Hyponatremia: evaluating the correction factor for hyperglycemia

Association between metabolic parameters and risks of anemia and electrolyte disturbances among stages 3-5 chronic kidney disease patients in Taiwan

Background

Anemia and electrolyte disturbances are adverse outcomes of chronic kidney disease (CKD). This study explored the association between metabolic parameters with anemia and electrolyte and mineral disorders among CKD patients in Taiwan.

Methods

This cross-sectional study with a total of 2176 CKD stages 3–5 patients were collected from the Department of Nephrology at Shuang Ho Hospital, Taipei Medical University through the “Chronic Kidney Disease Common Care Network” database from December 2008 to April 2019. A multivariable-adjusted logistic regression expressed as odd ratios (OR) was performed to assess the association of metabolic parameters with anemia and electrolyte and mineral disorders.

Results

Elevated diastolic blood pressure, fasting blood glucose, and glycated hemoglobin A1c (HbA1c) were associated with presence of anemia. Similarly, elevated fasting blood glucose and HbA1c were associated with hyponatremia (OR = 1.59 and 1.58, P for both < 0.01) and hypercalcemia (OR = 1.38 and 1.33, P for both < 0.05). There was no significant association in serum lipid levels with presence of anemia. However, total triglycerides, total cholesterol and low-density lipoprotein-cholesterol were only associated with presence of hypercalcemia (OR = 1.43, 1.95 and 3.08, respectively, P for all < 0.05).

Conclusions

Elevated diastolic blood pressure, fasting blood glucose, HbA1c and blood lipids are associated with anemia or electrolyte and mineral disorders in CKD patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-021-02590-w.

Frequency of Electrolyte Imbalance in Patients Presenting With Acute Stroke

Introduction Electrolyte disturbances are commonly reported in acute stroke in studies conducted in the western world. Presently, the data available about the prevalence of electrolyte disturbance in patients with stroke are not sufficient, especially from developing countries. The purpose of our study is to determine the frequency of occurrence of electrolyte imbalance in patients presenting with acute stroke in a tertiary care hospital. Methods This descriptive cross-sectional study was conducted in the department of internal medicine and neurology in a tertiary care hospital, Pakistan, from December 2019 to March 2021. A total of 300 patients, aged between 30 and 70 years, with either ischemic or hemorrhagic stroke, as diagnosed on contrast tomography (CT) scan of the head or magnetic resonance imaging (MRI) of the brain, were enrolled in the study. The biochemical analysis of the stroke patients was done. Results Out of the 300 participants, 139 (46.3%) participants were from the ischemic stroke group while 161 (53.7%) were from the hemorrhagic stroke group. The mean sodium level was significantly lower in the ischemic group as compared to the hemorrhagic group (129.41 ± 3.12 mEq/L vs. 134.42 ± 3.46 mEq/L; p-value: <0.0001). Potassium level was significantly higher in the hemorrhagic group compared to the ischemic group (6.27 ± 1.12 mmol vs. 4.31 ± 0.71 mmol; p-value: <0.0001). Conclusion Patients coming to emergency with stroke should be screened immediately for electrolyte imbalance. Early identification of rapid imbalances of serum electrolytes may aid in prompt medical intervention and resultant improved outcomes in stroke patients. It is crucial that electrolyte imbalances in these patients are closely monitored to avoid any complications.

NONPIGMENTED VERSUS PIGMENTED: HEALTH VARIABLES AND GENETICS OF ALBINO FLORIDA GREEN TURTLE (CHELONIA MYDAS) HATCHLINGS COMPARED WITH NORMALLY PIGMENTED HATCHLINGS FROM THE SAME CLUTCH

At the time of hatchling emergence from a nest laid on Juno Beach, Florida, USA, by a normally pigmented green turtle (Chelonia mydas), 23 albino hatchlings and 75 normally pigmented hatchlings were observed. This condition is rarely seen in sea turtles, and little is known about blood analytes and genetics of albino wildlife to date. Therefore, the objective of our study was to assess and compare morphometric measurements (mass, minimum straight carapace length, body condition index), carapacial scute anomalies, a suite of hematologic and plasma biochemical analytes, and two glucose analysis methodologies (glucometer and dry chemistry analysis) in albino (n=20) versus normally pigmented (n=24) hatchlings from this nest. Genetic analyses were completed to identify paternal contributions of hatchlings and to test Mendelian inheritance assumptions. Although morphometric measurements, scute anomalies, and leukocyte morphology were similar between albino and normally pigmented hatchlings, several differences were observed in blood analyte data: immature erythrocytes, packed cell volume, heterophil:lymphocyte ratio, and glucose concentrations (by both methodologies) were significantly higher, whereas absolute immature heterophils, absolute lymphocytes, number of erythrocyte micronuclei, sodium, and chloride were significantly lower in albino hatchlings compared with normally pigmented hatchlings. Considerations for these differences include a stress response from sampling (e.g., timing of procedures or possibly from photosensitivity or reduced visual acuity in albinos) and different osmoregulation, which may reflect physiologic variations or stress. There was a small positive bias (0.10 mmol/L) with glucose by glucometer, similar to reports in other sea turtle species and confirming its suitability for use in hatchlings. All albino hatchlings analyzed (n=10) were from the same father, but the normally pigmented hatchlings (n=24) were from two other fathers. These findings provide insight into the physiology and genetics of albinism in sea turtles.

[Hypo- and hypernatremia in the intensive care unit : Pitfalls in volume management]

Hypo- and hypernatremias are very frequent in intensive care unit (ICU) patients and are closely related to volume disturbances and volume management in the ICU. They are associated with longer ICU stays and significant increases in mortality. Treating them is more complex than it may initially appear. Hyponatremias are differentiated based on tonicity and volume status. With hypertonic and isotonic hyponatremias, the primary focus of treatment is the underlying hyperglycemia. In case of hypotonic hypovolemic hyponatremia, the condition is treated with balanced crystalloid solutions. In eu-/hypervolemic hypotonic hyponatremias acute treatment with hypertonic saline is necessary. Hypervolemic hypernatremia occurs almost exclusively in ICU patients, often due to infusion of hypertonic solutions. There is little evidence to guide treatment, although hypotonic infusions in conjunction with diuretics may represent a legitimate approach. Great emphasis should be placed on prevention and the infusion of hypertonic solutions should be avoided. Disturbances in plasma sodium concentrations are common, requiring close attention. Exact diagnostic classification needs to be made and volume managed accordingly.

New-Onset Pediatric Diabetes Complicated By Diabetic Ketoacidosis and Invasive Rhinocerebral Mucormycosis With Internal Carotid Artery Occlusion

BACKGROUND

Diabetic ketoacidosis (DKA) has increased in prevalence in the emergency department (ED) in recent years. The complications of DKA are life threatening and necessitate rapid identification and management. Pediatric complications include cerebral edema, venous thrombosis, acute kidney injury, and severe infections including necrotizing fasciitis and mucormycosis. Rhinocerebral mucormycosis carries a high mortality rate and requires early treatment with antifungals and surgical debridement.

CASE REPORT

A 16-year-old boy with no significant past medical history presented to the ED with new-onset DKA complicated by hypothermia, hyperosmolar hyperglycemic state, cerebral edema, and multifactorial shock. During a complicated pediatric intensive care unit admission, he was found to have fatal invasive rhinocerebral mucormycosis, causing internal carotid artery occlusion with evidence of both direct and hematogenous spread into his brain. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Early identification of shock and appropriate management with intravenous fluids, vasopressors, and reversal of the underlying process is key in hypotensive children. In pediatric DKA, the emergency physician must consider cerebral edema, appropriate fluid resuscitation, and identify the likely precipitants leading to the onset of DKA. Thorough workup for potential precipitants should be initiated in the ED, searching for etiologies including infection, intoxication, insulin deficiency, inflammation, and ischemia. We must remember that pediatric patients, especially those with new DKA, are susceptible to life-threatening infection, including mucormycosis. Mucormycosis is a rare diagnosis, and management includes antifungal therapies and involvement of otorhinolaryngology.

