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Baker CM, Goh GS, Tarabichi S, Sherman MB, Khan IA, Parvizi J. Hyponatremia Is an Overlooked Sign of Trouble Following Total Joint Arthroplasty. J Bone Joint Surg Am 2023; 105:744-754. [PMID: 37000860 DOI: 10.2106/jbjs.22.00928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
BACKGROUND Hyponatremia is a common electrolyte abnormality in arthroplasty patients. This issue, underrecognized by surgeons, can impact the postoperative course of patients. There are, however, little data on the implications of sodium disturbances following total joint arthroplasty (TJA). The primary aims of this study were to (1) report the rate of hyponatremia following TJA, and (2) examine the impact of hyponatremia on the perioperative course of TJA patients. METHODS This was a retrospective analysis of 3,071 primary and revision TJAs performed between 2015 and 2017. Based on preoperative and postoperative sodium values (pre-post), patients were classified into 4 groups: normonatremic-normonatremic (Group 1), normonatremic-hyponatremic (Group 2), hyponatremic-normonatremic (Group 3), and hyponatremic-hyponatremic (Group 4). Primary end points were length of stay (LOS), postoperative discharge, in-hospital complications, and 90-day readmissions. RESULTS The distribution of cases was 84.6% Group 1, 9.4% Group 2, 2.1% Group 3, and 3.8% Group 4. Overall, 13.2% of patients had hyponatremia after TJA. Older age, hip arthroplasty, general anesthesia, higher Charlson Comorbidity Index, congestive heart failure, revision surgery, and history of stroke, liver disease, and chronic kidney disease were risk factors for postoperative hyponatremia. Patients with postoperative hyponatremia (Groups 2 and 4) had greater likelihoods of having a 90-day complication and non-home discharge and greater LOS. CONCLUSIONS Postoperative hyponatremia was a relatively common occurrence in patients undergoing TJA, and was associated with greater LOS, complications, and non-home discharge. Surgeons should identify patients at risk for developing sodium abnormalities in order to optimize these patients and avoid increased resource utilization. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Colin M Baker
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Ohta R, Sano C. The Effectiveness of Family Medicine-Driven Interprofessional Collaboration on the Readmission Rate of Older Patients. Healthcare (Basel) 2023; 11:healthcare11020269. [PMID: 36673637 PMCID: PMC9859164 DOI: 10.3390/healthcare11020269] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/13/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Interprofessional collaboration (IPC) for older patient care among family physicians, dentists, therapists, nutritionists, nurses, and pharmacists in the rural hospital care of older patients could improve the hospital readmission rate. However, there is a lack of interventional studies on IPC for improving the readmission rate among Japanese older patients in rural hospitals. This quasi-experimental study was performed on patients >65 years who were discharged from a rural community hospital. The intervention was IPC implementation with effective information sharing and comprehensive management of older patients’ conditions for effective discharge and readmission prevention; implementation started on 1 April 2021. The study lasted 2 years, from 1 April 2021 to 31 March 2022 for the intervention group and from 1 April 2020 to 31 March 2021 for the comparison group. The average participant age was 79.86 (standard deviation = 15.38) years and the proportion of men was 45.0%. The Cox hazard model revealed that IPC intervention could reduce the readmission rate after adjustment for sex, serum albumin, polypharmacy, dependent condition, and Charlson Comorbidity Index score (hazard ratio = 0.66, 95% confidence interval: 0.54−0.81). Rural IPC intervention can improve inpatient care for older patients and decrease readmission rates. Thus, for effective rural IPC interventions, family physicians in hospitals should proactively collaborate with various medical professionals to improve inpatient health outcomes.
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Affiliation(s)
- Ryuichi Ohta
- Community Care, Unnan City Hospital, 699-1221 96-1 Iida, Daito-cho, Unnan 699-1221, Japan
- Correspondence: ; Tel.: +81-90-5060-5330
| | - Chiaki Sano
- Department of Community Medicine Management, Faculty of Medicine, Shimane University, 89-1 Enya cho, Izumo 693-8501, Japan
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Skov J, Falhammar H, Calissendorff J, Lindh JD, Mannheimer B. Association between lipid-lowering agents and severe hyponatremia: a population-based case-control study. Eur J Clin Pharmacol 2021; 77:747-755. [PMID: 33215235 PMCID: PMC8032630 DOI: 10.1007/s00228-020-03006-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 09/18/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE Drug-induced hyponatremia is common, with medications from many drug-classes implicated. Lipid-lowering agents are among the most prescribed drugs. Limited evidence suggests an inverse association between statins and hyponatremia, while data on other lipid-lowering agents is absent. The objective of this investigation was to study the association between lipid-lowering drugs and hospitalization due to hyponatremia. METHODS This was a register-based case-control study of the general Swedish population. Those hospitalized with a main diagnosis of hyponatremia (n = 11,213) were compared with matched controls (n = 44,801). Multivariable logistic regression adjusting for co-medication, diseases, previous hospitalizations, and socioeconomic factors was used to explore the association between severe hyponatremia and the use of lipid-lowering drugs. RESULTS Unadjusted ORs (95% CI) for hospitalization due to hyponatremia were 1.28 (1.22-1.35) for statins, 1.09 (0.79-1.47) for ezetimibe, 1.38 (0.88-2.12) for fibrates, and 2.12 (1.31-3.35) for resins. After adjustment for confounding factors the adjusted odds ratios (95% CI) compared with controls were 0.69 (0.64-0.74) for statins, 0.60 (0.41-0.86) for ezetimibe, 0.87 (0.51-1.42) for fibrates, and 1.21 (0.69-2.06) for resins. CONCLUSIONS Use of statins and ezetimibe was inversely correlated with severe hyponatremia. Consequently, these drugs are unlikely culprits in patients with hyponatremia, and they appear safe to initiate in hyponatremic patients. A potential protective effect warrants further studies on how statins and other lipid-lowering drugs are linked to dysnatremias.
