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Hyperchloremia is independently associated with mortality in critically ill children who ultimately require
Matthew F Barhight1,2, Jennifer Lusk1, John Brinton3
1Division of Critical Care, Children's Hospital Colorado, Aurora, CO, USA.
Insights
Hyperchloremia, or high chloride levels, is common in critically ill children before continuous renal replacement therapy (CRRT). This condition significantly increases the risk of death in these young patients.
Area of Science:
- Pediatric critical care medicine
- Nephrology
- Fluid and electrolyte balance
Background:
- Optimal fluid management in critically ill children is an area of ongoing research.
- Existing studies suggest that hyperchloremia, chloride load, and chloride-rich fluids may lead to adverse outcomes.
Purpose of the Study:
- To investigate the association between hyperchloremia and mortality in critically ill children requiring continuous renal replacement therapy (CRRT).
Main Methods:
- A single-center retrospective cohort study of Pediatric Intensive Care Unit (PICU) patients from 2008 to 2016.
- Patients requiring CRRT were analyzed and dichotomized based on peak chloride levels (<110 mmol/L vs. ≥110 mmol/L) prior to CRRT initiation.
- Exclusion criteria included end-stage renal disease, chloride transport disorders, and concurrent extracorporeal membrane oxygenation (ECMO).
Main Results:
- Hyperchloremia was present in 59% of the 66 studied patients.
- Fluid overload at CRRT initiation was more frequent in the hyperchloremic group (11.5% vs. 5.5%, p=0.04).
- Mortality was significantly higher in patients with hyperchloremia (67% vs. 29%, p=0.006), with 10.9 times greater odds of death after adjustment.
Conclusions:
- Hyperchloremia is a common finding in critically ill children before CRRT initiation.
- In this pediatric population, hyperchloremia is an independent predictor of mortality.
- Further research is warranted to elucidate the impact of hyperchloremia and chloride load on outcomes in all critically ill children.
Background:
The optimal fluid management in critically ill children is currently under investigation with several studies suggesting that hyperchloremia, chloride load, and the use of chloride-rich fluids contribute to worse outcomes.
Methods:
This is a single-center retrospective cohort study of Pediatric Intensive Care Unit patients from 2008 to 2016 requiring continuous renal replacement therapy (CRRT). Patients were excluded if they had end-stage renal disease, a disorder of chloride transport, or concurrent provision of extracorporeal membrane oxygenation therapy.
Results:
Patients (n = 66) were dichotomized into two groups (peak chloride (Cl) ≥ 110 mmol/L vs. peak Cl < 110 mmol/L prior to CRRT initiation). Hyperchloremia was present in 39 (59%) children. Baseline characteristics were similar between groups. Fluid overload at CRRT initiation was more common in patients with hyperchloremia (11.5% IQR 3.8-22.4) compared to those without (5.5% IQR 0.9-13.9) (p = 0.04). Mortality was significantly higher in patients with hyperchloremia (n = 26, 67%) compared to those without (n = 8, 29%) (p = 0.006). Patients with hyperchloremia had 10.9 times greater odds of death compared to those without hyperchloremia, after adjusting for percent fluid overload, PRISM III score, time to initiation of CRRT, height, and weight (95% CI 2.4 to 49.5, p = 0.002).
Conclusions:
Hyperchloremia is common among critically ill children prior to CRRT initiation. In this population, hyperchloremia is independently associated with mortality. Further studies are needed to determine the impact of hyperchloremia on all critically ill children and the impact of chloride load on outcomes.
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