Prevalence, risk factors, and complications associated with hyponatraemia following elective primary hip and knee arthroplasty

Background

Hyponatraemia, defined as a serum sodium [Na] concentration below 135 mmol/L, is common following surgery. As inpatient peri-operative stays shorten, there is a need to recognise pre-operative risk factors for post-operative hyponatraemia and complications associated with a peri-operative drop in Na. This audit aimed to investigate the prevalence of, risk factors for, and complications associated with hyponatraemia following elective primary hip and knee arthroplasty.

Methods

Data were collected within a retrospective audit of inpatient complications and unplanned reattendance or readmission at hospital in consecutive elective primary hip and knee arthroplasty patients in a single high throughput elective primary joint unit. The hospital’s electronic database identified 1000 patients who were admitted electively between February 2012 and June 2013 under the care of a single consultant orthopaedic surgeon for either total hip arthroplasty, total knee arthroplasty, or uni-compartmental knee arthroplasty. Groups were compared using appropriate tests, including chi-square analysis (or Fisher’s exact test), Mann-Whitney U test, Kruskal-Wallis test, and Wilcoxin signed-rank test. Logistic regression analysis was used to determine factors associated with hyponatraemia.

Results

Of the total 1000 patients, 217 (21.7%) developed post-operative hyponatraemia. Of these, 177 (81.6%) had mild (Na 130–134 mmol/L), 37 (17.1%) had moderate (Na 125–129 mmol/L), and 3 (1.4%) had severe (Na < 125 mmol/L) hyponatraemia. In multivariate analysis, age, pre-operative Na, and fasting glucose on day 1 remained significantly associated with having hyponatraemia post-operatively. There were no significant differences in reattendance at emergency departments and/or readmission within 90 days between those who had post-operative hyponatraemia whilst in hospital (39/217 = 18.0%) and those who did not (103/783 = 13.2%), or between those who were discharged with hyponatraemia (18/108 = 16.7%) and those discharged with normal Na (124/880 = 14.1%).

Conclusion

Approximately one fifth of elective joint arthroplasty patients had post-operative hyponatraemia. In these patients, older age, lower pre-operative Na and higher fasting glucose predicted post-operative hyponatraemia. We found no evidence that those discharged with hyponatraemia had more reattendance at emergency departments or readmission to hospital. We suggest that otherwise well patients with mild hyponatraemia can safely be discharged and followed up in the community.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13741-021-00197-1.

The impact of the correction of hyponatremia during hospital admission on the prognosis of SARS-CoV-2 infection

INTRODUCTION

SARS-CoV-2 infection is frequently associated with hyponatremia (plasma sodium<135mmol/L), being associated with a worse prognosis. The incidence of hyponatremia is estimated to be 20-37% according to the series, but there are no data on the prognosis after correction of hyponatremia. Therefore, our objectives were: to analyze the incidence and severity of hyponatremia at hospital admission, and to determine the association of this hyponatremia with the prognosis of COVID-19.

MATERIAL AND METHOD

Observational and retrospective cohort study. Patients who were admitted with a diagnosis of COVID-19 infection and hyponatremia, in the period March-May 2020, were included. We recorded epidemiological, demographic, clinical, biochemical, and radiological variables of SARS-CoV-2 infection and hyponatremia at the time of diagnosis and during hospitalization. The clinical follow-up ranged from admission to death or discharge.

RESULTS

91 patients (21.8%) of the 414 admitted for SARS-CoV-2 infection presented hyponatremia (81.32% mild hyponatremia, 9.89% moderate and 8.79% severe). The absence of correction of hyponatremia 72-96h after hospital admission was associated with higher mortality in patients with COVID-19 (Odds Ratio .165; 95% confidence interval: .018-.686; P=.011). 19 patients (20.9%) died. An increase in mortality was observed in patients with severe hyponatremia compared with moderate and mild hyponatremia during hospital admission (37.5% versus 11.1% versus 8.1%, P=.041).

CONCLUSIONS

We conclude that persistence of hyponatremia at 72-96h of hospital admission was associated with higher mortality in patients with SARS-CoV-2.

Increased Mortality in Elderly Patients Admitted with Hyponatremia: A Prospective Cohort Study

Hyponatremia is the most common electrolyte disorder, commonly affecting older hospitalized individuals; however, the literature is not clear regarding its effect on mortality. The aim of this 2-year observational prospective cohort study was to evaluate the mortality and re-admission rates, the clinical and laboratory characteristics and the causes of hyponatremia in patients older than 65 years admitted with a corrected serum sodium of 130 mEq/L or less in an internal medicine ward of a tertiary Greek university hospital. During the observation period, 138 patients (mean age 80.5 years, 36.2% male) fulfilled the inclusion criteria and were prospectively followed for 1 year after admission. Symptoms of hyponatremia were present in 59.4% of patients. Hypovolemia was the main sole cause of hyponatremia, but in about one third of patients, hyponatremia was multifactorial. Only a low proportion of patients (12.3%) fulfilled the criteria of the syndrome of inappropriate antidiuresis (SIAD) at admission according to the current guidelines. The re-admission rates at 3- and 12-months following discharge was 34.2% and 51.8%, respectively. Mortality during hospitalization was 17.4% and was higher compared to non-hyponatremic admitted older patients, while the total mortality at 1 year after admission was 28.3%, indicating that hyponatremia at admission is a marker of significant mortality during and after hospitalization in elderly patients.

Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State

BACKGROUND

Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations.

OBJECTIVE

This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state.

DISCUSSION

Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit.

CONCLUSIONS

Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Aetiological diagnosis of hyponatraemia in non-critical patients on total parenteral nutrition: A prospective multicentre study

BACKGROUND

In patients receiving total parenteral nutrition (TPN), the frequency of hyponatraemia is high. However, the causes of hyponatraemia in TPN have not been elucidated, although diagnosis is required for appropriate therapy. The aim of this study is to describe the aetiology of hyponatraemia in non-critical hospitalised patients receiving TPN.

METHODS

Prospective multicentre study in 19 Spanish hospitals. Non-critically hyponatraemic patients receiving TPN and presenting hyponatraemia over a 9-month period were studied. Data collected included sex, age, previous comorbidities, and serum sodium levels (SNa) before and following TPN initiation. Parameters for study of hyponatraemia were also included: clinical volaemia, the presence of pain, nausea, gastrointestinal losses, diuretic use, oedema, renal function, plasma and urine osmolality, urinary electrolytes, cortisolaemia, and thyroid stimulating hormone.

RESULTS

162 patients were included, 53.7% males, age 66.4 (SD13.8) years. Volume status was evaluated in 142 (88%): 21 (14.8%) were hypovolaemic, 96 (67.6%) euvolaemic and 25 (17.6%) hypervolaemic. In 111/142 patients the analytical assessment of hyponatraemia was completed. Hypovolaemic hyponatraemia was secondary to GI losses in 10/111 (9%), and to diuretics in 3/111 (2.7%). Euvolaemic hyponatraemia was due to Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) in 47/111 (42.4%), and to physiological stimuli of Arginine Vasopressin (AVP) secretion in 28/111 (25.2%). Hypervolaemic hyponatraemia was induced by heart failure in 19/111 (17.1%), cirrhosis of the liver in 4/111 (3.6%).

CONCLUSIONS

SIADH was the most frequent cause of hyponatraemia in patients receiving TPN. The second most frequent cause was physiological stimuli of AVP secretion induced by pain/nausea.