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Affiliation(s)
- Jakob Skov
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine, Karlstad Central Hospital, Karlstad, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Jan Calissendorff
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Jonatan D Lindh
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
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Pennington Z, Bomberger TT, Lubelski D, Benzel EC, Steinmetz MP, Mroz TE. Associations Between Preoperative Hyponatremia and 30-Day Perioperative Complications in Lumbar Interbody Spinal Fusion. Clin Spine Surg 2021; 34:E7-E12. [PMID: 32467442 DOI: 10.1097/bsd.0000000000001016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/23/2020] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN Retrospective population database study. OBJECTIVE To investigate the relationship of preoperative hyponatremia to postoperative morbidity and mortality in lumbar interbody fusion patients. SUMMARY OF BACKGROUND DATA Optimization of preoperative patient selection and perioperative management can improve patient outcomes in spinal surgery. Hyponatremia, incidentally identified in 1.7% of the US population, has previously been tied to poorer postoperative outcomes in both the general surgery and orthopedic surgery populations. MATERIALS AND METHODS Using the National Surgical Quality Improvement Program database, the authors identified all lumbar interbody fusion patients treated between 2012 and 2014. Patients were classified as hyponatremic (Na<135 mEq/L) or as having normal sodium levels (135-145 mEq/L) preoperatively. The primary outcome was major morbidity and secondary endpoints were prolonged hospitalization, 30-day readmission, and reoperation. Multivariable linear regression was used to find independent predictors of these outcomes. RESULTS Of 10,654 patients, 45.6% were male individuals, 5.5% were hyponatremic, and 4.2% experienced a major postoperative complication. On multivariable analysis, preoperative hyponatremia was independently associated with major morbidity (odds ratio, 1.22; 95% confidence interval, 1.03-1.44; P<0.05) and prolonged hospitalization (odds ratio, 1.14; 95% confidence interval, 1.02-1.27). CONCLUSIONS Here the authors provide the first evidence suggesting preoperative hyponatremia is an independent predictor of major morbidity after lumbar interbody fusion. Hyponatremia may represent a modifiable risk factor for improved patient care and preoperative risk counseling.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Edward C Benzel
- Cleveland Clinic Center for Spine Health
- Department of Neurological Surgery, Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Michael P Steinmetz
- Cleveland Clinic Center for Spine Health
- Department of Neurological Surgery, Cleveland Clinic
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Thomas E Mroz
- Cleveland Clinic Center for Spine Health
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
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Kutz A, Ebrahimi F, Aghlmandi S, Wagner U, Bromley M, Illigens B, Siepmann T, Schuetz P, Mueller B, Christ-Crain M. Risk of Adverse Clinical Outcomes in Hyponatremic Adult Patients Hospitalized for Acute Medical Conditions: A Population-Based Cohort Study. J Clin Endocrinol Metab 2020; 105:5894963. [PMID: 32818232 PMCID: PMC7500475 DOI: 10.1210/clinem/dgaa547] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/12/2020] [Indexed: 12/13/2022]
Abstract
CONTEXT Hyponatremia has been associated with excess long-term morbidity and mortality. However, effects during hospitalization are poorly studied. OBJECTIVE The objective of this work is to examine the association of hyponatremia with the risk of in-hospital mortality, 30-day readmission, and other short-term adverse events among medical inpatients. DESIGN AND SETTING A population-based cohort study was conducted using a Swiss claims database of medical inpatients from January 2012 to December 2017. PATIENTS Hyponatremic patients were 1:1 propensity-score matched with normonatremic medical inpatients. MAIN OUTCOME MEASURE The primary outcome was a composite of all-cause in-hospital mortality and 30-day hospital readmission. Secondary outcomes were intensive care unit (ICU) admission, intubation rate, length-of-hospital stay (LOS), and patient disposition after discharge. RESULTS After matching, 94 352 patients were included in the cohort. Among 47 176 patients with hyponatremia, 8383 (17.8%) reached the primary outcome compared with 7994 (17.0%) in the matched control group (odds ratio [OR] 1.06 [95% CI, 1.02-1.10], P = .001). Hyponatremic patients were more likely to be admitted to the ICU (OR 1.43 [95% CI, 1.37-1.50], P < .001), faced a 56% increase in prolonged LOS (95% CI, 1.52-1.60, P < .001), and were admitted more often to a postacute care facility (OR 1.38 [95% CI 1.34-1.42, P < .001). Of note, patients with the syndrome of inappropriate antidiuresis (SIAD) had lower in-hospital mortality (OR 0.67 [95% CI, 0.56-0.80], P < .001) as compared with matched normonatremic controls. CONCLUSION In this study, hyponatremia was associated with increased risk of short-term adverse events, primarily driven by higher readmission rates, which was consistent among all outcomes except for decreased in-hospital mortality in SIAD patients.
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Affiliation(s)
- Alexander Kutz
- Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Correspondence and Reprint Requests:Alexander Kutz, MD, MSc, Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland. E-mail:
| | - Fahim Ebrahimi
- Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- University Center for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ulrich Wagner
- Foundation National Institute for Cancer Epidemiology and Registration (NICER) University of Zurich, Zurich, Switzerland
| | - Miluska Bromley
- Center for Clinical Research and Management, Division of Health Care Sciences, Education Dresden, Dresden International University, Dresden, Germany
| | - Ben Illigens
- Center for Clinical Research and Management, Division of Health Care Sciences, Education Dresden, Dresden International University, Dresden, Germany
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Timo Siepmann
- Center for Clinical Research and Management, Division of Health Care Sciences, Education Dresden, Dresden International University, Dresden, Germany
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Philipp Schuetz
- Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Beat Mueller
- Endocrinology, Diabetes, and Metabolism, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Mirjam Christ-Crain
- Endocrinology, Diabetes, and Metabolism, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
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Pennington Z, Bomberger TT, Lubelski D, Benzel EC, Steinmetz MP, Mroz TE. Preoperative Hyponatremia and Perioperative Complications in Cervical Spinal Fusion. World Neurosurg 2020; 141:e864-e872. [PMID: 32553754 DOI: 10.1016/j.wneu.2020.06.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 06/01/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Preoperative patient optimization is increasingly recognized as key to good surgical outcomes. Preoperative hyponatremia is a modifiable risk factor linked to poorer postoperative outcomes in other surgical fields. We provide the first investigation of the association of preoperative hyponatremia with morbidity and mortality in patients undergoing cervical spine surgery. METHODS We queried the National Surgical Quality Improvement Program registry for patients who underwent cervical spine fusion. Preoperative serum sodium levels were classified as normal (135-145 mEq/L) or hyponatremic (<135 mEq/L); hypernatremic patients were excluded from the analysis. Multivariable logistic analyses using a multiple imputations methodology were performed to determine significant predictors of major morbidity and mortality (MMM). RESULTS We included 20,817 patients, of whom 5.2% were hyponatremic at presentation. Preoperative hyponatremia was a significant predictor of MMM (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.09-1.39), mortality (OR, 1.36; 95% CI, 1.03-1.77), major morbidity (OR, 1.24; 95% CI, 1.10-1.40), and odds of prolonged hospitalization (OR, 1.13; 95% CI, 1.04-1.23). Other significant predictors of MMM included age, undergoing an emergent versus nonemergent operation, having chronic obstructive pulmonary disease, having disseminated malignancy, being functionally dependent, presenting with sepsis or septic shock, and having an American Society of Anesthesiologists status of 3, 4, or 5. Similar results were seen in analyses using only complete cases and in sensitivity analyses. CONCLUSIONS Using the National Surgical Quality Improvement Program database, hyponatremia is observed in approximately 1 in every 20 patients undergoing cervical spine fusion. More importantly, it is a predictor of mortality, major morbidity, and prolonged hospitalization. From a systems-level perspective, preoperative hyponatremia may therefore represent a point of intervention for preoperative patient optimization.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas T Bomberger
- Department of Diagnostic Radiology, Case Western Reserve University, Cleveland, Ohio, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Edward C Benzel
- Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA; The Cleveland Clinic, Lerner College of Medicine, Cleveland, Ohio, USA
| | - Michael P Steinmetz
- Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA; The Cleveland Clinic, Lerner College of Medicine, Cleveland, Ohio, USA
| | - Thomas E Mroz
- Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA; The Cleveland Clinic, Lerner College of Medicine, Cleveland, Ohio, USA; Department of Orthopaedic Surgery, Cleveland Clinic Orthopaedic and Rheumatologic Institute, Cleveland, Ohio, USA.
