Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours

Nor'azim Mohd Yunos, Rinaldo Bellomo, David Mc D. Taylor, Simon Judkins, Fergus Kerr, Harvey Sutcliffe, Colin Hegarty, Michael Bailey

Research output: Contribution to journalArticleResearchpeer-review

5 Citations (Scopus)

Abstract

Objective: Patients commonly receive i.v. fluids in the ED. It is still unclear whether the choice of i.v. fluids in this setting influences renal or patient outcomes. We aimed to assess the effects of restricting i.v. chloride administration in the ED on the incidence of acute kidney injury (AKI). Methods: We conducted a before-and-after trial with 5008 consecutive ED-treated hospital admissions in the control period and 5146 consecutive admissions in the intervention period. During the control period (18 February 2008 to 17 August 2008), patients received standard i.v. fluids. During the intervention period (18 February 2009 to 17 August 2009), we restricted all chloride-rich fluids. We used the Kidney Disease: Improving Global Outcomes (KDIGO) staging to define AKI. Results: Stage 3 of KDIGO-defined AKI decreased from 54 (1.1%; 95% confidence interval [CI] 0.8–1.4) to 30 (0.6%; 95% CI 0.4–0.8) (P = 0.006). The rate of renal replacement therapy did not change, from 13 (0.3%; 95% CI 0.2–0.4) to 8 (0.2%; 95% CI 0.1–0.3) (P = 0.25). After adjustment for relevant covariates, liberal chloride therapy remained associated with a greater risk of KDIGO stage 3 (hazard ratio 1.82; 95% CI 1.13–2.95; P = 0.01). On sensitivity assessment after removing repeat admissions, KDIGO stage 3 remained significantly lower in the intervention period compared with the control period (P = 0.01). Conclusion: In a before-and-after trial, a chloride-restrictive strategy in an ED was associated with a significant decrease in the incidence of stage 3 of KDIGO-defined AKI.

Original languageEnglish
Pages (from-to)643-649
Number of pages7
JournalEMA - Emergency Medicine Australasia
Volume29
Issue number6
DOIs
Publication statusPublished - 1 Dec 2017

Keywords

  • acute kidney injury
  • chloride
  • emergency department
  • saline

Cite this

Yunos, Nor'azim Mohd ; Bellomo, Rinaldo ; Taylor, David Mc D. ; Judkins, Simon ; Kerr, Fergus ; Sutcliffe, Harvey ; Hegarty, Colin ; Bailey, Michael. / Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours. In: EMA - Emergency Medicine Australasia. 2017 ; Vol. 29, No. 6. pp. 643-649.
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title = "Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours",
abstract = "Objective: Patients commonly receive i.v. fluids in the ED. It is still unclear whether the choice of i.v. fluids in this setting influences renal or patient outcomes. We aimed to assess the effects of restricting i.v. chloride administration in the ED on the incidence of acute kidney injury (AKI). Methods: We conducted a before-and-after trial with 5008 consecutive ED-treated hospital admissions in the control period and 5146 consecutive admissions in the intervention period. During the control period (18 February 2008 to 17 August 2008), patients received standard i.v. fluids. During the intervention period (18 February 2009 to 17 August 2009), we restricted all chloride-rich fluids. We used the Kidney Disease: Improving Global Outcomes (KDIGO) staging to define AKI. Results: Stage 3 of KDIGO-defined AKI decreased from 54 (1.1{\%}; 95{\%} confidence interval [CI] 0.8–1.4) to 30 (0.6{\%}; 95{\%} CI 0.4–0.8) (P = 0.006). The rate of renal replacement therapy did not change, from 13 (0.3{\%}; 95{\%} CI 0.2–0.4) to 8 (0.2{\%}; 95{\%} CI 0.1–0.3) (P = 0.25). After adjustment for relevant covariates, liberal chloride therapy remained associated with a greater risk of KDIGO stage 3 (hazard ratio 1.82; 95{\%} CI 1.13–2.95; P = 0.01). On sensitivity assessment after removing repeat admissions, KDIGO stage 3 remained significantly lower in the intervention period compared with the control period (P = 0.01). Conclusion: In a before-and-after trial, a chloride-restrictive strategy in an ED was associated with a significant decrease in the incidence of stage 3 of KDIGO-defined AKI.",
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Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours. / Yunos, Nor'azim Mohd; Bellomo, Rinaldo; Taylor, David Mc D.; Judkins, Simon; Kerr, Fergus; Sutcliffe, Harvey; Hegarty, Colin; Bailey, Michael.

