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'''Hyperchloremia''' is an [[electrolyte disturbance]] in which there is an abnormally elevated level of the [[chloride]] ion in the [[blood]]<ref name="pmid9760315">{{cite journal|date=October 1998|title=Effects of hyperchloremia on blood oxygen binding in healthy calves|url=http://jap.physiology.org/cgi/pmidlookup?view=long&pmid=9760315|journal=J. Appl. Physiol.|volume=85|issue=4|pages=1267–72|doi=|pmid=9760315|vauthors=Cambier C, Detry B, Beerens D, etal}}</ref>. The normal serum range for chloride is 96 to 106 [[equivalent (chemistry)|mEq/L]]<ref name=":3" />. Chloride concentration in the plasma is regulated by the kidney, and normally 60% of chloride is reabsorbed into the interstitial fluid in the proximal tubule<ref name=":4" />. As of now there are no specific symptoms of hyperchloremia, however, it can be the results of multiple abnormalities like loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities can be a result of diarrhea, vomiting, salt intake, renal failure, prolonged use of bromide-infused drugs carbonic anhydrase inhibitors, or metabolic acidosis. Hyperchloremia should not be be mistaken for hyperchloremia metabolic acidosis as hyperchloremia metabolic acidosis is characterized by two changes: a decrease in blood pH and bicarbonate, as well as an increase in blood chloride levels<ref>{{Cite web|url=https://www.dynamed.com/topics/dmp~AN~T115404/Hyperchloremic-metabolic-acidosis|title=https://www.dynamed.com/topics/dmp~AN~T115404/Hyperchloremic-metabolic-acidosis|website=www.dynamed.com|access-date=2017-12-12}}</ref>. |
'''Hyperchloremia''' is an [[electrolyte disturbance]] in which there is an abnormally elevated level of the [[chloride]] ion in the [[blood]]<ref name="pmid9760315">{{cite journal|date=October 1998|title=Effects of hyperchloremia on blood oxygen binding in healthy calves|url=http://jap.physiology.org/cgi/pmidlookup?view=long&pmid=9760315|journal=J. Appl. Physiol.|volume=85|issue=4|pages=1267–72|doi=|pmid=9760315|vauthors=Cambier C, Detry B, Beerens D, etal}}</ref>. The normal serum range for chloride is 96 to 106 [[equivalent (chemistry)|mEq/L]]<ref name=":3" /> , therefore chloride levels above this range usually indicate an kidney dysfunction<ref name=":5">{{Cite web|url=http://chemocare.com/chemotherapy/side-effects/hyperchloremia-high-chloride.aspx|title=Hyperchloremia (High Chloride) - Managing Side Effects - Chemocare|last=Cancer|first=Cleveland Clinic|website=chemocare.com|language=en|access-date=2017-12-12}}</ref>. Chloride concentration in the plasma is regulated by the kidney, and normally 60% of chloride is reabsorbed into the interstitial fluid in the proximal tubule<ref name=":4" />. As of now there are no specific symptoms of hyperchloremia, however, it can be the results of multiple abnormalities like loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities can be a result of diarrhea, vomiting, salt intake, renal failure, prolonged use of bromide-infused drugs carbonic anhydrase inhibitors, or metabolic acidosis. Hyperchloremia should not be be mistaken for hyperchloremia metabolic acidosis as hyperchloremia metabolic acidosis is characterized by two changes: a decrease in blood pH and bicarbonate, as well as an increase in blood chloride levels<ref>{{Cite web|url=https://www.dynamed.com/topics/dmp~AN~T115404/Hyperchloremic-metabolic-acidosis|title=https://www.dynamed.com/topics/dmp~AN~T115404/Hyperchloremic-metabolic-acidosis|website=www.dynamed.com|access-date=2017-12-12}}</ref>. |
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There are many scenarios which may results in hyperchloremia. The first instance is when there is a loss of electrolyte-free fluid. This simply means that the body is losing increased amounts of fluids that do not contain electrolytes, like chloride, resulting in high concentration of these ions remaining in the body. This loss of fluids can be due to sweating (due to exercise or fever), burns to the skin, lack of adequate water intake, hyper-metabolic state, and diabetes insipidus. Losing fluids can lead to feelings of dehydration and dry mucous membrane<ref name=":1" /> <ref name=":2">{{Cite journal|last=Bandak|first=Ghassan|last2=Kashani|first2=Kianoush B.|date=2017-11-01|title=Chloride in intensive care units: a key electrolyte|url=https://f1000research.com/articles/6-1930/v1|journal=F1000Research|volume=6|doi=10.12688/f1000research.11401.1}}</ref>. |
There are many scenarios which may results in hyperchloremia. The first instance is when there is a loss of electrolyte-free fluid. This simply means that the body is losing increased amounts of fluids that do not contain electrolytes, like chloride, resulting in high concentration of these ions remaining in the body. This loss of fluids can be due to sweating (due to exercise or fever), burns to the skin, lack of adequate water intake, hyper-metabolic state, and diabetes insipidus. Losing fluids can lead to feelings of dehydration and dry mucous membrane<ref name=":1" /> <ref name=":2">{{Cite journal|last=Bandak|first=Ghassan|last2=Kashani|first2=Kianoush B.|date=2017-11-01|title=Chloride in intensive care units: a key electrolyte|url=https://f1000research.com/articles/6-1930/v1|journal=F1000Research|volume=6|doi=10.12688/f1000research.11401.1}}</ref>. |