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Real World Outcomes Associated with Idarucizumab: Population-Based Retrospective Cohort Study. Am J Cardiovasc Drugs 2020; 20:161-168. [PMID: 31332727 DOI: 10.1007/s40256-019-00360-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Idarucizumab reverses the anticoagulant effect of dabigatran, but few comparative studies have reported on clinical outcomes with idarucizumab. OBJECTIVE Our objective was to determine the effect of idarucizumab on clinical outcomes. METHODS We conducted a retrospective cohort study in a nationally representative sample of hospitals in the United States. The study population included adults ≥ 18 years who were hospitalized for dabigatran-associated major bleeding between January 1, 2015 and December 31, 2017. We compared idarucizumab-exposed patients to the unexposed group. Our primary outcome of interest was in-hospital mortality. RESULTS We included 266 exposed and 1345 non-exposed participants across 271 hospitals. Among participants with gastrointestinal bleeding, there was no statistically significant difference in the odds of in-hospital mortality [9/153 (5.9%) vs 37/1124 (3.3%); adjusted odds ratio = 1.39, 95% confidence interval 0.51-3.45] between the idarucizumab-exposed and non-exposed groups. Among participants with intracranial bleeding, there was an excess of in-hospital mortality [13/112 (11.6%) vs 6/217 (2.8%)] associated with idarucizumab exposure, but limitations include sparse data and the inability to rule out residual confounding or confounding by disease severity. CONCLUSIONS Among a large nationally representative sample of adult patients with dabigatran-associated major bleeding in the United States, we found no difference in in-hospital mortality among patients with gastrointestinal bleeding associated with idarucizumab exposure. An excess risk of in-hospital mortality associated with idarucizumab exposure among participants with intracranial bleeding deserves further exploration.
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Spanuchart I, Watanabe H, Aldan T, Chow D, Ng RC. Are Salt Tablets Effective in the Treatment of Euvolemic Hyponatremia? South Med J 2020; 113:125-129. [DOI: 10.14423/smj.0000000000001075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Tazmini K, Ranhoff AH. Electrolyte outpatient clinic at a local hospital - experience from diagnostics, treatment and follow-up. BMC Health Serv Res 2020; 20:154. [PMID: 32111205 PMCID: PMC7048094 DOI: 10.1186/s12913-020-5022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background Electrolyte imbalances (EI) are common among patients. Many patients have repeated hospitalizations with the same EI without being investigated and treated. We established an electrolyte outpatient clinic (EOC) to diagnose and treat patients with EI to improve symptoms and increase their quality of life (QoL). In addition, we also wanted to reduce the number of admissions with the same EI. Methods Uncontrolled before-after study reporting experiences from this outpatient clinic as a quality assurance project. From October 2010 to October 2015, doctors at our local hospital and general practitioners could refer adult patients with EI to the EOC. Ninety patients with EI were referred, of whom 60 were included. Medical history, clinical examination and laboratory tests were performed, and results registered. Admissions with the same EI were recorded 1 year before and 1 year after consultation at the EOC. Patients responded to a questionnaire, composed by the authors, about symptoms before the first consultation, as well as symptom and QoL improvement after the last consultation. Results Hyponatremia was the reason for referral in 45/60 patients. The total number of admissions with the same EI 1 year before the first consultation was 71, compared with 20 admissions 1 year after the last consultation. Improvement of symptoms was reported by 60% of patients, and 62% reported improvement in QoL. Conclusions An EOC may be an appropriate way to organize the assessment and treatment of patients with EI.
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Affiliation(s)
- Kiarash Tazmini
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway.,Department of Endocrinology, Morbid Obesity and Preventive Medicine, Faculty of Medicine, Oslo University Hospital, Postbox 4950 Nydalen, 0424, Oslo, Norway
| | - Anette Hylen Ranhoff
- Department of Medicine, Diakonhjemmet Hospital, Oslo, Norway. .,Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway.
