Kashani Mehdi, Wei Lifang, Singh Waryaam, Suppadungsuk Supawadee, Prokop Larry J, Kashani Kianoush B, Garces Juan Pablo Domecq
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
BMC Nephrol. 2025 Sep 26;26(1):536. doi: 10.1186/s12882-025-04466-9.
Electrolyte disturbances, including hyponatremia, are common in cirrhosis, with hyponatremia already incorporated into the MELD-Na score as a prognostic marker. However, the prognostic role of serum chloride, the main extracellular anion, remains underexplored. Emerging evidence suggests hypochloremia is independently associated with increased mortality and acute kidney injury (AKI) in cirrhotic patients. Proposed mechanisms include dysregulated activation of the renin-angiotensin, vasopressin, and sympathetic nervous systems, leading to renal vasoconstriction and impaired function. This systematic review evaluates the association between serum chloride levels and outcomes, including mortality and KDIGO-defined AKI rates, aiming to enhance understanding and inform management strategies.
This review followed PRISMA guidelines and a PROSPERO-registered protocol (CRD42024550945). Comprehensive searches of MEDLINE, EMBASE, Cochrane, Scopus, and Web of Science were conducted through June 6, 2024, without language restrictions. Controlled vocabulary and keywords were used to identify relevant studies. Two independent reviewers performed title, abstract, and full-text screening, with disagreements resolved through consensus or third-party arbitration. Inter-rater reliability was assessed using Cohen's kappa. Data extraction and risk of bias evaluations were performed using the PROBAST tool. Findings were summarized using a PRISMA flowchart.
Five studies (n = 3,150) were included, primarily retrospective cohorts, with one prospective study. Hypochloremia was defined as serum chloride < 99 mEq/L in most studies, except one, which used < 107.35 mmol/L. Cirrhosis etiologies included alcohol-related liver disease (40-64%), hepatitis B (7.9-59.9%), hepatitis C (7-8.9%), and non-alcoholic fatty liver disease (7-11.7%), with fewer cases of autoimmune and cryptogenic causes. Comorbidities included diabetes mellitus (21.3%), hypertension (13.4%), and varices (72-87%), with 62-99% having a history of decompensation. Extrahepatic organ failures were prevalent, affecting 79.4% of patients, with 31.6% and 13.4% experiencing two and three organ failures, respectively.Meta-analysis showed hypochloremia was significantly associated with increased mortality (pooled OR: 2.52; 95% CI: 1.88-3.39, p < 0.0001). Individual ORs ranged from 2.08 to 17.42, with low to moderate heterogeneity (I² = 36%). Hypochloremia also correlated with elevated creatinine levels and increased AKI prevalence.
Hypochloremia is a strong predictor of mortality and renal dysfunction in cirrhotic patients. Early recognition and management of hypochloremia are critical to improving outcomes in this high-risk population.
Not applicable.
电解质紊乱，包括低钠血症，在肝硬化患者中很常见，低钠血症已被纳入终末期肝病模型钠（MELD-Na）评分中作为预后指标。然而，血清氯作为主要的细胞外阴离子，其预后作用仍未得到充分研究。新出现的证据表明，低氯血症与肝硬化患者死亡率增加和急性肾损伤（AKI）独立相关。提出的机制包括肾素-血管紧张素、血管加压素和交感神经系统的失调激活，导致肾血管收缩和功能受损。本系统评价评估血清氯水平与包括死亡率和KDIGO定义的AKI发生率在内的结局之间的关联，旨在增进理解并为管理策略提供依据。
本评价遵循PRISMA指南和一项PROSPERO注册方案（CRD42024550945）。截至2024年6月6日，对MEDLINE、EMBASE、Cochrane、Scopus和Web of Science进行了全面检索，无语言限制。使用控制词汇和关键词来识别相关研究。两名独立评审员进行标题、摘要和全文筛选，分歧通过共识或第三方仲裁解决。使用Cohen's kappa评估评分者间信度。使用PROBAST工具进行数据提取和偏倚风险评估。研究结果使用PRISMA流程图进行总结。
纳入了五项研究（n = 3150），主要为回顾性队列研究，一项为前瞻性研究。在大多数研究中，低氯血症定义为血清氯<99 mEq/L，有一项研究使用的是<107.35 mmol/L。肝硬化病因包括酒精性肝病（40 - 64%）、乙型肝炎（7.9 - 59.9%）、丙型肝炎（7 - 8.9%）和非酒精性脂肪性肝病（7 - 11.7%），自身免疫性和隐源性病因的病例较少。合并症包括糖尿病（21.3%）、高血压（13.4%）和静脉曲张（72 - 87%），62 - 99%有失代偿病史。肝外器官衰竭很常见，影响79.4%的患者，分别有31.6%和13.4%的患者发生两种和三种器官衰竭。荟萃分析显示，低氯血症与死亡率增加显著相关（合并比值比：2.52；95%置信区间：1.88 - 3.39，p < 0.0001）。个体比值比范围为2.08至17.42，异质性低至中度（I² = 36%）。低氯血症还与肌酐水平升高和AKI患病率增加相关。
低氯血症是肝硬化患者死亡率和肾功能障碍的有力预测指标。早期识别和处理低氯血症对于改善这一高危人群的结局至关重要。
不适用。