A Case of Central Pontine Myelinolysis Occurred During Treatment of Hyperosmolar Hyperglycemic Syndrome

Central pontine myelinolysis (CPM) is a rare demyelinating condition which has been reported to occur in a variety of clinical settings, but most commonly in association with a rapid rise in plasma osmolality during correction of chronic hyponatremia. The clinical consequences can vary from a mild motor weakness that resolves completely over time to the devastating locked-in syndrome. In this presentation, we report a case of hyperosmolar hyperglycemic syndrome (HHS) with ponto-occipital disintegration. A 71-year-old female was transferred to our ER by an ambulance due to consciousness disorder and continuous fever for 10 days. We diagnosed septic shock caused by urinary tract infection (UTI), cerebral multiple infarctions, acute kidney injury (AKI) and HHS without treatment for diabetes. Then, we started therapeutic interventions for them based on the guideline with severe control for blood sugar (BS; primary 1635 mg/dl) under insulin therapy and hypernatremia (primary 153 mEq/l) under crystal infusion control in advanced care unit, apparently on routine lab data. However, the initial serum sodium value of 153 mEq/l was slowly compensated to 148 mEq/l in 60 hours under guideline on routine lab data, the initial compensated sodium value with osmolality was changed from 178 mEq/l to 150 mEq/l in the period. She recovered from her primary diagnosis and unconsciousness. After stabilized sepsis and HHS, we detected CPM on brain MRI due to following up multiple cerebral infarctions with left leg paralysis and verbal disorder. She gradually recovered over several months with intensive rehabilitation and eventually regained near normal functional capacity with stabilized BS. When we consider HHS with hypernatremia, it may be necessary to pay attention to not only to BS control and sodium control according to the guideline but also to osmolality changes to prevent CPM.

Hyponatremia is an independent predictor of emergency department revisits in acute exacerbation of COPD

INTRODUCTION

Hyponatremia is shown to prolong hospitalization and increase mortality. The role of hyponatremia in chronic obstructive pulmonary disease is widely studied with a focus on hospitalized patients.

OBJECTIVES

To investigate whether hyponatremia increases the probability of re-exacerbations in non-hospitalized patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD).

METHODS

Patients with AECOPD who required an emergency department (ED) visit and who were discharged home were included in this single-center, retrospective study. Demographics and laboratory values were compared between patients with hyponatremia (<135 mmol/L) and normonatremia (135-145 mmol/L). The predictors of the patients' ED revisit in the course of one year were analyzed.

RESULTS

Of all the 3274 patients, baseline sodium values were classified as hyponatremia in 720 (22%). Hyponatremia was most frequently present as mild (85%). Patients with hyponatremia had higher Charlson comorbidity scores, higher leucocytes, lower hemoglobin, lower platelet, higher neutrophil to lymphocyte ratios, lower eosinophilia, higher aspartate aminotransferase and C-reactive protein values (P < 0.001, for all), and higher frequency of 1-month revisit (36.7% vs. 31.5%, P = 0.009). Independent predictors of revisits within 1 year after the index visit were detected as long-term oxygen treatment requirement (HR: 0.768 CI: 0.695-0.848, P < 0.0001), higher urea levels (HR: 0.997 CI: 0.995-0.999, P = 0.003), and baseline hyponatremia (HR: 0.786 CI: 0.707-0.873, P < 0.001). Revisit interval was median 78 ± 3.4 days in patients with normonatremia and 51 ± 4.8 days in hyponatremia.

CONCLUSION

In non-hospitalized AECOPD, hyponatremia is relatively frequent and correlates with inflammatory markers. The presence of hyponatremia is an independent predictor of an earlier ED return visit within 1 year. For patients with AECOPD, sodium values may present guidance on discharge versus longer observation decisions.

Dysnatremia is a Predictor for Morbidity and Mortality in Hospitalized Patients with COVID-19

CONTEXT

Dysnatremia is an independent predictor of mortality in patients with bacterial pneumonia. There is paucity of data about the incidence and prognostic impact of abnormal sodium concentration in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE

This work aimed to examine the association of serum sodium during hospitalization with key clinical outcomes, including mortality, need for advanced respiratory support and acute kidney injury (AKI), and to explore the role of serum sodium as a marker of inflammatory response in COVID-19.

METHODS

This retrospective longitudinal cohort study, including all adult patients who presented with COVID-19 to 2 hospitals in London over an 8-week period, evaluated the association of dysnatremia (serum sodium < 135 or > 145 mmol/L, hyponatremia, and hypernatremia, respectively) at several time points with inpatient mortality, need for advanced ventilatory support, and AKI.

RESULTS

The study included 488 patients (median age, 68 years). At presentation, 24.6% of patients were hyponatremic, mainly due to hypovolemia, and 5.3% hypernatremic. Hypernatremia 2 days after admission and exposure to hypernatremia at any time point during hospitalization were associated with a 2.34-fold (95% CI, 1.08-5.05; P = .0014) and 3.05-fold (95% CI, 1.69-5.49; P < .0001) increased risk of death, respectively, compared to normonatremia. Hyponatremia at admission was linked with a 2.18-fold increase in the likelihood of needing ventilatory support (95% CI, 1.34-3.45, P = .0011). Hyponatremia was not a risk factor for in-hospital mortality, except for the subgroup of patients with hypovolemic hyponatremia. Sodium values were not associated with the risk for AKI and length of hospital stay.

CONCLUSION

Abnormal sodium levels during hospitalization are risk factors for poor prognosis, with hypernatremia and hyponatremia being associated with a greater risk of death and respiratory failure, respectively. Serum sodium values could be used for risk stratification in patients with COVID-19.

Serum sodium variability and acute kidney injury: a retrospective observational cohort study on a hospitalized population

Aim of our study was to analyze the association between serum sodium (Na) variability and acute kidney injury (AKI) development. We performed a retrospective observational cohort study on the inpatient population admitted to Fondazione Policlinico Universitario A. Gemelli IRCCS between January 1, 2010 and December 31, 2014 with inclusion of adult patients with ≥ 2 Na and ≥ 2 serum creatinine measurements. We included only patients with ≥ 2 Na measurements before AKI development. The outcome of interest was AKI. The exposures of interest were hyponatremia, hypernatremia and Na fluctuations before AKI development. Na variability was evaluated using the coefficient of variation (CV). Multivariable Cox proportional hazards and logistic regression models were fitted to obtain hazard ratios (HRs), odds ratios (ORs) and 95% confidence intervals (CIs) for the association between the exposures of interest and AKI. Overall, 56,961 patients met our inclusion criteria. During 1541 person-years of follow-up AKI occurred in 1450 patients. In multivariable hazard models, patients with pre-existent dysnatremia and those who developed dysnatremia had a higher risk of AKI compared with patients with normonatremia. Logistic models suggested a higher risk for AKI in the 3rd (OR 1.41, 95% CI 1.18, 1.70, p < 0.001) and 4th (OR 1.53, 95% CI 1.24, 1.91, p < 0.001) highest quartiles of Na CV with a significant linear trend across quartiles (p trend < 0.001). This association was also independent from Na highest and lowest peak value. Dysnatremia is a common condition and is positive associated with AKI development. Furthermore, high Na variability might be considered an independent early indicator for kidney injury development.

Distinct osmoregulatory responses to sodium loading in patients with altered glycosaminoglycan structure: a randomized cross-over trial

Background

By binding to negatively charged polysaccharides called glycosaminoglycans, sodium can be stored in the body—particularly in the skin—without concurrent water retention. Concordantly, individuals with changed glycosaminoglycan structure (e.g. type 1 diabetes (DM1) and hereditary multiple exostosis (HME) patients) may have altered sodium and water homeostasis.

Methods

We investigated responses to acute (30-min infusion) and chronic (1-week diet) sodium loading in 8 DM1 patients and 7 HME patients in comparison to 12 healthy controls. Blood samples, urine samples, and skin biopsies were taken to investigate glycosaminoglycan sulfation patterns and both systemic and cellular osmoregulatory responses.