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The second scenario is called loss of hypotonic fluid can be a direct result of loss of electrolyte fluid. Normally, water in the body is moving from an area of low ion concentration to an area of high ion concentration. In this case the water is being excreted in urine, therefore, less water will flow to areas of high concentration. This can be due to diuretic use, diarrhea, burns, renal disease, renal failure, and renal tubular acidosis . This can lead to feeling of dehydration<ref name=":1" /><ref name=":2" />. |
The second scenario is called loss of hypotonic fluid can be a direct result of loss of electrolyte fluid. Normally, water in the body is moving from an area of low ion concentration to an area of high ion concentration. In this case the water is being excreted in urine, therefore, less water will flow to areas of high concentration. This can be due to diuretic use, diarrhea, vomiting, burns, renal disease, renal failure, and renal tubular acidosis . This can lead to feeling of dehydration<ref name=":1" /><ref name=":2" />. |
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The third scenarios that may lead to hyperchloremia is when there is an increase in sodium chloride intake. This can be due to things like diet or intravenous fluid administration in hospital settings. This can lead to the body experiencing hypertension, edema, and cardiovascular dysfunction<ref name=":1" /><ref name=":2" />. |
The third scenarios that may lead to hyperchloremia is when there is an increase in sodium chloride intake. This can be due to things like diet or intravenous fluid administration in hospital settings. This can lead to the body experiencing hypertension, edema, and cardiovascular dysfunction<ref name=":1" /><ref name=":2" />. |
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==Diagnosis== |
==Diagnosis== |
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Elevated levels of chloride in the blood can be tested simply by requesting a serum chloride test. A doctor would request this test it there are signs their patient is experiencing an imbalance in acid-base levels. For the test to occur a healthcare provider must draw a sample of blood from the patient. It is preferred that blood is drawn from the vein in the inner elbow or the back of the hand. The sample will then be sent to a laboratory and results will be provided to the patient's physician. As mentioned earlier a normal serum chloride range is from 96 to 106 mEq/L. This test is important as it gives more detail into if a patient's acid-base levels are imbalanced<ref name=":3">{{Cite web|url=https://medlineplus.gov/ency/article/003485.htm|title=Chloride test - blood: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2017-12-12}}</ref>. |
Elevated levels of chloride in the blood can be tested simply by requesting a serum chloride test. A doctor would request this test it there are signs their patient is experiencing an imbalance in acid-base levels for a prolonged period of time<ref name=":3" /><ref name=":5" />. For the test to occur a healthcare provider must draw a sample of blood from the patient. It is preferred that blood is drawn from the vein in the inner elbow or the back of the hand. The sample will then be sent to a laboratory and results will be provided to the patient's physician. As mentioned earlier a normal serum chloride range is from 96 to 106 mEq/L. This test is important as it gives more detail into if a patient's acid-base levels are imbalanced<ref name=":3">{{Cite web|url=https://medlineplus.gov/ency/article/003485.htm|title=Chloride test - blood: MedlinePlus Medical Encyclopedia|website=medlineplus.gov|language=en|access-date=2017-12-12}}</ref>. |
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==Treatment and Prognosis== |
==Treatment and Prognosis== |
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Hyperchloremia is an electrolyte disturbance in which there is an abnormally elevated level of the chloride ion in the blood[1]. The normal serum range for chloride is 96 to 106 mEq/L[2] , therefore chloride levels above this range usually indicate an kidney dysfunction[3]. Chloride concentration in the plasma is regulated by the kidney, and normally 60% of chloride is reabsorbed into the interstitial fluid in the proximal tubule[4]. As of now there are no specific symptoms of hyperchloremia, however, it can be the results of multiple abnormalities like loss of electrolyte-free fluid, loss of hypotonic fluid, or increased administration of sodium chloride. These abnormalities can be a result of diarrhea, vomiting, salt intake, renal failure, prolonged use of bromide-infused drugs carbonic anhydrase inhibitors, or metabolic acidosis. Hyperchloremia should not be be mistaken for hyperchloremia metabolic acidosis as hyperchloremia metabolic acidosis is characterized by two changes: a decrease in blood pH and bicarbonate, as well as an increase in blood chloride levels[5].
