MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

JULIENNE PUCAN BSN III-D

HYPERCHLOREMIA
I. DEFINITION
 Hyperchloremia is a common electrolyte disorder that is associated with a
diverse group of clinical conditions. The kidney plays an important role in the
regulation of chloride concentration through a variety of transporters that
are present along the nephron. Nevertheless, hyperchloremia can occur
when water losses exceed sodium and chloride losses, when the capacity to
handle excessive chloride is overwhelmed, or when the serum bicarbonate is
low with a concomitant rise in chloride as occurs with a normal anion gap
metabolic acidosis or respiratory alkalosis. (Nagami, 2016)
 Hyperchloremia exists when the serum level exceeds 106 mEq/L (106
mmol/L). Hypernatremia, bicarbonate loss, and metabolic acidosis can occur
with high chloride levels. Hyperchloremic metabolic acidosis is also known as
normal anion gap acidosis. It is usually caused by the loss of bicarbonate ions
via the kidney or the GI tract with a corresponding increase in chloride ions.
Chloride ions in the form of acidifying salts accumulate and acidosis occurs
with a decrease in bicarbonate ions. (Smeltzer, 2019)
II. CAUSE/ RISK FACTORS
 According to Glenn Nagami (2016)
 Water loss. Hyperchloremia can result from a number of mechanisms. Water
loss in excess of chloride loss can raise the chloride concentration. In
dehydration, the renal response is to conserve water and lower urine output.
As there may also be a component of volume depletion with more severe
degrees of dehydration, conservation of chloride as well as sodium occurs via
increased proximal tubule reabsorption of chloride and other solutes, and
reduced delivery of chloride and sodium to more distal nephron segments.
The enhanced proximal tubular reabsorption of tubular fluid and its contents
will not necessarily change the chloride concentration as the absorption of
fluid occurs isotonically. The treatment of water deprivation is the judicious
administration of electrolyte-free water which will reduce both the sodium
and chloride concentrations.
 Excess chloride exposure. Hyperchloremia can occur when the body is
exposed to fluids that are high in chloride. An extreme example of this is salt
water drowning/ingestion. The sudden large input of seawater (average
salinity is 3.5%) overwhelms the ability of the kidney to excrete the sodium
chloride load and hypernatremia and hyperchloremia are common.23
Nevertheless, a component of the hypernatremia and hyperchloremia
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College of Health Sciences
associated with excessive saltwater ingestion comes from fluid losses
associated with diarrhea and urinary losses.
 Metabolic acidosis. Hyperchloremia also occurs when hydrochloric acid (HCl)
is added to the blood. HCl is rarely given as a direct acidifying agent but can
be created from the metabolism of ammonium chloride or cationic amino
acids such as lysine and arginine.31 The generation of HCl leads to reaction of
H+ with HCO3 − that results in CO2 production and a net loss of HCO3 − and
rise in chloride concentration.
 According to SelfHacked. (2021)
 Dehydration increases the concentration of chloride in the body by
decreasing the amount of water. In these conditions, the kidneys
reduce urine production to preserve more water. Can be caused by:
- Insufficient water intake
- Vomiting
- Diarrhea
- High fever
- Heat exposure
- Intense exercise
- Alcohol abuse
- Some medications (e.g., diuretics)
- Production of large amounts of diluted urine (diabetes insipidus)
- Increased urine production as a result of high salt intake
 Excessive salt intake (salty food, infusion of 0.9% salt solution during
patient resuscitation, or unintentionally swallowing salty water)
exceeds the capacity of the kidneys to excrete sodium and chloride,
and increases water loss from urination and diarrhea. This leads to a
buildup of both electrolytes
 Metabolic acidosis (low blood pH) occurs when the body produces
excessive acids or insufficient bicarbonate. This loss of
bicarbonate increases the concentration of chloride to maintain
negative charges in the blood. Alternatively, some forms of diarrhea
cause the excretion of bicarbonate, which increases chloride
retention. Chloride buildup linked to metabolic acidosis also occurs in
a condition in which the kidneys fail to absorb bicarbonate (proximal
kidney tubular acidosis) or in patients suffering from chronic kidney
failure. Blockers of the enzyme that transforms carbon dioxide into
bicarbonate (carbonic anhydrase II) also promote chloride buildup.
Excessive exposure to certain organic acids (e.g., toluene) can also
