Thongprayoon Charat, Cheungpasitporn Wisit, Cheng Zhen, Qian Qi
Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America.
Department of Anesthesiology, Mayo Clinic Rochester, Minnesota, United States of America.
PLoS One. 2017 Mar 22;12(3):e0174430. doi: 10.1371/journal.pone.0174430. eCollection 2017.
Serum Cl (sCl) alterations in hospitalized patients have not been comprehensively studied in recent years. The aim of this study is to investigate the prevalence and outcome significance of (1) sCl alterations on hospital admission, and (2) sCl evolution within the first 48 hr of hospital admission. We conducted a retrospective study of all hospital admissions in the years 2011-2013 at Mayo Clinic Rochester, a 2000-bed tertiary medical center. Outcome measures included hospital mortality, length of hospital stay and discharge disposition. 76,719 unique admissions (≥18 years old) were studied. Based on hospital mortality, sCl in the range of 105-108 mmol/L was found to be optimal. sCl <100 (n = 13,611) and >108 (n = 11,395) mmol/L independently predicted a higher risk of hospital mortality, longer hospital stay and being discharged to a care facility. 13,089 patients (17.1%) had serum anion gap >12 mmol/L; their hospital mortality, when compared to 63,630 patients (82.9%) with anion gap ≤12 mmol/L, was worse. Notably, patients with elevated anion gap displayed a progressively worsening mortality with rising sCl. sCl elevation within 48 hr of admission was associated with a higher proportion of 0.9% saline administration and was an independent predictor for hospital mortality. Moreover, the magnitude of sCl rise was inversely correlated to the days of patient survival. In conclusion, serum Cl alterations on admission predict poor clinical outcomes. Post-admission sCl increase, due to Cl-rich fluid infusion, independently predicts hospital mortality. These results raise a critical question of whether iatrogenic cause of hyperchloremia should be avoided, a question to be addressed by future prospective studies.
近年来，住院患者血清氯（sCl）的变化尚未得到全面研究。本研究的目的是调查：（1）入院时sCl变化的发生率及其对预后的意义；（2）入院后48小时内sCl的变化情况。我们对梅奥诊所罗切斯特院区2011 - 2013年所有住院患者进行了一项回顾性研究，该院区是一家拥有2000张床位的三级医疗中心。观察指标包括住院死亡率、住院时间和出院去向。共研究了76,719例（≥18岁）不同的住院患者。基于住院死亡率，发现sCl在105 - 108 mmol/L范围内最为理想。sCl <100（n = 13,611）和>108（n = 11,395）mmol/L独立预测了更高的住院死亡风险、更长的住院时间以及出院后入住护理机构的可能性。13,089例患者（17.1%）的血清阴离子间隙>12 mmol/L；与63,630例（82.9%）阴离子间隙≤12 mmol/L的患者相比，他们的住院死亡率更高。值得注意的是，阴离子间隙升高的患者死亡率随着sCl升高而逐渐恶化。入院后48小时内sCl升高与使用0.9%生理盐水的比例较高有关，并且是住院死亡率的独立预测因素。此外，sCl升高的幅度与患者存活天数呈负相关。总之，入院时血清氯变化预示着不良临床结局。入院后由于输注含氯液体导致的sCl升高独立预测了住院死亡率。这些结果提出了一个关键问题，即是否应避免医源性高氯血症的发生，这一问题有待未来的前瞻性研究加以解决。