A major concern in
Causes and Prevention
There are many scenarios which may results in hyperchloremia. The first instance is when there is a loss of electrolyte-free fluid. This simply means that the body is losing increased amounts of fluids that do not contain electrolytes, like chloride, resulting in high concentration of these ions remaining in the body. This loss of fluids can be due to sweating (due to exercise or fever), burns to the skin, lack of adequate water intake, hyper-metabolic state, and diabetes insipidus. Losing fluids can lead to feelings of dehydration and dry mucous membrane[6] [7].
The second scenario is called loss of hypotonic fluid can be a direct result of loss of electrolyte fluid. Normally, water in the body is moving from an area of low ion concentration to an area of high ion concentration. In this case the water is being excreted in urine, therefore, less water will flow to areas of high concentration. This can be due to diuretic use, diarrhea, vomiting, burns, renal disease, renal failure, and renal tubular acidosis . This can lead to feeling of dehydration[6][7].
The third scenarios that may lead to hyperchloremia is when there is an increase in sodium chloride intake. This can be due to things like diet or intravenous fluid administration in hospital settings. This can lead to the body experiencing hypertension, edema, and cardiovascular dysfunction[6][7].
Symptoms
Hyperchloremia does not have many noticeable symptoms and can only be confirmed with testing. Yet, hyperchloremia can contribute to metabolic acidosis which is when the blood has an acidic pH level usually due to dysfunction in the kidney. The symptoms associated with this disease are fatigue, muscle weakness, high blood pressure, thirst, and dry mucus membrane.
Hyperchloremia can also contribute
Often hyperchloremia does not produce any symptoms. In cases where symptoms develop, manifestation resembles hypernatremia. Reduction in blood chloride leads to cerebral dehydration; symptoms are most often caused by rapid rehydration which results in cerebral edema. If the sufferer were to be a diabetic, hyperchloremia could lead to poor control of blood sugar concentration, which could cause it to become elevated. Hyperchloremia can be symptomatic with signs of Kussmaul's breathing, weakness, and intense thirst.
Mechanism of Action
The nephrons in the kidney are responsible for regulating the level of chloride in the blood. The general mechanism is that as filtrate fluid passes through the nephrons varying concentrations of ions will be secreted into the interstitial fluid or absorbed into the lumen. All along the nephrons are blood capillaries waiting to reabsorb ions from the interstitial fluid back into the blood that will circulate in the body [8]. The amount of chloride to be released in the urine is due to the receptors lining the nephrons and the glomerulus filtration.
Normally, chloride reabsorption begins in the proximal tubule and nearly 60% of chloride is filtered here[4]. In a person with hyperchloremia, the absorption of chloride into the interstitial fluid and subsequently into the blood capillaries is increased. This means the concentration of chloride in the filtrate is decreased, therefore, a decreased amount of chloride is being excreted as waste in the urine[8]. In the proximal tubule chloride reabsorption occurs in two parts. In the 1st phase, organic solutes (such as phosphates, amino acids, glucose and anions), sodium ions, and hydronium ions are reabsorbed from the filtrate fluid into the interstitial fluid. This is an important step because this creates the concentration gradient in which chloride concentration in the lumen will increased in comparison to the chloride concentration in the interstitial fluid. In phase 2, chloride will diffuse along the concentration gradient, which means chloride ions will travel from areas of high concentration to areas of low concentration. As the filtrate passes through the descending Loop of Henle, sodium chloride will not be reabsorbed as it is not permeable to the membrane of the tubule. In the ascending Loop of Henle chloride will be reabsorbed into the interstitial fluid, though in smaller amounts. Chloride reabsorption continues in the distal tubule and the medullary collecting duct, then the filtrate passes through the remainder of the nephron into the bladder[6].
