Hypochloremia

What is Hypochloremia?

Hypochloremia is an imbalance in electrolyte, where there is abnormal chlorine ion depletion in the blood. Normal value ranges from 97-107 mEq/L. However, in hypochloremia, the chloride levels become less than 98mEq/L. It is often associated with hypokalemia, hyponatremia and metabolic acidosis.

Chloride Facts

• Chloride is the major anion seen in both, the blood and the extracellular fluid.
• According to The Vitamins and Nutrition Center, chloride, potassium and calcium are among the most important serum electrolytes.
• Anion is nothing, but the negatively charged portion of some substances like sodium chloride (NaCl) or table salt, on getting dissolved in liquid.
• Maximum of chloride ions we get by the food we eat. The normal values increase as we consume more of canned foods rich in salt.
• Helps in keeping the acid-base balance in the body.
• Sea water and human fluids has the same concentration of chloride ions.
• Chloride ion balance is regulated and maintained by the body. Any significant decrease or increase may have harmful or fatal consequences.
• During digestion, the intestines absorb the chloride.
• Excess chloride after the digestion process, gets excreted in the urine.
• Kidneys control the chloride levels in the blood.
• Abnormal elevation of chloride may be found in diarrhea, hyperparathyroidism and kidney diseases.
• Chloride joins with hydrogen for forming HCl (hydrochloric acid).

Hypochloremia Pathophysiology

Due to volume depletions, the chloride level decreases. Hence, the kidneys retain the bi-carbonate and sodium ions for balancing the incurred loss. As a result, bicarbonate accumulates in the ECF, thereby raising the pH level leading to hypochloremic metabolic alkalosis.

Hypochloremia Physiological alterations

1. ECF volume contraction
2. Intracellular acidosis
3. Potassium depletion
4. Increased bicarbonate production
5. Decreased serum osmolarity

Hypochloremia Causes

Metabolic Alkalosis

• Diarrhea
• Vomiting
• Respiratory losses
• Gastric suction (NG Suction)

Hyponatremia

• Adrenal Insufficiency (Addison’s Disease)
• Renal Failure
• Edematous states – Congestive Heart Failure
• Pseudohyponatremia
• Salt-losing nephritis
• Excessive IV fluids during hospitalization
• Excessive sweating
• Burns

Other Causes

Dietary changes (low sodium diet)

Medications:

• Loop and Thiazide Diuretics
• Aldosterone
• ACTH
• Corticosteroids
• Bicarbonates
• Laxatives

Genetic diseases

• Cystic fibrosis
• Bartter’s syndrome (is a group of several disorders due to impaired salt reabsorption in the thick ascending Henle’s loop)

Hypochloremia Symptoms

• Excess fluid loss or dehydration (diarrhea, vomiting)
• Low serum chloride levels
• Muscle hypertonicity (Spasticity)
• Tetany
• Shallow, depressed breathing
• Hyponatremia
• Muscle weakness
• Muscle twitching
• Sweating
• High fever

Hypochloremia Diagnosis

• Serum chloride levels < 98 mEq/L confirm the diagnosis.
• Serum pH is above 7.45
• Serum carbon dioxide levels > 32 mEq/L.
• Serum osmolarity < 280mOsm/L (normal = 280–295 mOsm/L ) – This reflects the decrease in particle’s concentration in ECF.
• Arterial blood gas analysis for identifying any acid base imbalance.
• Sometimes, a chloride test can be done on a sample of the total urine collected over a 24-hour period (24-hour urine sample). This finds out how much chloride is excreted in the urine.

Things to do when diagnosed with Hypochloremia

1. Inform your doctor
2. Do not take aspirin or aspirin containing products unless permitted
3. Inform your doctor if you have a history of diabetes, kidney, heart or liver diseases
4. Keep yourself hydrated by drinking 8 glasses of fluid every 24 hours.
5. Avoid alcohol and caffeine intake

Hypochloremia Treatment

Just like other electrolyte imbalances, the treatment of high blood chloride levels or hypochloremia is to correct the underlying cause. It includes the following causes:-

For dehydration:

• Establish and maintain adequate hydration

For particular drug treatment:

• Alter or discontinue the medications (especially loop and thiazides)

For kidney disease:

• Refer to a nephrologist

For hormone or endocrine causes:

• Refer to an endocrinologist

Treatment

Electrolyte replacement therapy

• IV administration of normal (0.9 sodium chloride) or half strength saline (0.45 sodium chloride).
• Ammonium chloride (an acidifying agent) – This is for treating the metabolic alkalosis. Dosage depends up on the serum chloride level and weight of the patient. This is contraindicated in cases of impaired renal or liver functions.
• Oral or intravenous KCl (10-40mEq PO). IV should not exceed 20 mEq/hr

Dietary modifications

• Consume sodium and potassium rich diet, as hypochloremia causes deficiency of these nutrients.

When to call your doctor?

• Extreme nausea that interferes with eating and not relieved by medicines
• Vomiting more than 4 to 5 times in a day
• Diarrhea – 4 to 6 episodes in a day, and not relieved by diet modification or anti-diarrhea drugs
• Severe constipation for 2 to 3 days, and not relieved by laxatives
• Irritability and muscle twitching
• Poor appetite and increased urination
• Excessive drowsiness or confusion

Hypochloremia Prevention

1. The chloride present in the diet we consume is the most common source of mineral, and can help to keep the blood level of chloride within normal limits.
2. According to the National Institute of Health, adults should consume 2 to 2.3 g of chloride/day. This necessity decreases as the age advances, and increases during pregnancy and lactation.
3. Some foods such as include tomatoes and tomato juice, olives, celery, lettuce, etc. are high in chloride. So, this should be consumed during depleted chloride ion levels.

References

Brunner and Suddarth’s textbook of medical-surgical nursing

http://en.wikipedia.org/wiki/Hypochloremia

http://www.chemocare.com/managing/hypochloremia-low-chloride.asp

http://www.fpnotebook.com/renal/Chloride/Hypchlrm.htm

http://www.unboundmedicine.com/nursingcentral/ub/view/Diseases-and-Disorders/73623/all/Hypochloremia