The high
chloride content of
0.9% saline leads to adverse pathophysiological effects in both animals and healthy human volunteers, changes not seen after balanced crystalloids. Small randomized trials confirm that the hyperchloremic
acidosis induced by saline also occurs in patients, but no clinical outcome benefit was demonstrable when compared with balanced crystalloids, perhaps due to a type II error. A strong signal is emerging from recent large propensity-matched and cohort studies for the adverse effects that
0.9% saline has on the clinical outcome in surgical and
critically ill patients when compared with balanced crystalloids. Major complications are the increased incidence of
acute kidney injury and the need for
renal replacement therapy, and that pathological hyperchloremia may increase postoperative mortality. However, there are no large-scale randomized trials comparing
0.9% saline with balanced crystalloids. Some balanced crystalloids are hypo-osmolar and may not be suitable for neurosurgical patients because of their propensity to cause
brain edema. Saline may be the
solution of choice used for the
resuscitation of patients with
alkalosis and hypochloremia. Nevertheless, there is evidence to suggest that balanced crystalloids cause less detriment to renal function than
0.9% saline, with perhaps better clinical outcome. Hence, we argue that
chloride-rich crystalloids such as
0.9% saline should be replaced with balanced crystalloids as the mainstay of fluid
resuscitation to prevent 'pre-renal'
acute kidney injury.