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Gao XP, Zheng CF, Liao MQ, He H, Liu YH, Jing CX, Zeng FF, Chen QS. Admission serum sodium and potassium levels predict survival among critically ill patients with acute kidney injury: a cohort study. BMC Nephrol 2019; 20:311. [PMID: 31395027 PMCID: PMC6686448 DOI: 10.1186/s12882-019-1505-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/31/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Patients suffering from acute kidney injury (AKI) were associated with impaired sodium and potassium homeostasis. We aimed to investigate how admission serum sodium and potassium independently and jointly modified adverse clinical outcomes among AKI patients. METHODS Patient data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care Database III. Participants were categorized into three groups according to admission serum sodium and potassium, and the cut-off values were determined using smooth curve fitting. The primary outcome was 90-day mortality in the intensive care unit (ICU). Cox proportional hazards models were used to evaluate the prognostic effects of admission serum sodium and potassium levels. RESULTS We included 13,621 ICU patients with AKI (mean age: 65.3 years; males: 55.4%). The middle category of admission serum sodium and potassium levels were 136.0-144.9 mmol/L and 3.7-4.7 mmol/L through fitting smooth curve. In multivariable Cox models, compared with the middle category, patients with hyponatremia or hypernatremia were associated with excess mortality and the HRs and its 95%CIs were 1.38 (1.27, 1.50) and 1.56 (1.36, 1.79), and patients with either hypokalemia or hyperkalemia were associated with excess mortality and the hazard ratios (HRs) and its 95% confidential intervals (95% CIs) were 1.12 (1.02, 1.24) and 1.25 (1.14, 1.36), respectively. Significant interactions were observed between admission serum sodium and potassium levels (P interaction = 0.001), with a higher serum potassium level associated with increased risk of 90-day mortality among patients with hyponatremia, whereas the effects of higher sodium level on prognostic effects of potassium were subtle. CONCLUSIONS Admission serum sodium and potassium were associated with survival in a U-shaped pattern among patients with AKI, and hyperkalemia predict a worse clinical outcome among patients with hyponatremia.
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Affiliation(s)
- Xu-ping Gao
- Department of Epidemiology, School of Medicine, Jinan University, No.601 Huangpu Road West, Guangzhou, 510630 Guangdong China
| | - Chen-fei Zheng
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000 China
| | - Min-qi Liao
- Department of Epidemiology, School of Medicine, Jinan University, No.601 Huangpu Road West, Guangzhou, 510630 Guangdong China
| | - Hong He
- Health Care and Physical Examination Center, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, 510080 China
| | - Yan-hua Liu
- The First Affiliated Hospital of Zhengzhou University, No. 1 East Jianshe Road, Zhengzhou, 450052 Henan China
| | - Chun-xia Jing
- Department of Epidemiology, School of Medicine, Jinan University, No.601 Huangpu Road West, Guangzhou, 510630 Guangdong China
| | - Fang-fang Zeng
- Department of Epidemiology, School of Medicine, Jinan University, No.601 Huangpu Road West, Guangzhou, 510630 Guangdong China
| | - Qing-shan Chen
- Department of Epidemiology, School of Medicine, Jinan University, No.601 Huangpu Road West, Guangzhou, 510630 Guangdong China
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Amin AN, Ortendahl JD, Harmon AL, Kamat SA, Stellhorn RA, Chase SL, Sundar SV. Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia. Am J Health Syst Pharm 2019; 76:374-380. [PMID: 31361839 DOI: 10.1093/ajhp/zxy064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
PURPOSE Costs associated with unplanned readmissions among patients with heart failure with and without hyponatremia were studied. METHODS This study estimated the costs of patients hospitalized for heart failure (HF) discharged with or without corrected sodium. A model was developed to monetize the 30-day readmission risk based on hyponatremia correction. Costs of discharging patient with corrected versus uncorrected hyponatremia were estimated using readmission rates from a previously published study and hospitalization costs from the Healthcare Costs and Utilization Cost Project and the Premier Healthcare Database. RESULTS Discharging patients with HF and hyponatremia increased costs from $488-$569 per discharge compared to patients with corrected hyponatremia. This range reflected differences in readmission rates and sources of hospitalization costs. Sensitivity analyses showed hospitalization costs and readmission rates had the largest impact on model results. CONCLUSION A retrospective study supports the value of upfront monitoring and correction of low serum sodium levels before discharge among patients with HF and hyponatremia by presenting an economic argument in addition to the clinical rational for reducing risk of readmission.
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Affiliation(s)
- Alpesh N Amin
- Department of Medicine, Irvine School of Medicine, University of California, Irvine, CA
| | - Jesse D Ortendahl
- Health Economics, Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Amanda L Harmon
- Health Economics, Partnership for Health Analytic Research, LLC, Beverly Hills, CA
| | - Siddhesh A Kamat
- Health Economics and Outcomes Research, Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ
| | - Robert A Stellhorn
- Health Outcomes Data Analytics, Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ
| | - Sandra L Chase
- Field Medical Affairs, Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ
| | - Shirin V Sundar
- Field Medical Affairs, Otsuka Pharmaceutical Development and Commercialization, Princeton, NJ
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Elliman MG, Vongxay O, Soumphonphakdy B, Gray A. Hyponatraemia in a Lao paediatric intensive care unit: Prevalence, associations and intravenous fluid use. J Paediatr Child Health 2019; 55:695-700. [PMID: 30315614 DOI: 10.1111/jpc.14278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 08/25/2018] [Accepted: 09/23/2018] [Indexed: 11/27/2022]
Abstract
AIM Hyponatraemia is a common and potentially deadly complication affecting hospitalised children world-wide. Hypotonic intravenous fluids can be a significant exacerbating factor. Exclusive use of isotonic fluids, coupled with rigorous blood monitoring, has proven effective in reducing hyponatraemia in developed settings. In developing countries, where hyponatraemia is often more common and severe, different factors may contribute to its incidence and detection. We aimed to determine the prevalence and disease associations of hyponatraemia and describe the intravenous maintenance fluid prescribing practices in a Lao paediatric intensive care unit. METHODS We conducted a cross-sectional study of 164 children aged 1 month to 15 years admitted to intensive care at a tertiary centre in Lao People's Democratic Republic (PDR) and recorded their serum sodium and clinical data at admission and on two subsequent days. RESULTS Hyponatraemia was detected in 41% (67/164, confidence interval 34-48%) of children, the majority of which was mild (34%, 56/164) and present at admission (35%, 55/158). Hyponatraemia was more common in malnourished children (odds ratio (OR) 2.3, P = 0.012) and females (OR 1.9, P = 0.045). Hyponatraemia correlated with death or expected death after discharge (OR 2.2, P = 0.015); 88% received maintenance intravenous fluids, with 67% of those receiving a hypotonic solution. Electrolyte testing was only performed in 20% (9/46) of patients outside the study protocol. CONCLUSIONS Hyponatraemia is highly prevalent in critically ill children in Lao PDR, as is the continued use of hypotonic intravenous fluids. With financial and practical barriers to safely detecting and monitoring electrolyte disorders in this setting, this local audit can help promote testing and has already encouraged changes to fluid prescribing.