Results

Hypertonic sodium infusion increased plasma sodium in all groups, but more in DM1 patients than in controls. High sodium diet increased expression of nuclear factor of activated t-cells 5 (NFAT5)—a transcription factor responsive to changes in osmolarity—and moderately sulfated heparan sulfate in skin of healthy controls. In HME patients, skin dermatan sulfate, rather than heparan sulfate, increased in response to high sodium diet, while in DM1 patients, no changes were observed.

Conclusion

DM1 and HME patients show distinct osmoregulatory responses to sodium loading when comparing to controls with indications for reduced sodium storage capacity in DM1 patients, suggesting that intact glycosaminoglycan biosynthesis is important in sodium and water homeostasis.

Trial registration These trials were registered with the Netherlands trial register with registration numbers: NTR4095 (https://www.trialregister.nl/trial/3933 at 2013-07-29) and NTR4788 (https://www.trialregister.nl/trial/4645 at 2014-09-12).

Relationship between Hyponatremia and Peripheral Neuropathy in Patients with Diabetes

OBJECTIVES

Hyponatremia is a common complication of diabetes. However, the relationship between serum sodium level and diabetic peripheral neuropathy (DPN) is unknown. This study was aimed at investigating the relationship between low serum sodium level and DPN in Chinese patients with type 2 diabetes mellitus.

METHODS

A retrospective study was performed on 1928 patients with type 2 diabetes between 2010 and 2018. The multivariate test was used to analyze the relationship between the serum sodium level and the nerve conduction function. A restricted cubic spline was used to flexibly model and visualize the relationship between the serum sodium level and DPN, followed by logistic regression with adjustment.

RESULTS

As the serum sodium level increased, the prevalence of DPN had a reverse J-curve distribution with the serum sodium levels (69.6%, 53.7%, 49.6%, 43.9%, and 49.7%; P = 0.001). Significant differences existed between the serum sodium level and the motor nerve conduction velocity, sensory nerve conduction velocity, part of compound muscle action potential, and sensory nerve action potential of the participants. Compared with hyponatremia, the higher serum sodium level was a relative lower risk factor for DPN after adjusting for several potential confounders (OR = 0.430, 95%CI = 0.220-0.841; OR = 0.386, 95%CI = 0.198-0.755; OR = 0.297, 95%CI = 0.152-0.580; OR = 0.376, 95%CI = 0.190-0.743; all P < 0.05). Compared with low-normal serum sodium groups, the high-normal serum sodium level was also a risk factor for DPN (OR = 0.690, 95%CI = 0.526-0.905, P = 0.007). This relationship was particularly apparent in male participants, those aged <65 years, those with a duration of diabetes of <10 years, and those with a urinary albumin - to - creatinine ratio (UACR) < 30 mg/g.

CONCLUSIONS

Low serum sodium levels were independently associated with DPN, even within the normal range of the serum sodium. We should pay more attention to avoid the low serum sodium level in patients with type 2 diabetes mellitus.

Hypernatremia and moderate-to-severe hyponatremia are independent predictors of mortality in septic patients at emergency department presentation: A sub-group analysis of the need-speed trial

STUDY OBJECTIVE

Early risk stratification of septic patients presenting to the emergency department (ED) is challenging. The aim of the study was to evaluate the prognostic role of plasmatic sodium level (_PNa⁺) derangements at ED presentation in septic patients.

METHODS

According to _PNa⁺ at ED presentation patients were divided in eunatremic (136-145 mEq/L), hypernatremic (>145 mEq/L) and hyponatremic (<136 mEq/L). Hyponatremic patients were subsequently divided in mild (130-135 mEq/L), moderate (125-129 mEq/L) and severe (<125 mEq/L). 7 and 30-day mortality was evaluated according to _PNa⁺ derangements and the degree of hyponatremia. The same analysis was then performed only in respiratory tract infection-related (RTI-r) sepsis patients.

RESULTS

879 septic patients were included in this analysis, 40.3% had hyponatremia, 5.7% hypernatremia. Hypernatremia showed higher mortality rates at both endpoints compared to eunatremia and hyponatremia (p<0.0001 for both). Eunatremia and mild hyponatremia were compared vs. moderate-to-severe hyponatremia showing a significant difference in terms of 7 and 30-day survival (p = 0.004 and p = 0.007, respectively). The Cox proportional model identified as independent predictors of 7 and 30-day mortality moderate-to-severe hyponatremia (HR 4.89[2.38-10.03] and 1.79[1.07-3.01], respectively) and hypernatremia (HR 3.52[1.58-7.82] and 2.14[1.17-3.92], respectively). The same analysis was performed in patients with respiratory tract infection-related sepsis (n = 549), with similar results.

CONCLUSION

Both hypernatremia and moderate-to-severe hyponatremia at ED presentation independently predict mortality in septic patients, allowing early risk stratification and suggesting more aggressive therapeutic strategies.

Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia: The SALSA Randomized Clinical Trial

IMPORTANCE

Few high-quality studies have clarified whether hypertonic saline is best administered as slow continuous infusion (SCI) therapy or rapid intermittent bolus (RIB) therapy for symptomatic severe hyponatremia.

OBJECTIVE

To compare the risk of overcorrection in RIB and SCI with hypertonic saline in patients with symptomatic hyponatremia.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, investigator-initiated, multicenter, open-label, randomized clinical trial enrolled 178 patients older than 18 years with moderately severe to severe hyponatremia and glucose-corrected serum sodium (sNa) levels of 125 mmol/L or less. Recruitment took place from August 24, 2016, until August 21, 2019, across emergency departments and wards of 3 general hospitals in the Republic of Korea.

INTERVENTIONS

Either RIB or SCI of hypertonic saline, 3%, for 24 to 48 hours stratified by the severity of clinical symptoms.

MAIN OUTCOME AND MEASURES

The primary outcome was overcorrection at any given period, defined as increase in the sNa level by greater than 12 or 18 mmol/L within 24 or 48 hours, respectively. Secondary and post hoc outcomes included efficacy and safety of the treatment approaches. The sNa concentrations were measured every 6 hours for 2 days.

RESULTS

The 178 patients (mean [SD] age, 73.1 [12.2] years; 80 (44.9%) male; mean [SD] sNa concentrations, 118.2 [5.0] mmol/L) were randomly assigned to the RIB group (n = 87) or the SCI group (n = 91). Overcorrection occurred in 15 of 87 (17.2%) and 22 of 91 (24.2%) patients in the RIB and SCI groups, respectively (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). The RIB group showed lower incidence of relowering treatment than the SCI group (36 of 87 [41.4%] vs 52 of 91 [57.1%] patients, respectively; absolute risk difference, -15.8% [95% CI, -30.3% to -1.3%]; P = .04; number needed to treat, 6.3). Groups did not differ in terms of efficacy in increasing sNa concentrations nor improving symptoms, but RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 28 of 87 (32.2%) vs 16 of 91 (17.6%) patients, respectively; absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; number needed to treat, 6.8; per-protocol analysis: 21 of 72 (29.2%) vs 12 of 73 (16.4%) patients, respectively; absolute risk difference, 12.7% [95% CI, -0.8% to 26.2%]; P = .07). The statistical significance of the intention-to-treat and per-protocol analyses were similar for all outcomes except for achieving the target correction rate within 1 hour.

CONCLUSIONS AND RELEVANCE

This randomized clinical trial found that both RIB and SIC therapies of hypertonic saline for treating hyponatremia were effective and safe, with no difference in the overcorrection risk. However, RIB had a lower incidence of therapeutic relowering treatment and tended to have a better efficacy in achieving sNa within 1 hour than SCI. RIB could be suggested as the preferred treatment of symptomatic hyponatremia, which is consistent with the current consensus guidelines.

