When was the last time you were paged about a serum Cl- level? Probably never.
Despite being the most abundant anion in the body, Cl- is under appreciated
Here’s why it matters (esp in heart failure!)
#tweetorial #medtwitter #nephtwitter #cardiotwitter #NSMC
Despite being the most abundant anion in the body, Cl- is under appreciated
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
#tweetorial #medtwitter #nephtwitter #cardiotwitter #NSMC
There is evidence supporting the use of hypertonic saline in patients with decompensated heart failure
See excellent blog post by @aldorodrig
https://www.renalfellow.org/2019/04/03/the-paradox-of-hypertonic-saline-use-in-heart-failure/
Mechanistically it never made sense to me, until I realized I may be focusing on the wrong ion
See excellent blog post by @aldorodrig
![Rückhand Zeigefinger nach rechts 👉](https://abs.twimg.com/emoji/v2/72x72/1f449.png)
Mechanistically it never made sense to me, until I realized I may be focusing on the wrong ion
![Achselzuckender Mann (durchschnittlich dunkler Hautton) 🤷🏾♂️](https://abs.twimg.com/emoji/v2/72x72/1f937-1f3fe-200d-2642-fe0f.png)
Chloride MAY be the
here. Something that will hopefully be more clear after the completion of ongoing trials
https://clinicaltrials.gov/ct2/show/NCT03446651?term=lysine+chloride&draw=2&rank=2
In heart failure patients
Cl- is associated with
1. Poor Prognosis
2. Neurohumoral activation
3. Diuretic Resistance
![Schlüssel 🔑](https://abs.twimg.com/emoji/v2/72x72/1f511.png)
![Rückhand Zeigefinger nach rechts (durchschnittlich dunkler Hautton) 👉🏾](https://abs.twimg.com/emoji/v2/72x72/1f449-1f3fe.png)
In heart failure patients
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
1. Poor Prognosis
2. Neurohumoral activation
3. Diuretic Resistance
Let's establish that
Cl- has prognostic consequences in HF
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
Cl- associated with
mortality
Assoc. is INDEPENDENT of serum Na levels
Unclear whether
Cl- is a therapeutic target or a marker of disease severity, ie
sodium levels by
V2 provides no mortality benefit
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Kreuzzeichen ❌](https://abs.twimg.com/emoji/v2/72x72/274c.png)
![Elektrische Glühbirne 💡](https://abs.twimg.com/emoji/v2/72x72/1f4a1.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
So hypothetically maintaining normochloremia MAY reduce RAAS activation
Low Cl- also plays a role in diuretic resistance
Common problem in HF pts
Loop diuretic resistance is due to DCT hypertrophy
In rat models, loop diuretic infusion
the number of NCC cotransporters
How does this relate to Cl-?
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
Cl- is assoc. with
diuretic efficiency
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
How does this relate to Cl-?
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
What’s the mechanism?
The
may be the WNK kinases, specifically WNK1 and WNK4, which regulate the sodium chloride cotransporter (NCC)
Simplistic view: WNK1 stimulates and WNK4 inhibits NCC activity
Both WNK1 and WNK4 have been shown to be intracellular chloride sensors
The
![Schlüssel 🔑](https://abs.twimg.com/emoji/v2/72x72/1f511.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Maus 🐁](https://abs.twimg.com/emoji/v2/72x72/1f401.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Symbol für eine Kollision 💥](https://abs.twimg.com/emoji/v2/72x72/1f4a5.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
![Pfeil nach unten ⬇️](https://abs.twimg.com/emoji/v2/72x72/2b07.png)
![Pfeil nach oben ⬆️](https://abs.twimg.com/emoji/v2/72x72/2b06.png)
Conclusion:
In heart failure patients Cl- is independently associated with
Poor Prognosis
Neurohumoral Activation
Diuretic Resistance
Yet another reason you should care about chloride
Thanks to @amyaimei for help editing this tweetorial
In heart failure patients Cl- is independently associated with
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
![Feuer 🔥](https://abs.twimg.com/emoji/v2/72x72/1f525.png)
Yet another reason you should care about chloride
Thanks to @amyaimei for help editing this tweetorial