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Affiliation(s)
- Mark G Elliman
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
| | - Oulaivanh Vongxay
- University of Health Sciences, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
| | | | - Amy Gray
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia.,Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Tazmini K, Nymo SH, Louch WE, Ranhoff AH, Øie E. Electrolyte imbalances in an unselected population in an emergency department: A retrospective cohort study. PLoS One 2019; 14:e0215673. [PMID: 31022222 PMCID: PMC6483356 DOI: 10.1371/journal.pone.0215673] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 04/05/2019] [Indexed: 11/18/2022] Open
Abstract
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.
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Affiliation(s)
- Kiarash Tazmini
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- * E-mail:
| | - Ståle H. Nymo
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
| | - William E. Louch
- Institute of Experimental Medical Research, Oslo University Hospital, Ullevål and University of Oslo, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
| | - Anette H. Ranhoff
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Erik Øie
- Department of Internal Medicine, Diakonhjemmet Hospital, Oslo, Norway
- Center for Heart Failure Research, University of Oslo, Oslo, Norway
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Abstract
The syndrome of inappropriate antidiuresis (SIAD) is a common cause of hyponatremia in hospitalized children. SIAD refers to euvolemic hyponatremia due to nonphysiologic stimuli for arginine vasopressin production in the absence of renal or endocrine dysfunction. SIAD can be broadly classified as a result of tumors, pulmonary or central nervous system disorders, medications, or other causes such as infection, inflammation, and the postoperative state. The presence of hypouricemia with an elevated fractional excretion of urate can aid in the diagnosis. Treatment options include fluid restriction, intravenous saline solutions, oral sodium supplements, loop diuretics, oral urea, and vasopressin receptor antagonists (vaptans).
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Affiliation(s)
- Michael L Moritz
- Pediatric Nephrology, Pediatric Dialysis, Division of Nephrology, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, The University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
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Feld LG, Neuspiel DR, Foster BA, Leu MG, Garber MD, Austin K, Basu RK, Conway EE, Fehr JJ, Hawkins C, Kaplan RL, Rowe EV, Waseem M, Moritz ML. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics 2018; 142:peds.2018-3083. [PMID: 30478247 DOI: 10.1542/peds.2018-3083] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Maintenance intravenous fluids (IVFs) are used to provide critical supportive care for children who are acutely ill. IVFs are required if sufficient fluids cannot be provided by using enteral administration for reasons such as gastrointestinal illness, respiratory compromise, neurologic impairment, a perioperative state, or being moribund from an acute or chronic illness. Despite the common use of maintenance IVFs, there is high variability in fluid prescribing practices and a lack of guidelines for fluid composition administration and electrolyte monitoring. The administration of hypotonic IVFs has been the standard in pediatrics. Concerns have been raised that this approach results in a high incidence of hyponatremia and that isotonic IVFs could prevent the development of hyponatremia. Our goal in this guideline is to provide an evidence-based approach for choosing the tonicity of maintenance IVFs in most patients from 28 days to 18 years of age who require maintenance IVFs. This guideline applies to children in surgical (postoperative) and medical acute-care settings, including critical care and the general inpatient ward. Patients with neurosurgical disorders, congenital or acquired cardiac disease, hepatic disease, cancer, renal dysfunction, diabetes insipidus, voluminous watery diarrhea, or severe burns; neonates who are younger than 28 days old or in the NICU; and adolescents older than 18 years old are excluded. We specifically address the tonicity of maintenance IVFs in children.The Key Action Statement of the subcommittee is as follows:1A: The American Academy of Pediatrics recommends that patients 28 days to 18 years of age requiring maintenance IVFs should receive isotonic solutions with appropriate potassium chloride and dextrose because they significantly decrease the risk of developing hyponatremia (evidence quality: A; recommendation strength: strong).
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Affiliation(s)
- Leonard G Feld
- Retired, Nicklaus Children's Health System, Miami, Florida;
| | | | | | - Michael G Leu
- School of Medicine, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Matthew D Garber
- Department of Pediatrics, College of Medicine - Jacksonville, University of Florida, Jacksonville, Florida
| | | | - Rajit K Basu
- Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia
| | - Edward E Conway
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Jacobi Medical Center, Bronx, New York
| | - James J Fehr
- Departments of Anesthesiology and Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Clare Hawkins
- Department of Family Medicine, Houston Methodist Hospital, Houston, Texas
| | | | - Echo V Rowe
- Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and
| | | | - Michael L Moritz
- Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Management Strategies and Outcomes for Hyponatremia in Cirrhosis in the Hyponatremia Registry. Can J Gastroenterol Hepatol 2018; 2018:1579508. [PMID: 30363747 PMCID: PMC6180997 DOI: 10.1155/2018/1579508] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/31/2018] [Accepted: 08/08/2018] [Indexed: 12/20/2022] Open
Abstract
AIM Treatment practices and effectiveness in cirrhotic patients with hyponatremia (HN) in the HN Registry were assessed. METHODS Characteristics, treatments, and outcomes were compared between patients with HN at admission and during hospitalization. For HN at admission, serum sodium concentration [Na] response was analyzed until correction to > 130 mmol/L, switch to secondary therapy, or discharge or death with sodium ≤ 130 mmol/L. RESULTS Patients with HN at admission had a lower [Na] and shorter length of stay (LOS) than those who developed HN (P < 0.001). Most common initial treatments were isotonic saline (NS, 36%), fluid restriction (FR, 33%), and no specific therapy (NST, 20%). Baseline [Na] was higher in patients treated with NST, FR, or NS versus hypertonic saline (HS) and tolvaptan (Tol) (P < 0.05). Treatment success occurred in 39%, 39%, 52%, 78%, and 81% of patients with NST, FR, NS, HS, and Tol, respectively. Relapse occurred in 55% after correction and was associated with increased LOS (9 versus 6 days, P < 0.001). 34% admitted with HN were discharged with HN corrected. CONCLUSIONS Treatment approaches for HN were variable and frequently ineffective. Success was greatest with HS and Tol. Relapse of HN is associated with increased LOS.
