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Emergence of Chloride as an Overlooked Cardiorenal Connector in Heart Failure

Is it the Sodium or the Chloride of NaCl that is the important factor in heart failure?
Good question!
Tat

Several studies have recently challenged the sodium-centric view that has been dominating the field of heart failure (HF) and cardiorenal syndrome. The previously observed benefits of severe dietary restriction of salt do not seem to be consistently reproduced by contemporary studies. Moreover, there is evidence that too low intake may paradoxically lead to adverse outcomes in more advanced stages of HF. Facing the escalating controversy, investigators have shifted their focus from sodium to its often overlooked counter ion in salt, the chloride. Emerging data suggest that serum chloride levels could portend robust independent prognostic value in a wide range of HF syndromes possibly stronger than that of sodium. The untoward impact of hypochloremia on the outcomes could be mechanistically linked to renal tubular regulatory pathways, neurohormonal activation, and diuretic resistance. As such, it can be a potential target of therapy in this setting. In this article, the authors provide a brief overview of the role of serum chloride as a cardiorenal connector and explore the context in which the contemporary data should be interpreted. Implementation of predictive and therapeutic strategies incorporating the emerging evidence would be refined through discussion of nuances of such findings as well as their biological and clinical relevance.

The Role of Serum Chloride in Acute and Chronic Heart Failure: A Narrative Review

Clinical guidelines include diuretics for the treatment of heart failure (HF), not to decrease mortality but to decrease symptoms and hospitalizations. More attention has been paid to the worse outcomes, including mortality, associated with continual diuretic therapy due to hypochloremia. Studies have revealed a pivotal role for serum chloride in the pathophysiology of HF and is now a target of treatment to decrease mortality. The prognostic value of serum chloride in HF has been the subject of much attention. Mechanistically, the macula densa, a region in the renal juxtaglomerular apparatus, relies on chloride levels to sense salt and volume status.

But what about potassium chloride...?

Since sodium reduction is still at the top of most lists, potassium chloride has become a popular salt substitute. I've never tried it because I don't give a rat's ass about most nutritional studies which change from day to day.

It's not that nutritional studies change, it's that with more experiments our understanding of how things work and interact gets better refined. Science is like that.

Morton Salt Substitute, Sodium Free, 3.12 Ounce potassium

Potassium Chloride is available at the grocery or Amazon. It is useful for those on Sodium restriction, but I use it for potassium replacement. Most folks who take thiazide diuretics lose potassium over time as thiazide spill some potassium along with the increased and desirable sodium excretion. Hypokalemia, low serum potassium, causes muscle weakness and is just treated (if still walking) by increasing oral potassium supplementation.
That is why I take it, but just stir a portion into water and drink it.
I used to have a bottle of reagent KCL that I still use for standards.
Kenya required prescriptions for all medications, and I didnt have one for KCL, so I dropped by the grocery and picked up this prep that is essentially KCL with a touch of fumaric acid for taste, and some sand for anti caking. The exact composition is available on line.
If you have reasonable renal function it is almost impossible to overdose on oral potassium as it's rapidly cleared by the kidneys. Renal failure patients have to be on low potassium diets for that reason as HYPERKalemia can stop the heart, sometimes undesirable.
Diabetics with slowly decreasing renal function have to be careful, as they are always taking some angiotensin converting enzyme ACE blockade (that spare potassium) to help retain renal function much longer, but with progression of renal disease, they can suddenly stop secreting potassium and get HYPERKalemia.

It tastes salty and not really unpleasant. I dont use it with food, I just chug it as needed.

In Jeff's Daryl's case it could be dangerous to use extra potassium, as many patients on intense diuretics go into episodes of renal insufficiency as the diuretic decrease blood pressure and cardiac output. This decreases blood flow to the kidneys and causes usually reversible renal insufficiency.

TAT

I would be really careful with KCl supplements and salt substitution. Back when I worked in medical research we used IV KCl as our euthanasia solution for years, because the better alternative is controlled (pentobarbitol). The stuff vets use now is much nicer. It really ODs the animals so they lose consciousness and stop breathing. IV KCl induces heart failure and did not look pleasant at all.

My son Daryl just got home yesterday after three weeks at UCLA Medical Ctr's Cardiac ICU/CCU.
He had ballooned to 384 pounds, and the ER team wasn't sure he would make it.
Now, three weeks later he has emerged weighing 270, 114 pounds of water weight gone.

Four months ago, just as edema trouble was starting


Last act of office at UCLA Medical, a quick shave. He's literally almost half the size he was going in.
129 pounds of water weight....GONE...in 25 days.

Wow, amazing he survived that. How are his kidneys doing? They got quite a workout.

That's the other tough part...like his Mom, he only has ONE kidney, but also like his Mom, it is also double the normal size and unlike hers, it works well and he isn't making stones like she does.

I'm convinced that the one kidney thing is common in the entire Mitchell family, only we're the only ones who actually know.
But I bet both her sisters and her brother only have the one kidney too. They've just never gotten checked out to know for sure.
If it was ME, and MY sister AND her son both had ONE kidney, I'd be getting myself checked immediately.
I would WANT to know if I have two, or just the one.

She didn't find out until MANY years after her military service!

"Ms. Trotter, can you tell us when you lost your kidney?"
"Excuse me?"
"We can't find your other kidney, did you have it removed?"
"What on earth are you talking about?"
"You don't have the other kidney, when did it come out?"
"Look, I did not sell it on the black market, and I didn't get abducted by aliens, so please FIND the damn thing."
"We're sorry but you only have the one kidney."