TRIAL REGISTRATION

ClinicalTrials.org Identifier: NCT02887469.

Hyponatraemia as a Predictor of Mortality in Medical Admissions in Ghana: A Comparative Study

Background

Hyponatraemia is the most common electrolyte abnormality in hospital admissions. It occurs in a quarter of medical admissions in Ghana, and it is associated with high mortality. Mortality has been suggested to be due to the underlying medical condition and not necessarily the hyponatraemia. We set out to compare the outcomes of patients with documented hyponatraemia as compared to those with normonatraemia in terms of mortality and length of hospital stay.

Methods

We conducted a comparative analysis of patients with hyponatraemia and those with normonatraemia on the medical ward at the Komfo Anokye Teaching Hospital between May 2018 and December 2018. The medical diagnoses, demographics, and laboratory data of the patients were recorded. Participants' age and gender were matched. Student's t-test was used to test for differences in continuous variables when parametric and Wilcoxon signed-rank test for nonparametric variables. Multiple logistic regression was used to identify predictors of in-hospital mortality. A p value of <0.05 was considered statistically significant.

Results

Within the study period, 846 patients with documented serum sodium were included in the study. The study involved 406 patients with hyponatraemia and 440 patients with normonatraemia. Serum albumin and protein were significantly lower in the hyponatraemia patients as compared to those with normonatraemia. The mortality rate in patients with hyponatraemia was significantly higher than those with normonatraemia (129 (31.8%) vs. 9 (22.3%); OR 1.62 (95% CI: 1.19–2.22), p = 0.002). In-hospital stay was longer in patients with hyponatraemia than normonatraemia (7 (4–10) vs. 6 (3–10) days) but not statistically significant (p = 0.09). Multiple logistic regression showed that low serum sodium (p < 0.001) and low serum albumin (p = 0.009) were the predictors of in-hospital mortality.

Conclusion

Hyponatraemia is associated with significantly higher mortality than normonatraemia and predicts worse prognosis in patients on medical admission. Low serum albumin is also a predictor of mortality in medical admission.

Electrolyte and acid-base disorders in cancer patients and its impact on clinical outcomes: evidence from a real-world study in China

Background: This study aims to delineate the incidence of electrolyte and acid-base disorders (EAD) in cancer patients, to figure out the risk factors of EAD, then to assess the impact of EAD on patients' in-hospital clinical outcomes.Methods: Patients with the diagnosis of malignancies hospitalized during 1 October 2014 and 30 September 2015 were recruited in Zhongshan Hospital, Fudan University in Shanghai of China. Demographic characteristics, comorbidities, and clinical data, including survival, length of stay and hospital cost, were extracted from the electronic medical record system. Electrolyte and acid-base data were acquired from the hospital laboratory database.Results: Of 25,881 cancer patients with electrolyte data, 15,000 (58.0%) cases had at least one electrolyte and acid-base abnormity. Hypocalcemia (27.8%) was the most common electrolyte disorder, followed by hypophosphatemia (26.7%), hypochloremia (24.5%) and hyponatremia (22.5%). The incidence of simple metabolic acidosis (MAC) and metabolic alkalosis (MAL) was 12.8% and 22.1% respectively. Patients with mixed metabolic acid-base disorders (MAC + MAL) accounted for 30.2%. Lower BMI score, preexisting hypertension and diabetes, renal dysfunction, receiving surgery/chemotherapy, anemia and hypoalbuminemia were screened out as the major risk factors of EAD. In-hospital mortality in patients with EAD was 2.1% as compared to those with normal electrolytes (0.3%). The risk of death significantly increased among patients with severe EAD. Similarly, the length of stay and hospital cost also tripled as the number and grade of EAD increased.Conclusion: EAD is commonly encountered in cancer patients and associated with an ominous prognosis. Patients with comorbidities, renal/liver dysfunction, and anti-tumor therapy have a higher risk of EAD. Regular monitoring of electrolytes, optimum regimen for intravenous infusion, timely correction of modifiable factors and appropriate management of EAD should not be neglected during anti-tumor treatment.

Sampling interstitial fluid from human skin using a microneedle patch

Tissue interstitial fluid (ISF) surrounds cells and is an underutilized source of biomarkers that complements conventional sources such as blood and urine. However, ISF has received limited attention due largely to lack of simple collection methods. Here, we developed a minimally invasive, microneedle-based method to sample ISF from human skin that was well tolerated by participants. Using a microneedle patch to create an array of micropores in skin coupled with mild suction, we sampled ISF from 21 human participants and identified clinically relevant and sometimes distinct biomarkers in ISF when compared to companion plasma samples based on mass spectrometry analysis. Many biomarkers used in research and current clinical practice were common to ISF and plasma. Because ISF does not clot, these biomarkers could be continuously monitored in ISF similar to current continuous glucose monitors but without requiring an indwelling subcutaneous sensor. Biomarkers distinct to ISF included molecules associated with systemic and dermatological physiology, as well as exogenous compounds from environmental exposures. We also determined that pharmacokinetics of caffeine in healthy adults and pharmacodynamics of glucose in children and young adults with diabetes were similar in ISF and plasma. Overall, these studies provide a minimally invasive method to sample dermal ISF using microneedles and demonstrate human ISF as a source of biomarkers that may enable research and translation for future clinical applications.

The Effect of the Dose of Isotonic Saline on the Correction of Serum Sodium in the Treatment of Hypovolemic Hyponatremia

BACKGROUND

Overcorrection of serum sodium (SNa) during therapy of hyponatremia can result in osmotic demyelination syndrome. Our aim was to determine the relationship between the isotonic saline solution dose (ISSD) administered and the 24-h SNa increase (24SNa) in patients with hypovolemic hyponatremia (HH).

METHODS

Retrospective study of HH patients treated with ISS in a tertiary hospital of Madrid, Spain, between 1 January-30 May 2019. The 24-h ISSD received and corresponding 24SNa were calculated. The latter was classified as 3 groups: ≥8 mmol/L, ≥6 mmol/L, or <4 mmol/L. Multivariate regression analyses were performed and ROC curves calculated to study the relationship between ISSD and 24SNa.

RESULTS

Thirty patients were included, age 72 years (60-80), 50% were women. 24SNa was ≥8 mmol/L/24 h in 33%, ≥6 mmol/L/24 h in 50%, and <4 mmol/L/24 h in 30%. Median ISSD in each group was: 32 mL/kg/24 h (29-37), 31 mL/kg/24 h (25-33), and 20 mL/kg/24 h (14-22), respectively. An ISSD ≥ 30 mL/kg/24 h had an odds ratio (OR) of 16 (95% CI: 2.5-95.1; p = 0.004) for a 24SNa ≥8 mmol/L, with a sensitivity and specificity of 80%.

CONCLUSIONS

The 24SNa depends on ISSD. An ISSD between 23-30 mL/kg/24 h seems to be safe and effective.

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review

Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.

Lower serum sodium levels predict poor clinical outcomes in patients with insomnia

Background

The association between lower serum sodium levels and the clinical outcomes of insomnia patients remains unclear. We explored whether lower serum sodium is associated with poor clinical outcomes in patients with insomnia.

Methods

We retrospectively enrolled patients with a diagnosis of insomnia from January 2011 to December 2012. We divided participants into three groups according to initial serum sodium level: tertile 1 (< 138 mmol/L), tertile 2 (138.0–140.9 mmol/L), and tertile 3 (≥ 141.0 mmol/L). To calculate the relative risk of death, hazard ratios (HRs) and 95% confidence intervals (CIs) were obtained using Cox proportional hazard models.