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Amin AN, Ortendahl JD, Harmon AL, Kamat SA, Stellhorn RA, Chase SL, Sundar SV. Utilization and budget impact of tolvaptan in the inpatient setting among patients with heart failure and hyponatremia. Curr Med Res Opin 2018; 34:559-566. [PMID: 29297709 DOI: 10.1080/03007995.2018.1423958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Assess characteristics of patients with heart failure (HF) and hyponatremia (HN) using tolvaptan, a selective vasopressin V2-receptor antagonist, for sodium correction, and estimate the budget impact of tolvaptan use in a hospital. METHODS The Premier hospital database was analyzed to assess the utilization of tolvaptan, characteristics of users and non-users, and hospitalization costs among patients with HF and HN. Using these findings, a model was developed to estimate tolvaptan costs in proportion to total medical costs of managing patients with HF and HN, and the budget impact of tolvaptan use. Results were regenerated using data from the Healthcare Cost and Utilization Project (HCUP) database, and robustness was assessed in sensitivity analyses. RESULTS Tolvaptan was used in 4.96% of inpatient visits among patients with HF and HN, more commonly among sicker patients as reflected in high utilization during intensive care stays (30.46%). Additionally, utilization increased by length of stay, which can serve as a proxy for disease severity. The model estimated that tolvaptan costs accounted for 0.3% of total hospitalization-related costs for patients with HF and HN, and the budget impact was $52.42 per visit. CONCLUSIONS Results demonstrate that tolvaptan is used infrequently among patients with HF and HN, and is utilized among sicker patients. Tolvaptan accounted for 0.3% of total spending on management of inpatient visits with HF and HN, and had a marginal impact on hospital budget when compared with fluid restriction for HN correction. Availability of tolvaptan can provide an additional therapeutic option for sodium correction.
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Affiliation(s)
- Alpesh N Amin
- a University of California, Irvine , Irvine , CA , USA
| | - Jesse D Ortendahl
- b Partnership for Health Analytic Research LLC , Beverly Hills , CA , USA
| | - Amanda L Harmon
- b Partnership for Health Analytic Research LLC , Beverly Hills , CA , USA
| | - Siddhesh A Kamat
- c Otsuka Pharmaceutical Development & Commercialization Inc. , Princeton , NJ , USA
| | - Robert A Stellhorn
- c Otsuka Pharmaceutical Development & Commercialization Inc. , Princeton , NJ , USA
| | - Sandra L Chase
- c Otsuka Pharmaceutical Development & Commercialization Inc. , Princeton , NJ , USA
| | - Shirin V Sundar
- c Otsuka Pharmaceutical Development & Commercialization Inc. , Princeton , NJ , USA
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Castello LM, Baldrighi M, Panizza A, Bartoli E, Avanzi GC. Efficacy and safety of two different tolvaptan doses in the treatment of hyponatremia in the Emergency Department. Intern Emerg Med 2017; 12:993-1001. [PMID: 27444946 DOI: 10.1007/s11739-016-1508-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 07/14/2016] [Indexed: 11/26/2022]
Abstract
Hyponatremia (plasma sodium concentration or P[Na+] <136 mEq/L) is the most common electrolyte unbalance in clinical practice. Although it constitutes a negative prognostic factor, it frequently remains underdiagnosed and undertreated. Tolvaptan is an oral V2-receptor antagonist which produces aquaresis. Given its emerging role in the treatment of dilutional hyponatremia, we aimed to compare the efficacy and safety of two different doses of this drug in an Emergency Department (ED) setting. Consecutive patients with moderate-severe euvolemic or hypervolemic hyponatremia were sequentially assigned to the 15 mg Group and to the 7.5 mg Group, and were revaluated at 6, 12 and 24 h. Further evaluations and administrations were scheduled daily until P[Na+] correction was achieved or the maximum period of 72 h was exceeded. A 1-month follow-up was performed. Twenty-three patients were enrolled: 12 were included in the 15 mg Group, 11 in the 7.5 mg Group. Both doses significantly elevated the P[Na+] over 24 h, although the 15 mg Group showed faster corrections than the 7.5 mg Group (12 vs 6 mEq/L/24 h; P = 0.025). An optimal correction rate (within 4-8 mEq/L/24 h) was observed in 45.4 % of the 7.5 mg Group against 25.0 % (P n.s.). The standard dose led to dangerous overcorrections (>12 mEq/L/24 h) in 41.7 % of the patients, while the low dose did not cause any (P = 0.037). No osmotic demyelination syndrome was observed. A 7.5 mg tolvaptan dose can be considered both effective and safe in treating hyponatremia in the ED, while a 15 mg dose implicates too high risk of overcorrection.
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Affiliation(s)
- Luigi Mario Castello
- Maggiore della Carità University Hospital, Novara, Italy.
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
| | - Marco Baldrighi
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Alice Panizza
- Maggiore della Carità University Hospital, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Ettore Bartoli
- Maggiore della Carità University Hospital, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Gian Carlo Avanzi
- Maggiore della Carità University Hospital, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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Gómez-Hoyos E, Cuesta M, Del Prado-González N, Matía P, Pérez-Ferre N, De Luis DA, Calle-Pascual A, Rubio MÁ, Runkle-De la Vega I. Prevalence of Hyponatremia and Its Associated Morbimortality in Hospitalized Patients Receiving Parenteral Nutrition. ANNALS OF NUTRITION AND METABOLISM 2017; 71:1-7. [DOI: 10.1159/000477675] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 05/15/2017] [Indexed: 12/20/2022]
Abstract
Background: The objective of the study was to determine the prevalence of hyponatremia (HN) and its associated morbimortality in hospitalized patients receiving parenteral nutrition (PN). Methods: A retrospective study including 222 patients receiving total PN (parenteral nutrition group [PNG]) over a 7-month period in a tertiary hospital and 176 matched to 179 control subjects without PN (control subjects group [CSG]). Demographic data, Charlson Comorbidity Index (CCI), date of HN detection-(serum sodium or SNa <135 mmol/L)-intrahospital mortality, and hospital length-of-stay (LOS) were registered. In the PNG, body mass index (BMI) and SNa before, during, and after PN were recorded. Results: HN was more prevalent in the PNG: 52.8 vs. 35.8% (p = 0.001), and independent of age, gender, or CCI (OR 1.8 [95% CI 1.1-2.8], p = 0.006). In patients on PN, sustained HN (75% of all intraindividual SNa <135 mmol/L) was associated with a higher mortality rate independent of age, gender, CCI, or BMI (OR 7.38 [95% CI 1.07-50.8], p = 0.042). The absence of HN in PN patients was associated with a shorter hospital LOS (<30 days) and was independent of other comorbidities (OR 3.89 [95% CI 2.11-7.18], p = 0.001). Conclusions: HN is more prevalent in patients on PN. Sustained HN is associated with a higher intrahospital mortality rate. Absence of HN is associated with a shorter hospital LOS.
