ArticleKidney international2014
Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent 'pre-renal' acute kidney injury?: con.
Article in Kidney international, 2014. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 59 papers, 4 of them syntheses that pooled it.
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The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
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Who cites it
59 citing papers in PubMed, 4 syntheses or guidelines pooled it, 146 citations in OpenAlex.
- 2025 Delphi consensus on robotic ventral mesh rectopexy.International journal of colorectal disease · 2025Guideline
- Plasma-lyte solution versus saline in kidney transplantation: A systematic review and meta-analysis of randomized controlled trials.PloS one · 2025Pooled it
- Intraoperative Goal-directed Fluid Therapy in Elective Major Abdominal Surgery: A Meta-analysis of Randomized Controlled Trials.Annals of surgery · 2016Pooled it
- Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation.The British journal of surgery · 2015Pooled it
- Trial
- Impact of Isolyte Versus 0.9% Saline on Postoperative Event of Acute Kidney Injury Assayed by Urinary [TIMP-2] × [IGFBP7] in Patients Undergoing Cardiac Surgery.Journal of cardiothoracic and vascular anesthesia · 2019Trial
- Effect of isotonic versus hypotonic maintenance fluid therapy on urine output, fluid balance, and electrolyte homeostasis: a crossover study in fasting adult volunteers.British journal of anaesthesia · 2017Trial
- Trial
- Ringer Lactate Versus Hybrid Isotonic/Hypotonic Saline in Delayed Graft Function in Deceased-donor Kidney Transplantation: A Real-world Protocol Change Study.Transplantation direct · 2026Article
- Perioperative hyperchloremia is associated with acute kidney injury in elderly patients undergoing bipolar plasmakinetic transurethral resection of the prostate: a prospective observational study.World journal of urology · 2026Observational
- Investigating the fluid and electrolyte prescribing knowledge of Foundation Year doctors.Annals of the Royal College of Surgeons of England · 2026Article
- Impact of fluid creep on volume and chloride load in critically ill adults: a prospective study on its prognostic significance and association with MAKE30.Renal failure · 2025Article
- A Comprehensive Review of Fluid Resuscitation Strategies in Traumatic Brain Injury.Journal of clinical medicine · 2025Review
- Fluid management strategies in critically ill patients with ARDS: a narrative review.European journal of medical research · 2025Review
- The Impact of Administering Human Plasma Protein Fraction 5% (PPF5%) in Major Liver Resection Surgeries.Cureus · 2025Article
- Balanced Electrolyte Solutions Versus 0.9% Saline for Kidney Transplantation: An Updated Systematic Review and Meta-analysis.Transplantation direct · 2025Article
- Key Considerations for Frail Patients Undergoing Hip Fracture Surgery.Clinics and practice · 2024Review
- Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland.Irish journal of medical science · 2024Article
- Review
- The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis.Pediatric nephrology (Berlin, Germany) · 2024Article
Corrections and comments
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Authors and funding
2 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
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. Major complications are the increased incidence of acute kidney injury and the need for renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing 0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause brain edema. 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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