Results

A total of 412 patients with insomnia were included, of whom 13.6% (n = 56) had hyponatremia. Patients with lower serum sodium concentrations were older and had lower hemoglobin, calcium, phosphorus, and albumin levels. At the median follow-up of 49.4 months, 44 patients had died and 62 experienced acute kidney injury (AKI). Kaplan-Meier analysis showed significantly higher mortality in patients in the lowest tertile for serum sodium. The lowest tertile of the serum sodium level and the AKI were associated with all-cause mortality. However, the lowest tertile of the serum sodium level was not significantly associated with AKI.

Conclusions

The lowest tertile of the serum sodium level was associated with a higher mortality rate in insomnia patients. Our results suggest that the serum sodium level could serve as a prognostic factor in insomniacs; patients with lower sodium levels require particular care.

Corrected sodium levels for hyperglycemia is a better predictor than measured sodium levels for clinical outcomes among patients with extreme hyperglycemia

BACKGROUND

Abnormal serum sodium levels in various diseases increase mortality; however, hyperglycemia depresses serum sodium concentration significantly. This study aimed to evaluate the clinical impact of measured serum sodium levels and corrected sodium levels among patients with severe hyperglycemia.

METHODS

Patients with blood glucose levels ≥500 mg/dL visiting the emergency department between July 2008 and September 2010 were enrolled retrospectively. The participants were divided into five groups for measured sodium levels and five groups for corrected sodium levels according to blood glucose levels. Multivariate Cox regression was used. The primary outcome was all-cause 90-day mortality. Secondary outcomes included rate of intensive care unit hospitalization, respiratory failure, and renal failure.

RESULTS

A total of 755 patients with severe hyperglycemia were enrolled, and the 90-day mortality was 17.2%. Compared with the reference group, the 90-day mortality was higher in the patients with measured hypernatremia (adjusted hazard ratio [HR], 2.86; 95% confidence interval [CI], 1.39-5.87), corrected hyponatremia (adjusted HR, 3.56; 95% CI, 1.44-8.80), and severe corrected hypernatremia (adjusted HR, 2.68; 95% CI, 1.28-5.62). However, patients with severe measured hyponatremia did not show increased mortality (adjusted HR, 1.67; 95% CI, 0.84-3.32).

CONCLUSION

Among patients with severe hyperglycemia, corrected sodium level is a better indicator of clinical outcomes compared with measured sodium levels, especially in this population with measured hyponatremia.

Fatal case of hospital-acquired hypernatraemia in a neonate: lessons learned from a tragic error

A 3-week-old boy with viral gastroenteritis was by error given 200 mL 1 mmol/mL hypertonic saline intravenously instead of isotonic saline. His plasma sodium concentration (PNa) increased from 136 to 206 mmol/L. Extreme brain shrinkage and universal hypoperfusion despite arterial hypertension resulted. Treatment with glucose infusion induced severe hyperglycaemia. Acute haemodialysis decreased the PNa to 160 mmol/L with an episode of hypoperfusion. The infant developed intractable seizures, severe brain injury on magnetic resonance imaging and died. The most important lesson is to avoid recurrence of this tragic error. The case is unique because a known amount of sodium was given intravenously to a well-monitored infant. Therefore the findings give us valuable data on the effect of fluid shifts on the PNa, the circulation and the brain’s response to salt intoxication and the role of dialysis in managing it. The acute salt intoxication increased PNa to a level predicted by the Edelman equation with no evidence of osmotic inactivation of sodium. Treatment with glucose in water caused severe hypervolaemia and hyperglycaemia; the resulting increase in urine volume exacerbated hypernatraemia despite the high urine sodium concentration, because electrolyte-free water clearance was positive. When applying dialysis, caution regarding circulatory instability is imperative and a treatment algorithm is proposed.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.

Is postoperative hyponatremia a real threat for total hip and knee arthroplasty surgery?

Postoperative hyponatremia (POH) is thought to be a fearsome complication of orthopedic surgery. Primary aim of this cohort study was to evaluate the incidence of POH and its clinical relevance in elective surgery, outlining differences between total knee arthroplasty (TKA) and total hip arthroplasty, looking for the presence of any risk factor commonly related to POH.Four hundred two patients that underwent total hip arthroplasty and total knee arthroplasty performed between 2016 and 2017 were retrospectively examined. Serum electrolytes, hemoglobin, hematocrit, glucose, and creatinine were evaluated preoperatively and at day 0-I-II from surgery. Age, sex, body mass index, comorbidities, drugs, surgery data, transfusions, postoperative symptoms, and length of stay (LOS) were determined. All surgeries were performed by the same equipe. Patients had the same perioperative management, excluded those that took thiazides, already at risk of POH.Patients were divided in 2 groups: group A, patients with normal postoperative natremia (294 patients) and group B, patients who developed POH (108, 26.9%); 66.7% of these developed POH within 24 hours postoperatively. In group B mean postoperative natremia was 133.38 (127.78-134.85) mmol/L. Two patients (1.8%) developed moderate hyponatremia, no severe hyponatremia was documented. Type of surgery, operation time, LOS, and presence of postoperative symptoms did not show statistically significant differences within groups. At multivariate logistic analysis chronic use of thiazides was the only variable associated to a decreased risk of developing POH (OR = 0.39; P = .03). Hemoglobin postoperative values (OR = 1.22; P = .03), the need of postoperative transfusion (OR = 2.50; P = .02) and diabetes (OR = 2.70; P = .01) were associated to an increased risk of POH.Although 26.9% of our patients exhibited POH, the onset of this disorder had no implication on postoperative symptoms and on LOS. Diabetes and transfusion are factors most often associated to POH.

First-in-Human Experience With Peritoneal Direct Sodium Removal Using a Zero-Sodium Solution: A New Candidate Therapy for Volume Overload

BACKGROUND

Loop diuretics have well-described toxicities, and loss of response to these agents is common. Alternative strategies are needed for the maintenance of euvolemia in heart failure (HF). Nonrenal removal of sodium directly across the peritoneal membrane (direct sodium removal [DSR]) with a sodium-free osmotic solution should result in extraction of large quantities of sodium with limited off-target solute removal.

METHODS

This article describes the preclinical development and first-in-human proof of concept for DSR. Sodium-free 10% dextrose was used as the DSR solution. Porcine experiments were conducted to investigate the optimal dwell time, safety, and scalability and to determine the effect of experimental heart failure. In the human study, participants with end-stage renal disease on peritoneal dialysis (PD) underwent randomization and crossover to either a 2-hour dwell with 1 L DSR solution or standard PD solution (Dianeal 4.25% dextrose, Baxter). The primary end point was completion of the 2-hour dwell without significant discomfort or adverse events, and the secondary end point was difference in sodium removal between DSR and standard PD solution.

RESULTS

Porcine experiments revealed that 1 L DSR solution removed 4.1±0.4 g sodium in 2 hours with negligible off-target solute removal and overall stable serum electrolytes. Increasing the volume of DSR solution cycled across the peritoneum increased sodium removal and substantially decreased plasma volume (P=0.005). In the setting of experimental heart failure with elevated right atrial pressure, sodium removal was ≈4 times greater than in healthy animals (P<0.001). In the human proof-of-concept study, DSR solution was well tolerated and not associated with significant discomfort or adverse events. Plasma electrolyte concentrations were stable, and off-target solute removal was negligible. Sodium removal was substantially higher with DSR (4.5±0.4 g) compared with standard PD solution (1.0±0.3 g; P<0.0001).

CONCLUSIONS

DSR was well tolerated in both animals and human subjects and produced substantially greater sodium removal than standard PD solution. Additional research evaluating the use of DSR as a method to prevent and treat hypervolemia in heart failure is warranted. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03801226.

Do Hyponatremia or Its Underlying Mechanisms Associate With Mortality Risk in Observational Data?

Supplemental Digital Content is available in the text.

Objectives:

Whether unaccounted determinants of hyponatremia, rather than water excess per se, primarily associate with mortality in observational studies has not been explicitly examined.