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20
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Ramamohan V, Mladsi D, Ronquest N, Kamat S, Boklage S. An economic analysis of tolvaptan compared with fluid restriction among hospitalized patients with hyponatremia. Hosp Pract (1995) 2017; 45:111-117. [PMID: 28449624 DOI: 10.1080/21548331.2017.1324227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The vasopressin-receptor antagonist tolvaptan is used for the treatment of hyponatremia (HN) in hospitalized patients with congestive heart failure (CHF) or syndrome of inappropriate antidiuretic hormone secretion (SIADH). The objective of this economic modeling study was to assess the potential cost and health outcomes associated with tolvaptan in comparison with fluid restriction (FR). METHODS A decision-analytic model was developed to estimate potential cost and health outcomes associated with tolvaptan compared with FR among hospitalized CHF and SIADH patients with severe HN (serum sodium [SS] levels < 125 mEq/L). The model, which was populated with data from the published literature, assumes that response to treatment influences hospital length of stay, probability of an intensive care unit (ICU) admission, and probability of a 30-day all-cause hospital readmission. One-way and probabilistic sensitivity analyses (PSAs) assessed the influence of parameter uncertainty on model results. RESULTS Model results suggest that, among hospitalized CHF patients with severe HN, the use of tolvaptan compared with FR may lead to reductions of 7.2% and 4.6% in ICU admissions and 30-day readmissions, respectively. Compared with FR, tolvaptan may result in total cost-savings of $156 per hospitalized CHF patient. Among hospitalized SIADH patients with severe HN, the model suggested reductions of 14.6% and 5.1% in ICU admissions and 30-day readmissions, respectively. Compared with FR, tolvaptan may result in total cost-savings of $135 per hospitalized SIADH patient. PSAs found that the probabilities of net cost-savings from the use of tolvaptan compared with FR were 64% and 59% among patients with severe HN with CHF and SIADH, respectively. CONCLUSIONS Decision-analytic modeling based on published data for hospitalized CHF and SIADH patients with severe HN, indicates that tolvaptan compared with FR has the potential to improve health outcomes and produce cost-savings that more than offset the cost of tolvaptan.
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Affiliation(s)
- Varun Ramamohan
- a Department of Health Economics , RTI Health Solutions , Research Triangle Park , NC 27709-2194 , USA
| | - Deirdre Mladsi
- a Department of Health Economics , RTI Health Solutions , Research Triangle Park , NC 27709-2194 , USA
| | - Naoko Ronquest
- a Department of Health Economics , RTI Health Solutions , Research Triangle Park , NC 27709-2194 , USA
| | - Siddhesh Kamat
- b Department of Health Economics and Outcomes Research , Otsuka Pharmaceutical Development & Commercialization , Princeton , NJ , USA
| | - Susan Boklage
- b Department of Health Economics and Outcomes Research , Otsuka Pharmaceutical Development & Commercialization , Princeton , NJ , USA
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Tzoulis P, Carr H, Bagkeris E, Bouloux PM. Improving care and outcomes of inpatients with syndrome of inappropriate antidiuresis (SIAD): a prospective intervention study of intensive endocrine input vs. routine care. Endocrine 2017; 55:539-546. [PMID: 27837439 PMCID: PMC5272879 DOI: 10.1007/s12020-016-1161-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 10/25/2016] [Indexed: 01/15/2023]
Abstract
PURPOSE The syndrome of inappropriate antidiuresis is often undertreated with most patients discharged with persistent hyponatraemia. This study tested the hypothesis that an endocrine input is superior to routine care in correcting hyponatraemia and can improve patient outcomes. METHODS This single-centre prospective-controlled intervention study included inpatients admitted at a UK teaching hospital, with serum sodium ≤ 127 mmol/l, due to syndrome of inappropriate antidiuresis over a 6-month period. The prospective intervention group (18 subjects with mean serum sodium 120.7 mmol/l) received prompt endocrine input, while the historical control group (23 patients with mean serum sodium 124.1 mmol/l) received routine care. The time needed for serum sodium increase ≥ 5 mmol/l was the primary endpoint. RESULTS The intervention group achieved serum sodium rise by ≥5 mmol/l in 3.5 vs. 7.1 days in the control group (P = 0.005). In the intervention group, the mean total serum sodium increase was 12 mmol/l with only 5.8 % of patients discharged with serum sodium < 130 vs. 6.3 mmol/l increase (P < 0.001) and 42.1 % of the subjects discharged with serum sodium < 130 mmol/l in the control group (P = 0.012). The mean length of hospital stay in the intervention group (10.9 days) was significantly shorter than in the control group (14.5 days; P = 0.004).The inpatient mortality rate was 5.5 % in intervention arm vs. 17.4 % in control arm, but this difference was not statistically significant. CONCLUSIONS Since the endocrine input improved time for correction of hyponatraemia and shortened length of hospitalisation, widespread provision of endocrine input should be considered.
