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Background: Renal function tends to deteriorate in a hyperchloremic acidifying environment, which is reflected by a decrease in the difference between sodium and chloride. Objectives: To examine the effect of furosemide administered under hyperchloremic acidosis on intraoperative oliguria and acute kidney injury in patients with preoperatively normal renal function. Methods: In patients undergoing abdominal or orthopedic surgeries (April 2010–November 2018), we retrospectively identified patients who preoperatively had a normal renal function but experienced intraoperative oliguria under hyperchloremic acidosis (a sodium-chloride difference < 30 mEq/L) without dehydration. We compared the perioperative urine output and the incidence of postoperative acute kidney injury between patients who intraoperatively received an initial dose of 5 mg of furosemide (the furosemide group) and patients who did not intraoperatively receive furosemide (the control group). Results: We identified 62 patients in the furosemide group and 48 patients in the control group. The furosemide group intraoperatively received 0.11 ± 0.06 mg/kg of furosemide (range 0.06–0.39 mg/kg). Compared to the control group, the furosemide group had greater urine output (mL/kg/h) in the operating room (1.1 ± 0.7 vs. 0.3 ± 0.1, p < 0.01) and on postoperative day 1 (1.2 ± 0.5 vs. 1.1 ± 0.4, p = 0.02). The incidence of postoperative acute kidney injury was lesser in the furosemide group than that in the control group (8.0 vs. 27.0%, p < 0.01; multivariate OR 0.18; 95% CI 0.05–0.61; p < 0.01). Conclusions: In surgery patients under hyperchloremic acidosis, furosemide (0.1 mg/kg) resolved intraoperative oliguria and reduced the incidence of postoperative acute kidney injury.

1.
Bellomo R, Kellum JA, Ronco C. Acute kidney injury.
Lancet
. 2012 Aug; 380(9843): 756–66.
2.
Goren O, Matot I. Perioperative acute kidney injury.
Br J Anaesth
. 2015 Dec; 115 Suppl 2:ii3–14.
3.
Lobo DN, Awad S. Should chloride-rich crystalloids remain the mainstay of fluid resuscitation to prevent ‘pre-renal’ acute kidney injury?: con.
Kidney Int
. 2014 Dec; 86(6): 1096–105.
4.
Williams EL, Hildebrand KL, McCormick SA, Bedel MJ. The effect of intravenous lactated Ringer’s solution versus 0.9% sodium chloride solution on serum osmolality in human volunteers.
Anesth Analg
. 1999 May; 88(5): 999–1003.
5.
Reid F, Lobo DN, Williams RN, Rowlands BJ, Allison SP. (Ab)normal saline and physiological Hartmann’s solution: a randomized double-blind crossover study.
Clin Sci (Lond)
. 2003 Jan; 104(1): 17–24.
6.
Chowdhury AH, Cox EF, Francis ST, Lobo DN. A randomized, controlled, double-blind crossover study on the effects of 2-L infusions of 0.9% saline and plasma-lyte® 148 on renal blood flow velocity and renal cortical tissue perfusion in healthy volunteers.
Ann Surg
. 2012 Jul; 256(1): 18–24.
7.
Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults.
JAMA
. 2012 Oct; 308(15): 1566–72.
8.
Shaw AD, Bagshaw SM, Goldstein SL, Scherer LA, Duan M, Schermer CR, et al. Major complications, mortality, and resource utilization after open abdominal surgery: 0.9% saline compared to Plasma-Lyte.
Ann Surg
. 2012 May; 255(5): 821–9.
9.
Stewart PA. Modern quantitative acid-base chemistry.
Can J Physiol Pharmacol
. 1983 Dec; 61(12): 1444–61.
10.
Toyonaga Y, Kikura M. Hyperchloremic acidosis is associated with acute kidney injury after abdominal surgery.
Nephrology (Carlton)
. 2017 Sep; 22(9): 720–7.
11.
Self WH, Semler MW, Wanderer JP, Wang L, Byrne DW, Collins SP, et al.; SALT-ED Investigators. Balanced Crystalloids versus Saline in Noncritically Ill Adults.
N Engl J Med
. 2018 Mar; 378(9): 819–28.
12.
Semler MW, Self WH, Wanderer JP, Ehrenfeld JM, Wang L, Byrne DW, et al.; SMART Investigators and the Pragmatic Critical Care Research Group. Balanced Crystalloids versus Saline in Critically Ill Adults.
N Engl J Med
. 2018 Mar; 378(9): 829–39.
13.
Ho KM, Power BM. Benefits and risks of furosemide in acute kidney injury.
Anaesthesia
. 2010 Mar; 65(3): 283–93.
14.
Zazzeron L, Ottolina D, Scotti E, Ferrari M, Bruzzone P, Sibilla S, et al. Real-time urinary electrolyte monitoring after furosemide administration in surgical ICU patients with normal renal function.
Ann Intensive Care
. 2016 Dec; 6(1): 72.
15.
Swärd K, Valsson F, Sellgren J, Ricksten SE. Differential effects of human atrial natriuretic peptide and furosemide on glomerular filtration rate and renal oxygen consumption in humans.
Intensive Care Med
. 2005 Jan; 31(1): 79–85.
16.
Matsuo S, Imai E, Horio M, Yasuda Y, Tomita K, Nitta K, et al.; Collaborators developing the Japanese equation for estimated GFR. Revised equations for estimated GFR from serum creatinine in Japan.
Am J Kidney Dis
. 2009 Jun; 53(6): 982–92.
17.
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group: KDIGO Clinical Practice Guideline for Acute Kidney Injury.
Kidney Int
. 2012;Suppl: 1–138.