Design:

Retrospective cohort study of the association between hyponatremia and mortality, stratified by outpatient diuretic use in three strata.

Setting:

An inception cohort of 13,661 critically ill patients from a tertiary medical center.

Measurements and Main Results:

Admission serum sodium concentrations, obtained within 12 hours of admission to the ICU, were the primary exposure. Hyponatremia was associated with 1.82 (95% CI, 1.56–2.11; p < 0.001) higher odds of mortality, yet differed according to outpatient diuretic use (multiplicative interaction between thiazide and serum sodium < 133 mEq/L; p = 0.002). Although hyponatremia was associated with a three-fold higher (odds ratio, 3.11; 95% CI, 2.32–4.17; p < 0.001) odds of mortality among those prescribed loop diuretics, no increase of risk was observed among thiazide diuretic users (odds ratio, 0.87; 95% CI, 0.47–1.51; p = 0.63). When examined as a continuous variable, each one mEq/L higher serum sodium was associated with 8% (odds ratio, 0.92; 95% CI, 0.90–0.94; p < 0.001) lower odds of mortality in loop diuretic patients and 5% (odds ratio, 0.95; 95% CI, 0.93–0.96, p < 0.001) lower in diuretic naïve patients, but was not associated with mortality risk among thiazide users (odds ratio, 0.99; 95% CI, 0.95–1.02; p = 0.45).

Conclusions:

Hyponatremia is not uniformly associated with increased mortality, but differs according to diuretic exposure. Our results suggest that the underlying pathophysiologic factors that lead to water excess, rather water excess itself, account in part for the association between hyponatremia and poor outcomes. More accurate estimations about the association between hyponatremia and outcomes might influence clinical decision-making.

Effects of correction equation for actual sodium concentration on the reduction in frequency of reports on pseudohyponatremia

Background

Serum sodium concentration could be spuriously reduced by excess glucose or lipid; thus, hyponatremia should be reassessed before reporting in order to exclude the possibility of pseudohyponatremia.

Methods

In this study, we used the calculation of corrected serum sodium concentration in hyperglycemic or lipemic samples and evaluated its effect on the reduction in frequency of reports on pseudohyponatremia. We retrospectively analyzed 1-year data from the laboratory information system.

Results

From August 2017 to July 2018, hyponatremia was initially noted in 30,465 results, of which 6614 results reported hyperglycemia. Corrected sodium concentrations were calculated using the results with glucose >170 mg/dL or lipemia index ≥3. The reported frequency of hyponatremia before and after correction of sodium concentration was reduced by 42.9%. Moreover, only 51.9% of the patients with severe hyponatremia had “true” severe hyponatremia. After applying the formula, the degree of hyponatremia was unchanged in only 45.8% of the total results.

Conclusions

Our report on the corrected sodium concentration reduced the frequency of pseudohyponatremia in hyperglycemic samples. Calculation of corrected sodium concentration is a useful tool to help clinicians establish appropriate care and treatment plans. Further prospective study is required to validate to our system in a real clinical practice.

Severe Hyponatremia, Hyperglycemia, and Hyperlactatemia Are Associated with Intraoperative Hyperthermic Intraperitoneal Chemoperfusion with Oxaliplatin

Background

Since the introduction of surgical debulking in combination with intraoperative hyperthermic intra-peritoneal chemoperfusion (HIPEC) with oxaliplatin in our institution, severe hyponatremia (sodium: 126.5 ± 3.8 mmol/L), hyperglycemia (glucose: 22.37 ± 4.89 mmol/L), and hyperlactatemia (lactate: 3.17 ± 1.8 mmol/L) have been observed post HIPEC. This metabolic disorder was not observed in patients in whom cisplatin or mitomycin C was used as a chemotherapeutic drug.

Methods

In order to understand the pathophysiology of this finding, an analysis of our data was made. In a first analysis, plasma sodium was corrected for hyperglycemia based on the formula of Hillier. In a second analysis, the influence of total exchangeable sodium, total exchangeable potassium, and total body water on plasma sodium concentration was modeled.

Results

Analysis of our data revealed a double mechanism for the observed metabolic disorder: hyperglycemia caused by dextrose 5%, which is used as a carrier for the oxaliplatin, and major loss of sodium into the dialysate (256.7 ± 68.7 mmol).

Conclusion

Better control of hyperglycemia and intravenous compensation of sodium loss into the dialysate can attenuate the reported biochemical disturbance.

Impact of Hyponatremia on COPD Exacerbation Prognosis

The most common electrolyte disorder among hospitalized patients, hyponatremia is a predictor of poor prognosis in various diseases. The aim of this study was to establish the prevalence of hyponatremia in patients admitted for acute exacerbation of chronic obstructive pulmonary disease (AECOPD), as well as its association with poor clinical progress. Prospective observational study carried out from 1 October 2016 to 1 October 2018 in the following hospitals: Salnés in Vilagarcía de Arousa, Arquitecto Marcide in Ferrol, and the University Hospital Complex of Santiago de Compostela, Galicia, Spain, on patients admitted for AECOPD. Patient baseline treatment was identified, including hyponatremia-inducing drugs. Poor progress was defined as follows: prolonged stay, death during hospitalization, or readmission within one month after the index episode discharge. 602 patients were enrolled, 65 cases of hyponatremia (10.8%) were recorded, all of a mild nature (mean 131.6; SD 2.67). Of all the patients, 362 (60%) showed poor progress: 18 (3%) died at admission; 327 (54.3%) had a prolonged stay; and 91 (15.1%) were readmitted within one month after discharge. Patients with hyponatremia had a more frequent history of atrial fibrillation (AF) (p 0.005), pleural effusion (p 0.01), and prolonged stay (p 0.01). The factors independently associated with poor progress were hyponatremia, pneumonia, and not receiving home O₂ treatment prior to admission. Hyponatremia is relatively frequent in patients admitted for AECOPD, and it has important prognostic implications, even when mild in nature.

Dialysis-associated hyperglycemia: manifestations and treatment

PURPOSE

Dialysis-associated hyperglycemia (DAH), is associated with a distinct fluid and electrolyte pathophysiology. The purpose of this report was to review the pathophysiology and provide treatment guidelines for DAH.

METHODS

Review of published reports on DAH. Synthesis of guidelines based on these reports.

RESULTS

The following fluid and solute abnormalities have been identified in DAH: (a) hypoglycemia: this is a frequent complication of insulin treatment and its prevention requires special attention. (b) Elevated serum tonicity. The degree of hypertonicity in DAH is lower than in similar levels of hyperglycemia in patients with preserved renal function. Typically, correction of hyperglycemia with insulin corrects the hypertonicity of DAH. (c) Extracellular volume abnormalities ranging from pulmonary edema associated with osmotic fluid shift from the intracellular into the extracellular compartment as a consequence of gain in extracellular solute (glucose) to hypovolemia from osmotic diuresis in patients with residual renal function or from fluid losses through extrarenal routes. Correction of DAH by insulin infusion reverses the osmotic fluid transfer between the intracellular and extracellular compartments and corrects the pulmonary edema, but can worsen the manifestations of hypovolemia, which require saline infusion. (d) A variety of acid-base disorders including ketoacidosis correctable with insulin infusion and no other interventions. (e) Hyperkalemia, which is frequent in DAH and is more severe when ketoacidosis is also present. Insulin infusion corrects the hyperkalemia. Extreme hyperkalemia at presentation or hypokalemia developing during insulin infusion require additional measures.

CONCLUSIONS

In DAH, insulin infusion is the primary management strategy and corrects the fluid and electrolyte abnormalities. Patients treated for DAH should be monitored for the development of hypoglycemia or fluid and electrolyte abnormalities that may require additional treatments.

