa-Escaro F, Li X, Manllo J, Adams-Huet B, Yee J, Yessayan L, Acute Kidney Injury in Critical Illness Study Group (2015) Association of hyperchloremia with hospital mortality in critically ill septic patients. Crit Care Med 43:1938–1944
    • View reference on publisher's website
  5. McCluskey SA, Karkouti K, Wijeysundera D, Minkovich L, Tait G, Beattie WS (2013) Hyperchloremia after noncardiac surgery is independently associated with increased morbidity and mortality: a propensity-matched cohort study. Anesth Analg 117:412–421
    • View reference on publisher's website
  6. Suetrong B, Pisitsak C, Boyd JH, Russell JA, Walley KR (2016) Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients. Crit Care 20:315
    • View reference on publisher's website
  7. Zhang Z, Xu X, Fan H, Li D, Deng H (2013) Higher serum chloride concentrations are associated with acute kidney injury in unselected critically ill patients. BMC Nephrology 14:235
    • View reference on publisher's website
  8. Noritomi DT, Soriano FG, Kellum JA, Cappi SB, Biselli PJ, Liborio AB, Park M (2009) Metabolic acidosis in patients with severe sepsis and septic shock: a longitudinal quantitative study. Crit Care Med 37:2733–2739
    • View reference on publisher's website
  9. O’Dell E, Tibby SM, Durward A, Murdoch IA (2007) Hyperchloremia is the dominant cause of metabolic acidosis in the postresuscitation phase of pediatric meningococcal sepsis. Crit Care Med 35:2390–2394
    • View reference on publisher's website
  10. Sakata F, Ito Y, Mizuno M, Sawai A, Suzuki Y, Tomita T, Tawada M, Tanaka A, Hirayama A, Sagara A, Wada T, Maruyama S, Soga T, Matsuo S, Imai E, Takei Y (2017) Sodium chloride promotes tissue inflammation via osmotic stimuli in subtotal-nephrectomized mice. Lab Investig 97:432–446
    • View reference on publisher's website
  11. Kellum JA, Song M, Almasri E (2006) Hyperchloremic acidosis increases circulating inflammatory molecules in experimental sepsis. Chest 130:962–967
    • View reference on publisher's website
  12. 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
    • View reference on publisher's website
  13. Oh HJ, Kim SJ, Kim YC, Kim EJ, Jung IY, Oh DH, Jeong SJ, Ku NS, Han SH, Choi JY, Song YG, Ryu DR, Kim JM (2017) An increased chloride level in hypochloremia is associated with decreased mortality in patients with severe sepsis or septic shock. Sci Rep 7:15883
    • View reference on publisher's website
  14. Tani M, Morimatsu H, Takatsu F, Morita K (2012) The incidence and prognostic value of hypochloremia in critically ill patients. Sci World J 2012:474185
    • View reference on publisher's website
  15. Khwaja A (2012) KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract 120:c179–c184
  16. Schwartz GJ, Munoz A, Schneider MF, Mak RH, Kaskel F, Warady BA, Furth SL (2009) New equations to estimate GFR in children with CKD. J Am Soc Nephrol 20:629–637
    • View reference on publisher's website
  17. Zappitelli M, Parikh CR, Akcan-Arikan A, Washburn KK, Moffett BS, Goldstein SL (2008) Ascertainment and epidemiology of acute kidney injury varies with definition interpretation. Clin J Am Soc Nephrol 3:948–954
    • View reference on publisher's website
  18. Kaddourah A, Basu RK, Bagshaw SM, Goldstein SL, Investigators A (2017) Epidemiology of acute kidney injury in critically ill children and young adults. New Engl J Med 376:11–20
    • View reference on publisher's website
  19. Pollack MM, Patel KM, Ruttimann UE (1996) PRISM III: an updated pediatric risk of mortality score. Crit Care Med 24:743–752
    • View reference on publisher's website
  20. Sutherland SM, Zappitelli M, Alexander SR, Chua AN, Brophy PD, Bunchman TE, Hackbarth R, Somers MJ, Baum M, Symons JM, Flores FX, Benfield M, Askenazi D, Chand D, Fortenberry JD, Mahan JD, McBryde K, Blowey D, Goldstein SL (2010) Fluid overload and mortality in children receiving continuous renal replacement therapy: the prospective pediatric continuous renal replacement therapy registry. Am J Kidney Dis 55:316–325
    • View reference on publisher's website
  21. Vdl A, Shaffer C, Schaefer E (2014) Early intensive care unit-acquired hypernatremia in severe sepsis patients receiving 0.9% saline fluid resuscitation. Acta Anaesthesiol Scand 58:1007–1014
    • View reference on publisher's website
  22. Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, Stollings JL, Kumar AB, Hughes CG, Hernandez A, Guillamondegui OD, May AK, Weavind L, Casey JD, Siew ED, Shaw AD, Bernard GR, Rice TW, SMART Investigators, Pragmatic Critical Care Research Group (2018) Balanced crystalloids versus saline in critically ill adults. N Engl J Med 378:829–839
    • View reference on publisher's website
  23. Young P, Bailey M, Beasley R, Henderson S, Mackle D, McArthur C, McGuinness S, Mehrtens J, Myburgh J, Psirides A, Reddy S, Bellomo R, SPLIT Investigators, ANZICS CTG (2015) Effect of a buffered crystalloid solution vs saline on acute kidney injury among patients in the intensive care unit: the SPLIT randomized clinical trial. JAMA 314:1701–1710
    • View reference on publisher's website

Sign In

Connect with ICM

Top 5 Articles Editors Picks Supplement