Kidney international
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Kidney international · Dec 2014
Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury?: con.
The high chloride content of 0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that 0.9% saline has on the clinical outcome in surgical and critically ill patients when compared with balanced crystalloids. ⋯ Saline may be the solution of choice used for the resuscitation of patients with alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than 0.9% saline, with perhaps better clinical outcome. Hence, we argue that chloride-rich crystalloids such as 0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury.
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Kidney international · Dec 2014
Randomized Controlled Trial Multicenter Study Comparative StudyResults of the HepZero study comparing heparin-grafted membrane and standard care show that heparin-grafted dialyzer is safe and easy to use for heparin-free dialysis.
Heparin is used to prevent clotting during hemodialysis, but heparin-free hemodialysis is sometimes needed to decrease the risk of bleeding. The HepZero study is a randomized, multicenter international controlled open-label trial comparing no-heparin hemodialysis strategies designed to assess non-inferiority of a heparin grafted dialyzer (NCT01318486). A total of 251 maintenance hemodialysis patients at increased risk of hemorrhage were randomly allocated for up to three heparin-free hemodialysis sessions using a heparin-grafted dialyzer or the center standard-of-care consisting of regular saline flushes or pre-dilution. ⋯ The absolute difference between the heparin-grafted membrane and the controls was 18.2%, with a lower bound of the 90% confidence interval equal to plus 7.9%. The hypothesis of the non-inferiority at the minus 15% level was accepted, although superiority at the plus 15% level was not reached. Thus, use of a heparin-grafted membrane is a safe, helpful, and easy-to-use method for heparin-free hemodialysis in patients at increased risk of hemorrhage.
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Although 0.9% NaCl solution is by far the most-used fluid for fluid therapy in resuscitation, it is difficult to find a paper advocating its use over other types of crystalloid solutions. Literature on the deleterious effects of 0.9% NaCl has accumulated over the last decade, but critical appraisal of alternative crystalloid solutions is lacking. As such, the literature seems to suggest that 0.9% NaCl should be avoided at all costs, whereas alternative crystalloid solutions can be used without scrutiny. ⋯ Although it has some deleterious effects, all fluids share common features of concern. As such the emphasis on fluid resuscitation should be on volume rather than on composition and should be accompanied by a physiological assessment of the impact of fluids. In this paper, we hope to discuss the context within which fluids, specifically 0.9% NaCl, can be given in a safe and effective manner.