Survival Following Extreme Hypernatraemia Associated with Severe Dehydration and Undiagnosed Diabetes Mellitus

We report a case of a previously well 58-year-old man, who presented with delirium and low GCS, and was found to have extreme hypernatraemia (Na⁺ = 191 mmol/L) and hyperglycaemia (glucose = 31 mmol/L). This resulted in a corrected serum sodium of 202 mmol/L. He was treated with fluid and electrolyte replacement in the intensive care unit, and had returned to essentially normal function by hospital discharge. The aetiology was believed to be due to severe dehydration and a new diagnosis of diabetes mellitus. Extreme hypernatraemia (serum sodium level greater than 190 mmol/L) is rare and associated with a high mortality. The mainstay of treatment is careful fluid and electrolyte management. Most recommendations advise to reduce the serum sodium by 0.5 mmol/L/hour, due to concerns over cerebral oedema; however, there are reports that slower correction is associated with higher mortality. In this case, the initial corrected sodium of 202 mmol/L was steadily corrected to 160 mmol/L over 91 hours, at a rate of 0.46 mmol/L/hour. This demonstrates the safety of the recommended approach.

Continuous noninvasive glucose monitoring; water as a relevant marker of glucose uptake in vivo

With diabetes set to become the number 3 killer in the Western hemisphere and proportionally growing in other parts of the world, the subject of noninvasive monitoring of glucose dynamics in blood remains a "hot" topic, with the involvement of many groups worldwide. There is a plethora of techniques involved in this academic push, but the so-called multisensor system with an impedance-based core seems to feature increasingly strongly. However, the symmetrical structure of the glucose molecule and its shielding by the smaller dipoles of water would suggest that this option should be less enticing. Yet there is enough phenomenological evidence to suggest that impedance-based methods are truly sensitive to the biophysical effects of glucose variations in the blood. We have been trying to answer this very fundamental conundrum: "Why is impedance or dielectric spectroscopy sensitive to glucose concentration changes in the blood and why can this be done over a very broad frequency band, including microwaves?" The vistas for medical diagnostics are very enticing. There have been a significant number of papers published that look seriously at this problem. In this review, we want to summarize this body of research and the underlying mechanisms and propose a perspective toward utilizing the phenomena. It is our impression that the current world view on the dielectric response of glucose in solution, as outlined below, will support the further evolution and implementation toward practical noninvasive glucose monitoring solutions.

Immune checkpoint inhibitors and type 1 diabetes mellitus: a case report and systematic review

OBJECTIVE

To better define the rare adverse event (AE) of diabetes mellitus associated with immune checkpoint inhibitors (ICIs).

DESIGN AND METHODS

We report the case of a lung cancer patient with diabetic ketoacidosis (DKA) and autoimmune thyroiditis during pembrolizumab treatment. We provide a systematic review of all published cases (PubMed/Web of Science/Cochrane, through November 2018) of autoimmune diabetes mellitus related to blockade of the cytotoxic T-lymphocyte antigen 4 (CTLA-4)-, programmed cell death 1 (PD-1) receptor or its ligand (PD-L1) or combination (ICI) therapy.

RESULTS

Our literature search identified 90 patient cases (our case excluded). Most patients were treated with anti-PD-1 or anti-PD-L1 as monotherapy (79%) or in combination with CTLA-4 blockade (15%). On average, diabetes mellitus was diagnosed after 4.5 cycles; earlier for combination ICI at 2.7 cycles. Early-onset diabetes mellitus (after one or two cycles) was observed during all treatment regimens. Diabetic ketoacidosis was present in 71%, while elevated lipase levels were detected in 52% (13/25). Islet autoantibodies were positive in 53% of patients with a predominance of glutamic acid decarboxylase antibodies. Susceptible HLA genotypes were present in 65% (mostly DR4). Thyroid dysfunction was the most frequent other endocrine AE at 24% incidence in this patient population.

CONCLUSION

ICI-related diabetes mellitus is a rare but often life-threatening metabolic urgency of which health-care professionals and patients should be aware. Close monitoring of blood glucose and prompt endocrine investigation in case of hyperglycemia is advisable. Predisposing factors such as HLA genotype might explain why some individuals are at risk.

Sodium Fluctuations and Mortality in a General Hospitalized Population

Background/Aims: Aim of our study was to describe the association between natremia (Na) fluctuation and hospital mortality in a general population admitted to a tertiary medical center. Methods: We performed a retrospective observational cohort study on the patient population admitted to the Fondazione Policlinico A. Gemelli IRCCS Hospital between January 2010 and December 2014 with inclusion of adult patients with at least 2 Na values available and with a normonatremic condition at hospital admission. Patients were categorized according to all Na values recorded during hospital stay in the following groups: normonatremia, hyponatremia, hypernatremia, and mixed dysnatremia. The difference between the highest or the lowest Na value reached during hospital stay and the Na value read at hospital admission was used to identify the maximum Na fluctuation. Cox proportional hazards models were used to estimate hazard ratios (HRs) for in-hospital death in the groups with dysnatremias and across quartiles of Na fluctuation. Covariates assessed were age, sex, highest and lowest Na level, Charlson/Deyo score, cardiovascular diseases, cerebrovascular diseases, dementia, congestive heart failure, severe kidney disease, estimated glomerular filtration rate, and number of Na measurements during hospital stay. Results: 46,634 admissions matched inclusion criteria. Incident dysnatremia was independently associated with in-hospital mortality (hyponatremia: HR 3.11, 95% CI 2.53, 3.84, p < 0.001; hypernatremia: HR 5.12, 95% CI 3.94, 6.65, p < 0.001; mixed-dysnatremia: HR 4.94, 95% CI 3.08, 7.92, p < 0.001). We found a higher risk of in-hospital death by linear increase of quartile of Na fluctuation (p trend <0.001) irrespective of severity of dysnatremia (HR 2.34, 95% CI 1.55, 3.54, p < 0.001, for the highest quartile of Na fluctuation compared with the lowest). Conclusions: Incident dysnatremia is associated with higher hospital mortality. Fluctuation of Na during hospital stay is a prognostic marker for hospital death independent of dysnatremia severity.

Electrolyte imbalances in an unselected population in an emergency department: A retrospective cohort study

BACKGROUND

Although electrolyte imbalances (EIs) are common in the emergency department (ED), few studies have examined the occurrence of such conditions in an unselected population.

OBJECTIVES

To investigate the frequency of EI among adult patients who present to the ED, with regards to type and severity, and the association with age and sex of the patient, hospital length of stay (LOS), readmission, and mortality.

METHODS

A retrospective cohort study. All patients ≥18 years referred for any reason to the ED between January 1, 2010, and December 31, 2015, who had measured blood electrolytes were included. In total, 62 991 visits involving 31 966 patients were registered.

RESULTS

EIs were mostly mild, and the most common EI was hyponatremia (glucose-corrected) (24.6%). Patients with increasing severity of EI had longer LOS compared with patients with normal electrolyte measurements. Among all admitted patients, there were 12928 (20.5%) readmissions within 30 days from discharge during the study period. Hyponatremia (glucose-corrected) was associated with readmission, with an adjusted odds ratio (OR) of 1.25 (95% CI, 1.18-1.32). Hypomagnesemia and hypocalcemia (albumin-corrected) were also associated with readmission, with ORs of 1.25 (95% CI, 1.07-1.45) and 1.22 (95% CI, 1.02-1.46), respectively. Dysnatremia, dyskalemia, hypercalcemia, hypermagnesemia, and hyperphosphatemia were associated with increased in-hospital mortality, whereas all EIs except hypophosphatemia were associated with increased 30-day and 1-year mortality.

CONCLUSIONS

EIs were common and increasing severity of EIs was associated with longer LOS and increased in-hospital, 30-days and 1-year mortality. EI monitoring is crucial for newly admitted patients, and up-to-date training in EI diagnosis and treatment is essential for ED physicians.