Acute Kidney Injury: SALT-ED (Saline against Lactated Ringer’s or Plasma-Lyte in the Emergency Department)

Question 1

SALT-ED Clinical Q

Answer 1

Among noncritically ill adult patients in the ED, does fluid management with balanced crystalloid result in earlier hospital discharge compared to isotonic crystalloids?

Question 2

SALT-ED Bottom Line

Answer 2

Among non-critically ill ED patients, initial fluid resuscitation with balanced crystalloids (Lactated Ringer’s or Plasma-Lyte) does not reduce duration of hospitalization when compared to the isotonic crystalloid, normal saline. However, balanced crystalloid use is associated with a reduction in major kidney-related events.

Question 3

SALT-ED Primary Outcome

Answer 3

Hospital-free days to day 28 (Composite)

Question 4

SALT-ED inclusion criteria

Answer 4

• Age ≥18 years
• Received ≥500mL isotonic crystalloids in Emergency Department, subsequently hospitalized outside an ICU

Question 5

SALT-ED Exclusion Criteria

Answer 5

• <500mL crystalloid received in emergency department
• Subsequent hospitalization in an ICU
• Relative contraindication to randomized therapy at discretion of treating physician

—Balanced crystalloids: hyperkalemia, brain injury

Question 6

SALT-ED Criticisms

Answer 6

1. Single center, open label study
2. No separate analysis of Lactated Ringer’s vs. Plasma-Lyte Only ~5% use of Plasma-Lyte in the balanced crystalloids arm
3. Composite outcomes inherently not patient-centered as each of the outcomes may not be as equally meaningful to patients Composite endpoints are susceptible to confounding
4. Difference in adverse kidney events is a surrogate outcome, a increase in creatinine and not a clinical patient outcome (death, need for dialysis)
5. EHR data is not of the same level of quality as research data collected by trained observers This doesn’t address use of fluids beyond initial ED resuscitation
6. The AKI definition did not incorporate rate of urine output, which is included in the KDIGO definitions

Question 7

the chloride concentration of normal saline is ____physiologic

Answer 7

supra