cause high chloride.
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 Electrolyte Imbalances. Positive and negative charges in the blood
must be balanced to remain electrically neutral. Conditions promoting
the increased buildup of positive electrolytes such as sodium and
potassium in the blood will lead to the excessive accumulation of
chloride
 Genetic Disorders
Gordon’s Syndrome. Pseudohypoaldosteronism type II (PHAII), also
known as Gordon’s syndrome, is a rare hereditary disease
characterized by high blood chloride levels. In the kidneys, the
proteins WNK1 and WNK4 activate the electrolyte transporters
Na+/Cl- cotransporter (NCC) and Na+/K+/2Cl- cotransporters 1 and 2
(NKCC1 and NKCC2), thus causing the increased intake of sodium,
chloride, and potassium. Additionally, the proteins KLHL3 and CUL3
form a complex that binds to WNK4 and breaks it down, thus
decreasing the absorption of these electrolytes. Mutations in all these
proteins can cause Gordon’s syndrome
III. PATHOPHYSIOLOGY
 Hyperchloremia can occur when water losses exceed sodium and chloride
losses, when the capacity to handle excessive chloride is overwhelmed, or
when the serum bicarbonate is low with a concomitant rise in chloride as
occurs with a normal anion gap metabolic acidosis or respiratory alkalosis.
The varied nature of the underlying causes of the hyperchloremia will, to a
large extent, determine how to treat this electrolyte disturbance. (Nagami,
2016)
 HYPERCHLOREMIA FROM WATER LOSS: Hyperchloremia can result from a
number of mechanisms. Water loss in excess of chloride loss can raise the
chloride concentration. In dehydration, the renal response is to conserve
water and lower urine output. As there may also be a component of volume
depletion with more severe degrees of dehydration, conservation of chloride
as well as sodium occurs via increased proximal tubule reabsorption of
chloride and other solutes, and reduced delivery of chloride and sodium to
more distal nephron segments. The enhanced proximal tubular reabsorption
of tubular fluid and its contents will not necessarily change the chloride
concentration as the absorption of fluid occurs isotonically. The treatment of
water deprivation is the judicious administration of electrolyte-free water
which will reduce both the sodium and chloride concentrations (Nagami,
2016).
 HYPERCHLOREMIA DUE TO EXCESS CHLORIDE EXPOSURE: Hyperchloremia
can occur when the body is exposed to fluids that are high in chloride. An
extreme example of this is salt water drowning/ingestion. The sudden large
input of seawater (average salinity is 3.5%) overwhelms the ability of the
 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences
kidney to excrete the sodium chloride load and hypernatremia and
hyperchloremia are common. A less extreme example of hyperchloremia
with an excessive sodium chloride load is the administration of large volumes
of isotonic (0.9%) sodium chloride solution (normal saline) frequently used
for volume resuscitation of patients. It is noteworthy that when a normal
individual is given a large bolus of isotonic saline, it may take up to 2 days to
return to the pre-treatment state of sodium and chloride balance. This
retention of chloride occurs with exposure to the supraphysiologic levels of
chloride in normal saline. The normal chloride concentration in the plasma is
in the 95– 110meq/L range, while normal saline has a chloride concentration
of 154meq/L (Nagami, 2016).
 HYPERCHLOREMIA WITH METABOLIC ACIDOSIS: Metabolic acidosis (low
blood pH) occurs when the body produces excessive acids or insufficient
bicarbonate. This loss of bicarbonate increases the concentration of chloride
to maintain negative charges in the blood. Alternatively, some forms of
diarrhea cause the excretion of bicarbonate, which increases chloride
retention. Chloride buildup linked to metabolic acidosis also occurs in a
condition in which the kidneys fail to absorb bicarbonate (proximal kidney
tubular acidosis) or in patients suffering from chronic kidney failure. Blockers
of the enzyme that transforms carbon dioxide into bicarbonate (carbonic
anhydrase II) also promote chloride buildup (Tello, 2021).
IV. CLINICAL MANIFESTATIONS
 The signs and symptoms of hyperchloremia are the same as those of
metabolic acidosis, hypervolemia, and hypernatremia. Tachy-pnea;
weakness; lethargy; deep, rapid respirations; diminished cognitive ability;
and hypertension occur. If untreated, hyper-chloremia can lead to a decrease
in cardiac output, dysrhythmias, and coma. A high chloride level is
accompanied by a high sodium level and fluid retention. (Smeltzer, 2019)