Diagnosis
Elevated levels of chloride in the blood can be tested simply by requesting a serum chloride test. A doctor would request this test it there are signs their patient is experiencing an imbalance in acid-base levels for a prolonged period of time[2][3]. For the test to occur a healthcare provider must draw a sample of blood from the patient. It is preferred that blood is drawn from the vein in the inner elbow or the back of the hand. The sample will then be sent to a laboratory and results will be provided to the patient's physician. As mentioned earlier a normal serum chloride range is from 96 to 106 mEq/L. This test is important as it gives more detail into if a patient's acid-base levels are imbalanced[2].
Treatment and Prognosis
As with most types of electrolyte imbalance, the treatment of high blood chloride levels is based on correcting the underlying cause.
- If the patient is dehydrated, therapy consists of establishing and maintaining adequate hydration[1].
- If the condition is caused or exacerbated by medications or treatments, these may be altered or discontinued, if deemed prudent[1].
- If there is underlying kidney disease (which is likely if there are other electrolyte disturbances), then the patient will be referred to a nephrologist for further care[1].
- If there is an underlying dysfunction of the endocrine or hormone system, the patient will likely be referred to an endocrinologist for further assessment.[1]
Recent Research
In patients with sepsis or septic shock they are more susceptible to experience acute kidney injury (AKI) and the factors that may contribute to AKI are still being investigated. In a study conducted by Suetrong et al., (2016) using patients admitted to St. Paul Hospital in Vancouver with sepsis or septic shock had their body concentration of chloride checked over the course of 48 hours to determine if there is a relation between hyperchloremia and AKI. This is an important relationship to study because many times a form of therapy to treat sepsis and septic shock is to administer saline solution, which is a solution containing sodium chloride. It should be noted that saline has a much higher concentration of chloride than blood. In this study they defined hyperchloremia as concentration of chloride greater than 110 mmol/L. This research demonstrated that hyperchloremia will influence a patient developing AKI. In fact, even patients that had a conservative increase in serum chloride saw some association with developing AKI. This research study suggest that there still needs to be more investigation in the risk of using saline as a form of therapy and the risk of experiencing AKI[9].
References
- ^ a b c d e Cambier C, Detry B, Beerens D, et al. (October 1998). "Effects of hyperchloremia on blood oxygen binding in healthy calves". J. Appl. Physiol. 85 (4): 1267–72. PMID 9760315.
- ^ a b c "Chloride test - blood: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2017-12-12.
- ^ a b Cancer, Cleveland Clinic. "Hyperchloremia (High Chloride) - Managing Side Effects - Chemocare". chemocare.com. Retrieved 2017-12-12.
- ^ a b "Hyperchloremia – Why and how". Nefrología (English Edition). 36 (4): 347–353. 2016-07-01. doi:10.1016/j.nefroe.2016.06.006. ISSN 2013-2514.
- ^ "https://www.dynamed.com/topics/dmp~AN~T115404/Hyperchloremic-metabolic-acidosis". www.dynamed.com. Retrieved 2017-12-12.
{{cite web}}: External link in|title= - ^ a b c d Morrison, Gail (1990). Walker, H. Kenneth; Hall, W. Dallas; Hurst, J. Willis (eds.). Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.). Boston: Butterworths. ISBN 040990077X. PMID 21250151.
- ^ a b c Bandak, Ghassan; Kashani, Kianoush B. (2017-11-01). "Chloride in intensive care units: a key electrolyte". F1000Research. 6. doi:10.12688/f1000research.11401.1.
{{cite journal}}: CS1 maint: unflagged free DOI (link) - ^ a b Hall, J;, Guyton, A (2016). Textbook of Medical Physiology. Elsevier. ISBN 978-1455770052.
{{cite book}}: CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link) - ^ Suetrong, Bandarn; Pisitsak, Chawika; Boyd, John H.; Russell, James A.; Walley, Keith R. (2016-10-06). "Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients". Critical Care. 20: 315. doi:10.1186/s13054-016-1499-7. ISSN 1364-8535.
{{cite journal}}: CS1 maint: unflagged free DOI (link)