In: EMA - Emergency Medicine Australasia, Vol. 29, No. 6, 01.12.2017, p. 643-649.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - Renal effects of an emergency department chloride-restrictive intravenous fluid strategy in patients admitted to hospital for more than 48 hours

AU - Yunos, Nor'azim Mohd

AU - Bellomo, Rinaldo

AU - Taylor, David Mc D.

AU - Judkins, Simon

AU - Kerr, Fergus

AU - Sutcliffe, Harvey

AU - Hegarty, Colin

AU - Bailey, Michael

PY - 2017/12/1

Y1 - 2017/12/1

N2 - Objective: Patients commonly receive i.v. fluids in the ED. It is still unclear whether the choice of i.v. fluids in this setting influences renal or patient outcomes. We aimed to assess the effects of restricting i.v. chloride administration in the ED on the incidence of acute kidney injury (AKI). Methods: We conducted a before-and-after trial with 5008 consecutive ED-treated hospital admissions in the control period and 5146 consecutive admissions in the intervention period. During the control period (18 February 2008 to 17 August 2008), patients received standard i.v. fluids. During the intervention period (18 February 2009 to 17 August 2009), we restricted all chloride-rich fluids. We used the Kidney Disease: Improving Global Outcomes (KDIGO) staging to define AKI. Results: Stage 3 of KDIGO-defined AKI decreased from 54 (1.1%; 95% confidence interval [CI] 0.8–1.4) to 30 (0.6%; 95% CI 0.4–0.8) (P = 0.006). The rate of renal replacement therapy did not change, from 13 (0.3%; 95% CI 0.2–0.4) to 8 (0.2%; 95% CI 0.1–0.3) (P = 0.25). After adjustment for relevant covariates, liberal chloride therapy remained associated with a greater risk of KDIGO stage 3 (hazard ratio 1.82; 95% CI 1.13–2.95; P = 0.01). On sensitivity assessment after removing repeat admissions, KDIGO stage 3 remained significantly lower in the intervention period compared with the control period (P = 0.01). Conclusion: In a before-and-after trial, a chloride-restrictive strategy in an ED was associated with a significant decrease in the incidence of stage 3 of KDIGO-defined AKI.

AB - Objective: Patients commonly receive i.v. fluids in the ED. It is still unclear whether the choice of i.v. fluids in this setting influences renal or patient outcomes. We aimed to assess the effects of restricting i.v. chloride administration in the ED on the incidence of acute kidney injury (AKI). Methods: We conducted a before-and-after trial with 5008 consecutive ED-treated hospital admissions in the control period and 5146 consecutive admissions in the intervention period. During the control period (18 February 2008 to 17 August 2008), patients received standard i.v. fluids. During the intervention period (18 February 2009 to 17 August 2009), we restricted all chloride-rich fluids. We used the Kidney Disease: Improving Global Outcomes (KDIGO) staging to define AKI. Results: Stage 3 of KDIGO-defined AKI decreased from 54 (1.1%; 95% confidence interval [CI] 0.8–1.4) to 30 (0.6%; 95% CI 0.4–0.8) (P = 0.006). The rate of renal replacement therapy did not change, from 13 (0.3%; 95% CI 0.2–0.4) to 8 (0.2%; 95% CI 0.1–0.3) (P = 0.25). After adjustment for relevant covariates, liberal chloride therapy remained associated with a greater risk of KDIGO stage 3 (hazard ratio 1.82; 95% CI 1.13–2.95; P = 0.01). On sensitivity assessment after removing repeat admissions, KDIGO stage 3 remained significantly lower in the intervention period compared with the control period (P = 0.01). Conclusion: In a before-and-after trial, a chloride-restrictive strategy in an ED was associated with a significant decrease in the incidence of stage 3 of KDIGO-defined AKI.

KW - acute kidney injury

KW - chloride

KW - emergency department

KW - saline

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DO - 10.1111/1742-6723.12821

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