 According to SelfHacked (2021), high chloride levels (>106-110 mEq/L) are

known as hyperchloremia. Long-term or severe hyperchloremia can have the
following symptoms from dehydration and metabolic acidosis (low blood pH)

 Diarrhea  Irregular heart

 Vomiting rate
 Headache  Confusion
 Apathy  Numbness or
 Thirst tingling
 Muscle cramps  Seizures
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 Breathing  Fever
problems  Sweating

V. COMPLICATIONS
 According SelfHacked. (2021)
 Kidney Function. Several studies found a link between high blood
chloride levels and increased incidence of kidney injury
 Death rate found to have a relationship between high blood chloride
levels and increased death rate of critically ill patients
 Blood circulation
 Immune system
 In-Hospital Complications. Infusion with high-chloride fluids was
associated with the requirement for longer mechanical ventilation
times. Infusion with 0.9% salt caused increased readmission rates
when compared to a balanced solution in people with systemic
inflammatory syndrome. High blood chloride levels caused by infusion
with 0.9% salt increased the length of hospital stay in people with
systemic inflammatory syndrome and undergoing surgery
VI. DIAGNOSTIC PROCEDURES
 According to Cafasso (2018)
Hyperchloremia is typically diagnosed by a test known as a chloride blood
test. A metabolic panel measures the levels of several electrolytes in your
blood, including:

 carbon dioxide or  potassium

bicarbonate  sodium
 chloride
Normal levels of chloride for adults are in the 98–107 mEq/L range. If your test
shows a chloride level higher than 107 mEq/L, you have hyperchloremia.
 Chloride Test
 This test detects abnormal blood chloride levels for your doctor to
diagnose certain health conditions. These conditions include alkalosis,
which happens when your blood is either too alkaline or basic, and
acidosis, which happens when your blood is too acidic (Moore, 2018).
 If your test shows a chloride level higher than 107 mEq/L, indicating
hyperchloremia, in this case, your doctor may also test your urine for
chloride and blood sugar levels to see if you have diabetes. A basic
urinalysis can help detect problems with your kidneys (Cafasso, 2018).
VII. MANAGEMENT
 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences
a. Medical Management
 Correcting the underlying cause of hyperchloremia and restoring electrolyte,
fluid, and acid–base balance are essential. Lactated Ringer’s solution may be
prescribed to convert lactate to bicarbonate in the liver, which will increase
the base bicarbonate level and correct the acidosis. Sodium bicarbonate may
be given IV to increase bicarbonate levels, which leads to the renal excretion
of chloride ions as bicarbonate and chloride compete for combination with
sodium. Diuretics may be administered to eliminate chloride as well

 According to Cafasso (2018)

The exact treatment for hyperchloremia will depend on its cause:

 For dehydration, treatment will include hydration.
 If received too much saline, the supply of saline will be stopped until you
recover.
 If medications are causing the issue, your doctor might modify or stop the
medication.
 For a kidney problem, likely be referred to a nephrologist, a doctor
specializing in kidney health. You may need dialysis to filter your blood in
place of your kidneys if your condition is severe.
 Hyperchloremic metabolic acidosis may be treated with a base called
sodium bicarbonate.
If having hyperchloremia, keep well hydrated. Avoid caffeine and alcohol as
these can make dehydration worse.
b. Nursing Management
 Monitoring vital signs, arterial blood gas values, and intake and output is
important to assess the patient’s status and the effectiveness of
treatment.
 Teach the patient about the diet that should be followed to manage
hyperchloremia.
VIII. PREVENTION
 According to Cafasso (2018)
Hyperchloremia can be hard to prevent, particularly when it is caused by a
medical condition such as Addison’s disease. For people who are at risk of
developing hyperchloremia, some strategies that may help include:
 Talking to a doctor about medications that can cause hyperchloremia.
 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences
 Discussing options for reducing the effects of drugs that can cause
hyperchloremia. For example, a person may need to drink more
water or receive IV fluids when they feel dehydrated.
 Eating a balanced diet, and avoiding extreme food restrictions.
 Taking diabetes medications exactly as a doctor prescribes.

IX. PROGNOSIS

 According to Cafasso (2018), The outlook depends on what caused the

hyperchloremia and how quickly it’s treated. People who don’t have kidney
problems should be able to recover easily from hyperchloremia caused by
receiving too much saline.
For people with hyperchloremia that stems from another illness, the outlook
is typically related to that of their particular illness.

References

Cafasso, J. (2018, September 18). Hyperchloremia (High Chloride Levels). Healthline. Retrived

from https://www.healthline.com/health/hyperchloremia#diagnosis

SelfHacked. (2021, January 13). High Chloride Levels (Hyperchloremia) Symptoms & Causes.

