Effects of restricting perioperative use of intravenous chloride on kidney injury in patients undergoing cardiac surgery: the LICRA pragmatic controlled clinical trial.
OBJECTIVE
The administration of chloride-rich intravenous (IV) fluid and hyperchloraemia have been associated with perioperative renal injury. The aim of this study was to determine whether a comprehensive perioperative protocol for the administration of chloride-limited IV fluid would reduce perioperative renal injury in adults undergoing cardiac surgery.


METHODS
From February 2014 through to December 2015, all adult patients undergoing cardiac surgery within a single academic medical center received IV fluid according to the study protocol. The perioperative protocol governed all fluid administration from commencement of anesthesia through to discharge from the intensive care unit and varied over four sequential periods, each lasting 5 months. In periods 1 and 4 a chloride-rich strategy, consisting of 0.9% saline and 4% albumin, was adopted; in periods 2 and 3, a chloride-limited strategy, consisting of a buffered salt solution and 20% albumin, was used. Co-primary outcomes were peak delta serum creatinine (∆SCr) within 5 days after the operation and KDIGO-defined stage 2 or stage 3 acute kidney injury (AKI) within 5 days after the operation.


RESULTS
We enrolled and analysed data from 1136 patients, with 569 patients assigned to a chloride-rich fluid strategy and 567 to a chloride-limited one. Compared with a chloride-limited strategy and adjusted for prespecified covariates, there was no association between a chloride-rich perioperative fluid strategy and either peak ∆SCr, transformed to satisfy the assumptions of multivariable linear regression [regression coefficient 0.03, 95% confidence interval (CI) -0.03 to 0.08); p = 0.39], or stage 2 or 3 AKI (adjusted odds ratio 0.97, 95% CI 0.65-1.47; p = 0.90].


CONCLUSIONS
A perioperative fluid strategy to restrict IV chloride administration was not associated with an altered incidence of AKI or other metrics of renal injury in adult patients undergoing cardiac surgery.


BACKGROUND
Clinicaltrials.gov Identifier: NCT02020538.
Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia. D.mcilroy@alfred.org.au.|Monash University, Commercial Road, Melbourne, VIC, 3004, Australia. D.mcilroy@alfred.org.au.
David
D
McIlroy
Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia.
Deirdre
D
Murphy
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Jessica
J
Kasza
Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
Dhiraj
D
Bhatia
Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, 55 Commercial Road, Melbourne, VIC, 3004, Australia.
Lisa
L
Wutzlhofer
Monash University, Commercial Road, Melbourne, VIC, 3004, Australia.|Department of Surgery, Alfred Hospital, Melbourne, VIC, Australia.
Silvana
S
Marasco
D058186:Acute Kidney Injury / Q000209:etiology* / Q000628:therapy*; D061605:Administration, Intravenous; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006348:Cardiac Surgical Procedures / Q000379:methods*; D003422:Critical Care / Q000379:methods*; D005260:Female; D005440:Fluid Therapy / Q000379:methods*; D006801:Humans; D015994:Incidence; D007262:Infusions, Intravenous; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000379:methods*; D012965:Sodium Chloride / Q000008:administration & dosage / Q000009:adverse effects*
D012965:Sodium Chloride
Acute kidney injury; Chloride; Critical care; Intensive care; Perioperative; Saline