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Critical Care

, 23:10 | Cite as

Hyperchloremia-associated acute chronic kidney injury: beware of confounders!

  • Patrick M. Honore
  • David De Bels
  • Luc Kugener
  • Sebastien Redant
  • Rachid Attou
  • Andrea Gallerani
  • Herbert D. Spapen
Open Access
Letter

Abbreviations

AKI

Acute kidney injury

CKD

Chronic kidney disease

ICU

Intensive care unit

NSAIDs

Non-steroidal anti-inflammatory drugs

We read with great interest the recent paper by Oh et al. [1] investigating the association between perioperative hyperchloremia and postoperative acute kidney injury (AKI) in a large population of postsurgical patients admitted to the intensive care unit (ICU). One of the conclusions was that a substantial perioperative increase in serum chloride levels may reflect a higher risk of AKI in patients with moderate-to-severe chronic kidney disease (CKD) [1].

The authors exemplified some thoughtful limitations of the study. However, when looking carefully at the patient characteristics in the different cohorts, we came across several risk factors for AKI that were more present in hyperchloremic than in normochloremic subjects. The hyperchloremia group received significantly more radiocontrast (52.8 vs 28.4%; P < 0.001), non-steroidal anti-inflammatory drugs (NSAIDs; 40.2 vs 35.9%; P = 0.001), and diuretics, including mannitol and furosemide (69.3 vs 56.0%; P < 0.001). Also, patients who developed hyperchloremia had more severe shock as indicated by a higher need for inotropic and vasopressor support (87.2 vs 70.1%; P < 0.001) and more frequently underwent emergency surgery (17.5 vs 12.3%; P < 0.001). Contrast agents [2], NSAIDs [3], mannitol [4], and furosemide [5] are all associated with a potential deterioration of renal function in ICU patients and particularly in those with underlying CKD. In addition, emergency surgery and shock may markedly increase the incidence of AKI in the perioperative period. Taken together, the patient groups with and without hyperchloremia were not adequately balanced with regard to specific and independent AKI risk factors.

Notes

Acknowledgements

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Authors’ contributions

PMH and HDS designed the paper. All authors participated in drafting and reviewing. All authors read and approved the final version of the manuscript.

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Competing interests

The authors declare that they have no competing interests.

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References

  1. 1.
    Oh TK, Song IA, Kim SJ, Lim SY, Do SH, Hwang JW, et al. Hyperchloremia and postoperative acute kidney injury: a retrospective analysis of data from the surgical intensive care unit. Crit Care 2018;22(1):277.CrossRefGoogle Scholar
  2. 2.
    Pistolesi V, Regolisti G, Morabito S, Gandolfini I, Corrado S, Piotti G, et al. Contrast medium induced acute kidney injury: a narrative review. J Nephrol 2018;31(6):797–812.3.CrossRefGoogle Scholar
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    Zhang X, Donnan PT, Bell S, Guthrie B. Non-steroidal anti-inflammatory drug induced acute kidney injury in the community dwelling general population and people with chronic kidney disease: systematic review and meta-analysis. BMC Nephrol 2017;18(1):256.CrossRefGoogle Scholar
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    Fang L, You H, Chen B, Xu Z, Gao L, Liu J, et al. Mannitol is an independent risk factor of acute kidney injury after cerebral trauma: a case-control study. Ren Fail 2010;32(6):673–9.CrossRefGoogle Scholar
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    Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury. Anaesthesia 2010;65(3):283–93.CrossRefGoogle Scholar

Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  • Patrick M. Honore
    • 1
  • David De Bels
    • 1
  • Luc Kugener
    • 1
  • Sebastien Redant
    • 1
  • Rachid Attou
    • 1
  • Andrea Gallerani
    • 1
  • Herbert D. Spapen
    • 2
  1. 1.ICU DepartmentCentre Hospitalier Universitaire Brugmann, Brugmann University HospitalBrusselsBelgium
  2. 2.Ageing & Pathology Research GroupVrije Universiteit BrusselBrusselsBelgium

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