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Hyperchloremia After Fluid Resuscitation in Severe Sepsis - Does It Predict Renal Outcomes? FREE TO VIEW

Ryan Schroeder; Maria Herera; Rahul Nanchal; Gagan Kumar
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Medical College of Wisconsin, Milwaukee, WI

Chest. 2014;146(4_MeetingAbstracts):232A. doi:10.1378/chest.1994006
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SESSION TITLE: Sepsis & Septic Shock Posters

SESSION TYPE: Original Investigation Poster

PRESENTED ON: Wednesday, October 29, 2014 at 01:30 PM - 02:30 PM

PURPOSE: 0.9% saline has been typically used for fluid resuscitation in patients with severe sepsis. However, there have been few recent reports of worsened kidney injury and increased use of renal replacement therapy (RRT) with use of 0.9% saline. The underlying mechanism is unclear but may be due to chloride induced renal afferent arteriolar contractility. We hypothesized that hyperchloremia after fluid resuscitation will be associated with worse glomerular filtration rate (GFR) and increased use of RRT.

METHODS: A retrospective chart review was done in patients admitted with severe sepsis at a tertiary care academic hospital from January 2013 to March 2013. Chloride levels at admission and after 24 hours of fluid resuscitation along with baseline GFR, GFR on day 1 and day 7, need for RRT, APACHE II score, amount and type of fluid used for resuscitation, type and dose of vasopressor, nephrotoxic drugs and other risk factors for kidney disease were collected. The outcomes studied were worsening in GFR by >25% by day 7 and need for RRT. Wilcoxan rank test was used to compare the continuous variables and Pearson chi square test for categorical variables. We constructed multivariable logistic regression models to examine association of chloride levels at 24 hours with our primary outcomes. The variables which were found significantly associated in a bivariable model with p< 0.10 were kept in the final model, these were APACHE II scores, baseline GFR, urine output in first 24 hours, chloride level 24 hours after fluid resuscitation and need for invasive mechanical ventilation (IMV).

RESULTS: Of 54 patients admitted with severe sepsis, 15 patients had worsening of GFR by >25% and 4 required RRT. Hyperchloremia (chloride>110meq/dl) was observed in 21 patients. Mean volume of fluid resuscitation was 4.2L. Patients who had worsening of GFR had higher APACHE II scores, lower chloride levels 24 hours after resuscitation, higher requirement of norepinephrine, lower urine output and longer duration of IMV. On multivariate analysis, hyperchloremia at 24 hours was not associated with worsening of GFR at day 7 or with requirement for RRT. Hyperchloremia was however associated with lower in hospital mortality.

CONCLUSIONS: Hyperchloremia after fluid resuscitation in severe sepsis is not associated with worsening of renal function and need for RRT and may be associated with lower mortality in this group.

CLINICAL IMPLICATIONS: Hyperchloremia after fluid resuscitation in severe sepsis is not associated with worse renal function.

DISCLOSURE: The following authors have nothing to disclose: Ryan Schroeder, Maria Herera, Rahul Nanchal, Gagan Kumar

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