How to manage hyperchloremia in patients with acute kidney injury (AKI)?

Management of Hyperchloremia in Acute Kidney Injury

Buffered crystalloid solutions should be used instead of 0.9% saline in patients with acute kidney injury who have hyperchloremia, as hyperchloremia is associated with increased risk of AKI, renal vasoconstriction, and higher mortality. 1

Relationship Between Hyperchloremia and AKI

Hyperchloremia is commonly present in critically ill patients and has significant implications for kidney function:

• Hyperchloremia is present in approximately 40% of patients with severe sepsis and septic shock 2
• Even moderate increases in serum chloride (≥5 mmol/L) are independently associated with AKI development 2
• Administration of large volumes of 0.9% saline can cause hyperchloremic acidosis, renal vasoconstriction, and AKI 1
• Hyperchloremia is associated with increased 30-day mortality in surgical patients 1

Management Algorithm for Hyperchloremia in AKI

Step 1: Identify and Address the Source of Hyperchloremia

• Discontinue 0.9% saline infusions and replace with buffered crystalloid solutions 1
• Review all medications that may contribute to chloride load
• Assess volume status to determine appropriate fluid management strategy

Step 2: Fluid Management Based on Volume Status

For Hypovolemic Patients:

• Use buffered crystalloid solutions (e.g., Ringer's lactate, Plasma-Lyte) for volume expansion 1
• Initial bolus of 500-1000 mL of buffered crystalloid, then reassess 3
• For patients with cirrhosis and ascites, consider albumin 1 g/kg/day (maximum 100g) for two consecutive days 1, 3

For Euvolemic or Hypervolemic Patients:

• Avoid excessive fluid administration to prevent fluid overload 3
• Consider diuretics only for managing volume overload, not for treating AKI itself 3
• If using diuretics, monitor for electrolyte imbalances, particularly hypokalemia 4

Step 3: Consider Renal Replacement Therapy (RRT)

Initiate RRT when any of the following are present:

• Severe metabolic acidosis
• Refractory hyperchloremia
• Volume overload unresponsive to diuretics
• Uremic symptoms 3, 5

Monitoring and Follow-up

• Monitor daily serum creatinine, BUN, electrolytes, and acid-base status 3
• Track fluid balance (intake, output, and weight) 1
• Assess for signs of fluid overload (peripheral edema, pulmonary congestion) 1
• Monitor for other electrolyte disturbances that may accompany hyperchloremia (hypokalemia, metabolic acidosis) 6

Special Considerations

Patients with Cirrhosis

• Follow specific algorithm for AKI in cirrhosis:
  • Withdraw diuretics and nephrotoxic drugs
  • Expand volume with albumin
  • Consider vasoconstrictors plus albumin if no response 1

Critically Ill Patients

• Maintain optimal fluid status (euvolemia) to reduce AKI incidence 1
• Be aware that treatments for COVID-19 and other critical illnesses may increase AKI risk 1
• Consider protocol-based management of hemodynamic and oxygenation parameters 1

Common Pitfalls to Avoid

1. Using 0.9% saline for fluid resuscitation in patients with hyperchloremia

   • This can worsen hyperchloremic acidosis and AKI 1

2. Excessive fluid administration

   • Can lead to fluid overload, tissue edema, and worsening organ dysfunction 7

3. Ignoring subclinical elevations in creatinine

   • Even small increases (<0.3 mg/dL) can indicate kidney injury and increased risk 3

4. Delaying RRT when indicated

   • Timely initiation of RRT can help correct severe electrolyte and acid-base disturbances 5, 6

By implementing this management approach, you can effectively address hyperchloremia in AKI patients, potentially improving outcomes by reducing kidney injury progression and associated complications.