SelfDecode Labs. Retrieved from https://labs.selfdecode.com/blog/high-chloride-levels-

hyperchloremia/

HYPOCHLOREMIA

I. DEFINITION
 According to Healthline (2018), hypochloremia is an electrolyte imbalance
that occurs when there’s a low amount of chloride in the body.
II. CAUSE/ RISK FACTORS
 According to Healthline (2018), since the levels of electrolytes in the blood
are regulated by the kidneys, an electrolyte imbalance such as
hypochloremia may be caused by a problem with the kidneys.
Hypochloremia can also be caused by any of the following conditions:
 congestive heart failure
 prolonged diarrhea or vomiting
 MARIANO MARCOS STATE UNIVERSITY
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 chronic lung disease, such as emphysema
 metabolic alkalosis, when your blood pH is higher than normal
Certain types of drugs, such as laxatives, diuretics, corticosteroids, and
bicarbonates, can also cause hypochloremia.
Hypochloremia and Chemotherapy
 Hypochloremia, along with other electrolyte imbalances, can be caused by
chemotherapy treatment. The side effects of chemotherapy can include:
 prolonged vomiting or diarrhea
 sweating
 fever
These side effects can contribute to a loss of fluids. Fluid loss through
vomiting and diarrhea can lead to an electrolyte imbalance.
III. INCIDENCE
 Similarly, low blood levels of chloride, sodium, and albumins due to
malnutrition reduced the survival of HIV patients taking antiretroviral
therapy in a study on over 600 African women
 Drug-related hypochloremic alkalosis is observed at all ages. Males and
females are affected in equal numbers
 According to Medscape (2018), The frequency of hypochloremic alkalosis is
unknown, both in the United States and worldwide. However, there is some
reason to think that this condition may be more common worldwide than
was previously accepted. Many cases of CLD have emerged from Eastern
Europe and Middle Eastern Arab countries; indeed, the largest purported
series is from Saudi Arabia.
IV. PATHOPHYSIOLOGY
 Hypochloremia occurs when there's a low level of chloride in your body. It
can be caused by fluid loss through nausea or vomiting or by existing
conditions, diseases, or medications.
V. CLINICAL MANIFESTATIONS
 According to Healthline (2018), symptoms of hypochloremia are difficult to
notice. Instead, symptoms of other electrolyte imbalances are present or
from a condition that’s causing hypochloremia. Symptoms include:

 fluid loss  difficulty

 dehydration breathing
 weakness or  diarrhea or
fatigue vomiting, caused
by fluid loss
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VI. DIAGNOSTIC PROCEDURES

 According to the Medindia (2017), the diagnosis of hypochloremia is
made on the basis of the patient's history of the disease or medication
causing the imbalance, along with the lab assessment of chloride values.
 A chloride blood test is carried out to detect abnormal concentrations of
chloride. As hypochloremia co-exists with other electrolyte imbalances
such as hyponatremia, hypokalemia (low potassium), blood tests for
other electrolytes are also performed to screen for a variety of
conditions. When serum chloride is less than 95 mEq/L, the patient is
considered to have hypochloremia
 If an electrolyte imbalance is detected during the tests, the physician may
recommend electrolyte testing at regular intervals to monitor the
effectiveness of treatment, until the results are within the normal range.
 If an acid-base imbalance is suspected, they may consider conducting
tests for blood gases to further evaluate the severity and cause of the
imbalance.
 Occasionally, a urinary chloride test is performed to assess the cause of
loss of salts, such as in cases of excessive vomiting, dehydration, or use of
diuretics where urinary chloride would be very low
 Excess of certain hormones such as aldosterone or cortisol can also affect
electrolyte levels.
VII. MANAGEMENT
a. Medical Management
 If the doctor detects an electrolyte imbalance such as hypochloremia,
they’ll investigate whether a condition, disease, or medication the patient
is taking is causing the imbalance to occur. The doctor will work with the
patient to treat the underlying problem that’s causing the electrolyte
imbalance.
 If the hypochloremia is due to a medication or drug that the patient is
taking, then the doctor may adjust the dosage, if possible. If the
hypochloremia is due to problems with the kidneys or an endocrine
disorder, the doctor may refer the patient to a specialist.
 The patient may receive intravenous (IV) fluids, such as normal saline
solution, to restore electrolytes to normal levels.
 The doctor may also request that the patient’s electrolyte levels be tested
regularly for monitoring purposes.
 If the hypochloremia is mild, then it can sometimes be corrected by an
adjustment to your diet. This could be as simple as consuming more
sodium chloride (salt).
b. Nursing Management
 Maintain fluid volume at a functional level to exhibits normal
laboratory values
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 Emphasize demonstration of appropriate changes in lifestyle and
behaviors including eating patterns and food quantity/quality
 Re-establishing and maintaining normal pattern and GI functioning
VIII. PREVENTION
 According to Healthline (2018), these are the following measures to avoid
hypochloremia:
 Make sure that the doctor is aware of the patient's medical history
— especially if he or she has kidney disease, heart disease, liver
disease, or diabetes.
 Make sure that the doctor is aware of all medications that the
patient is taking.
 Stay hydrated.
 Try to avoid both caffeine and alcohol. Both can contribute to
dehydration.