18.
Figge J, Mydosh T, Fencl V. Serum proteins and acid-base equilibria: a follow-up.
J Lab Clin Med
. 1992 Nov; 120(5): 713–9.
19.
Balasubramanyan N, Havens PL, Hoffman GM. Unmeasured anions identified by the Fencl-Stewart method predict mortality better than base excess, anion gap, and lactate in patients in the pediatric intensive care unit.
Crit Care Med
. 1999 Aug; 27(8): 1577–81.
20.
Kheterpal S, Tremper KK, Englesbe MJ, O’Reilly M, Shanks AM, Fetterman DM, et al. Predictors of postoperative acute renal failure after noncardiac surgery in patients with previously normal renal function.
Anesthesiology
. 2007 Dec; 107(6): 892–902.
21.
Kheterpal S, Tremper KK, Heung M, Rosenberg AL, Englesbe M, Shanks AM, et al. Development and validation of an acute kidney injury risk index for patients undergoing general surgery: results from a national data set.
Anesthesiology
. 2009 Mar; 110(3): 505–15.
22.
Zarychanski R, Abou-Setta AM, Turgeon AF, Houston BL, McIntyre L, Marshall JC, et al. Association of hydroxyethyl starch administration with mortality and acute kidney injury in critically ill patients requiring volume resuscitation: a systematic review and meta-analysis.
JAMA
. 2013 Feb; 309(7): 678–88.
23.
Opperer M, Poeran J, Rasul R, Mazumdar M, Memtsoudis SG. Use of perioperative hydroxyethyl starch 6% and albumin 5% in elective joint arthroplasty and association with adverse outcomes: a retrospective population based analysis.
BMJ
. 2015 Mar; 350:h1567.
24.
Bell PD, Lapointe JY, Cardinal J: Direct measurement of basolateral membrane potentials from cells of the macula densa. Am J Physiol. 1989; 257:F463–8.
25.
Ren Y, Garvin JL, Liu R, Carretero OA. Role of macula densa adenosine triphosphate (ATP) in tubuloglomerular feedback.
Kidney Int
. 2004 Oct; 66(4): 1479–85.
26.
Bell PD, Komlosi P, Zhang ZR. ATP as a mediator of macula densa cell signalling.
Purinergic Signal
. 2009 Dec; 5(4): 461–71.
27.
Constable PD. Hyperchloremic acidosis: the classic example of strong ion acidosis.
Anesth Analg
. 2003 Apr; 96(4): 919–22.
28.
Story DA, Morimatsu H, Bellomo R. Hyperchloremic acidosis in the critically ill: one of the strong-ion acidoses? [table of contents.].
Anesth Analg
. 2006 Jul; 103(1): 144–8.
29.
Story DA. Stewart Acid-Base: A Simplified Bedside Approach.
Anesth Analg
. 2016 Aug; 123(2): 511–5.
30.
Mallat J, Barrailler S, Lemyze M, Pepy F, Gasan G, Tronchon L, et al. Use of sodium-chloride difference and corrected anion gap as surrogates of Stewart variables in critically ill patients.
PLoS One
. 2013; 8(2):e56635.
31.
Story DA. Hyperchloraemic acidosis: another misnomer?
Crit Care Resusc
. 2004 Sep; 6(3): 188–92.
32.
Moviat M, van den Boogaard M, Intven F, van der Voort P, van der Hoeven H, Pickkers P. Stewart analysis of apparently normal acid-base state in the critically ill.
J Crit Care
. 2013 Dec; 28(6): 1048–54.
33.
Johnston PA, Kau ST. The effect of loop of Henle diuretics on the tubuloglomerular feedback mechanism.
Methods Find Exp Clin Pharmacol
. 1992 Sep; 14(7): 523–9.
34.
Wang X, Breaks J, Loutzenhiser K, Loutzenhiser R. Effects of inhibition of the Na+/K+/2Cl- cotransporter on myogenic and angiotensin II responses of the rat afferent arteriole.
Am J Physiol Renal Physiol
. 2007 Mar; 292(3):F999–1006.
35.
Mcilroy D, Sladen R. Renal Physiology, Pathophysiology, and Pharmacology. In: Miller R, editor.
Miller’s Anesthesia, 2-Volume Set
. Volume 1. 8th ed. Philadelphia (PA): Elsevier; 2015. pp. 556–8.
36.
Macedo E, Malhotra R, Bouchard J, Wynn SK, Mehta RL. Oliguria is an early predictor of higher mortality in critically ill patients.
Kidney Int
. 2011 Oct; 80(7): 760–7.
37.
Mizota T, Minamisawa S, Imanaka Y, Fukuda K. Oliguria without serum creatinine increase after living donor liver transplantation is associated with adverse post-operative outcomes.
Acta Anaesthesiol Scand
. 2016 Aug; 60(7): 874–81.
38.
Mizota T, Yamamoto Y, Hamada M, Matsukawa S, Shimizu S, Kai S. Intraoperative oliguria predicts acute kidney injury after major abdominal surgery.
Br J Anaesth
. 2017 Dec; 119(6): 1127–34.
39.
Shiba A, Uchino S, Fujii T, Takinami M, Uezono S. Association Between Intraoperative Oliguria and Acute Kidney Injury After Major Noncardiac Surgery.
Anesth Analg
. 2018 Nov; 127(5): 1229–35.
40.
Zacharias M, Mugawar M, Herbison GP, Walker RJ, Hovhannisyan K, Sivalingam P, et al. Interventions for protecting renal function in the perioperative period.
Cochrane Database Syst Rev
. 2013 Sep;(9):CD003590.
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