High versus low chloride load in adult hyperglycemic emergencies with acute kidney injury: a great fluid debate

Excerpt

Acute kidney injury (AKI), defined as an abrupt decrease of kidney function, represents a rapidly evolving and potentially treatable clinical complication in hospitalized patients, with a significant impact on global patients’ outcome. In clinical practice, the diagnosis and classification of AKI are assessed from the increase of serum creatinine levels and reduction of urine output, with a direct relation between the severity of AKI and increased risk of death, prolonged hospital length of stay, occurrence of cardiovascular disease and progression to chronic kidney disease. The incidence of AKI may significantly vary among different studies, accounting for one out of five hospitalized adult patients and more than 30% in the critical care settings [1]. Particularly in this latter clinical context, different predisposing factors often coexist, including systemic hemodynamic and inflammatory alterations which may promote the onset of the functional forms of AKI together with specific kidney diseases (e.g., acute interstitial nephritis) and postrenal obstructive nephropathy. Among different etiologies, the occurrence of AKI is consistent in hyperglycemic emergencies, intended as diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS) and can reach up to 50%, mostly in presence of severe acidosis and dehydration [2]. Massive fluid administration, mostly in form of 0.9% sodium chloride solution, represents the milestone of the therapeutic approach, with the aim to correct the associated hypovolemia and to prevent organ hypoperfusion. In the recent years, a lot of attention has been paid to the chloride content in the different types of intravenous solutions, due to the possible hyperchloremia-related renal side effects in this high-risk patients’ population [3]. …