Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults.
BACKGROUND
Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury (AKI).


OBJECTIVE
To assess the association of a chloride-restrictive (vs chloride-liberal) intravenous fluid strategy with AKI in critically ill patients.


METHODS
Prospective, open-label, sequential period pilot study of 760 patients admitted consecutively to the intensive care unit (ICU) during the control period (February 18 to August 17, 2008) compared with 773 patients admitted consecutively during the intervention period (February 18 to August 17, 2009) at a university-affiliated hospital in Melbourne, Australia.


METHODS
During the control period, patients received standard intravenous fluids. After a 6-month phase-out period (August 18, 2008, to February 17, 2009), any use of chloride-rich intravenous fluids (0.9% saline, 4% succinylated gelatin solution, or 4% albumin solution) was restricted to attending specialist approval only during the intervention period; patients instead received a lactated solution (Hartmann solution), a balanced solution (Plasma-Lyte 148), and chloride-poor 20% albumin.


METHODS
The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk, injury, failure, loss, end-stage (RIFLE) classification. Secondary post hoc analysis outcomes included the need for renal replacement therapy (RRT), length of stay in ICU and hospital, and survival. RESULTS Chloride administration decreased by 144 504 mmol (from 694 to 496 mmol/patient) from the control period to the intervention period. Comparing the control period with the intervention period, the mean serum creatinine level increase while in the ICU was 22.6 μmol/L (95% CI, 17.5-27.7 μmol/L) vs 14.8 μmol/L (95% CI, 9.8-19.9 μmol/L) (P = .03), the incidence of injury and failure class of RIFLE-defined AKI was 14% (95% CI, 11%-16%; n = 105) vs 8.4% (95% CI, 6.4%-10%; n = 65) (P <.001), and the use of RRT was 10% (95% CI, 8.1%-12%; n = 78) vs 6.3% (95% CI, 4.6%-8.1%; n = 49) (P = .005). After adjustment for covariates, this association remained for incidence of injury and failure class of RIFLE-defined AKI (odds ratio, 0.52 [95% CI, 0.37-0.75]; P <.001) and use of RRT (odds ratio, 0.52 [95% CI, 0.33-0.81]; P = .004). There were no differences in hospital mortality, hospital or ICU length of stay, or need for RRT after hospital discharge. CONCLUSION The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT.


BACKGROUND
Clinicaltrials.gov Identifier: NCT00885404.
Affiliations: Johor Bahru Clinical School, Monash University Sunway Campus, Malaysia.
Nor'azim Mohd
NM
Yunos
Rinaldo
R
Bellomo
Colin
C
Hegarty
David
D
Story
Lisa
L
Ho
Michael
M
Bailey
D058186:Acute Kidney Injury / Q000209:etiology*; D002712:Chlorides / Q000008:administration & dosage* / Q000009:adverse effects*; D016638:Critical Illness; D005260:Female; D005440:Fluid Therapy / Q000009:adverse effects*; D017052:Hospital Mortality; D006784:Hospitals, Teaching; D006801:Humans; D007362:Intensive Care Units; D007552:Isotonic Solutions / Q000008:administration & dosage; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D011446:Prospective Studies; D017582:Renal Replacement Therapy; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic / Q000008:administration & dosage / Q000009:adverse effects
D002712:Chlorides; D007552:Isotonic Solutions; D000077325:Ringer's Lactate; D012462:Saline Solution, Hypertonic