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Affiliation(s)
- Ploutarchos Tzoulis
- Centre for Neuroendocrinology, Royal Free Campus, University College London Medical School, London, NW3 2QG, UK.
| | - Helen Carr
- Centre for Neuroendocrinology, Royal Free Campus, University College London Medical School, London, NW3 2QG, UK
| | - Emmanouil Bagkeris
- Centre of Epidemiology and Biostatistics, Institute of Child Health, University College London, London, UK
| | - Pierre Marc Bouloux
- Centre for Neuroendocrinology, Royal Free Campus, University College London Medical School, London, NW3 2QG, UK
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The Economic Burden of Hyponatremia: Systematic Review and Meta-Analysis. Am J Med 2016; 129:823-835.e4. [PMID: 27059386 DOI: 10.1016/j.amjmed.2016.03.007] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/10/2016] [Accepted: 03/10/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Hyponatremia is the most common electrolyte abnormality observed in clinical practice. Several studies have demonstrated that hyponatremia is associated with an increased length of hospital stay and of hospital resource utilization. To clarify the impact of hyponatremia on the length of hospitalization and costs, we performed a meta-analysis based on published studies that compared hospital length of stay and cost between patients with and without hyponatremia. METHODS An extensive Medline, Embase, and Cochrane search was performed to retrieve all studies published up to April 1, 2015 using the following words: "hyponatremia" or "hyponatraemia" AND "hospitalization" or "hospitalisation." A meta-analysis was performed including all studies comparing duration of hospitalization and hospital readmission rate in subjects with and without hyponatremia. RESULTS Of 444 retrieved articles, 46 studies satisfied the inclusion criteria, encompassing a total of 3,940,042 patients; among these, 757,763 (19.2%) were hyponatremic. Across all studies, hyponatremia was associated with a significantly longer duration of hospitalization (3.30 [2.90-3.71; 95% CIs] mean days; P < .000). Similar results were obtained when patients with associated morbidities were analyzed separately. Furthermore, hyponatremic patients had a higher risk of readmission after the first hospitalization (odds ratio 1.32 [1.18-1.48; 95% CIs]; P < .000). A meta-regression analysis showed that the hyponatremia-related length of hospital stay was higher in males (Slope = 0.09 [0.05-0.12; 95% CIs]; P = .000 and Intercept = -1.36 [-3.03-0.32; 95% CIs]; P = .11) and in elderly patients (Slope = 0.002 [0.001-0.003; 95% CIs]; P < .000 and Intercept = 0.89 [0.83-0.97; 95% CIs]; P < .001). A negative association between serum [Na(+)] cutoff and duration of hospitalization was detected. No association between duration of hospitalization, serum [Na(+)], and associated morbidities was observed. Finally, when only US studies (n = 8) were considered, hyponatremia was associated with up to around $3000 higher hospital costs/patient when compared with the cost of normonatremic subjects. CONCLUSIONS This meta-analysis confirms that hyponatremia is associated with a prolonged hospital length of stay and higher risk of readmission. These observations suggest that hyponatremia may represent one important determinant of the hospitalization costs.
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Verbalis JG, Greenberg A, Burst V, Haymann JP, Johannsson G, Peri A, Poch E, Chiodo JA, Dave J. Diagnosing and Treating the Syndrome of Inappropriate Antidiuretic Hormone Secretion. Am J Med 2016; 129:537.e9-537.e23. [PMID: 26584969 DOI: 10.1016/j.amjmed.2015.11.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 10/29/2015] [Accepted: 11/03/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND The syndrome of inappropriate antidiuretic hormone secretion is the most common cause of hyponatremia in clinical practice, but current management of hyponatremia and outcomes in patients with syndrome of inappropriate antidiuretic hormone secretion are not well understood. The objective of the Hyponatremia Registry was to assess the current state of management of hyponatremia due to syndrome of inappropriate antidiuretic hormone secretion in diverse hospital settings, specifically which diagnostic and treatment modalities are currently used and how rapidly and reliably they result in an increase in serum sodium concentration ([Na(+)]). A secondary objective was to determine whether treatment choices and outcomes differ across the United States and the European Union. METHODS The Hyponatremia Registry recorded selected diagnostic measures and use, efficacy, and outcomes of therapy for euvolemic hyponatremia diagnosed clinically as syndrome of inappropriate antidiuretic hormone secretion in 1524 adult patients with [Na(+)] ≤130 mEq/L (1034 from 146 US sites and 490 from 79 EU sites). A subgroup of patients with more rigorously defined syndrome of inappropriate antidiuretic hormone secretion via measurement of relevant laboratory parameters was also analyzed. RESULTS The most common monotherapy treatments for hyponatremia in syndrome of inappropriate antidiuretic hormone secretion were fluid restriction (48%), isotonic (27%) or hypertonic (6%) saline, and tolvaptan (13%); 11% received no active agent. The mean rate of [Na(+)] change (mEq/L/d) was greater for all active therapies than no active treatment. Hypertonic saline and tolvaptan produced the greatest mean rate of [Na(+)] change (interquartile range, both 3.0 [6.0] mEq/L/d) compared with lower interquartile range rates of [Na(+)] change for isotonic saline (1.5 [3.0] mEq/L/d) and fluid restriction (1.0 [2.3] mEq/L/d). The general pattern of responses was similar in both the US and EU cohorts. At discharge, [Na(+)] was <135 mEq/L in 75% of patients and ≤130 mEq/L in 43% of patients. Overly rapid correction occurred in 10.2% of patients. CONCLUSIONS Current treatment of hyponatremia in syndrome of inappropriate antidiuretic hormone secretion often uses therapies with limited efficacy; the most commonly chosen monotherapy treatments, fluid restriction and isotonic saline, failed to increase the serum [Na(+)] by ≥5 mEq/L in 55% and 64% of monotherapy treatment episodes, respectively. Appropriate laboratory tests to diagnose syndrome of inappropriate antidiuretic hormone secretion were obtained in <50% of patients; success rates in correcting hyponatremia were significantly higher when such tests were obtained. Few outcome differences were found between the United States and the European Union. A notable exception was hospital length of stay; use of tolvaptan was associated with significantly shorter length of stay in the European Union but not in the United States. Despite the availability of effective therapies, most patients with syndrome of inappropriate antidiuretic hormone secretion were discharged from the hospital still hyponatremic.
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Affiliation(s)
- Joseph G Verbalis
- Division of Endocrinology and Metabolism, Georgetown University Medical Center, Washington, DC.
| | | | - Volker Burst
- Department 2 of Internal Medicine and Center for Molecular Medicine, University Hospital of Cologne, Cologne, Germany
| | | | - Gudmundur Johannsson
- Department of Endocrinology, Institute of Medicine, University of Göteborg and Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Esteban Poch
- Nephrology Department, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | | | - Jiten Dave
- Otsuka Pharmaceuticals Europe Ltd, Wexham, United Kingdom
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Cuesta M, Hannon MJ, Thompson CJ. Diagnosis and treatment of hyponatraemia in neurosurgical patients. ACTA ACUST UNITED AC 2016; 63:230-8. [PMID: 26965574 DOI: 10.1016/j.endonu.2015.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 12/01/2015] [Accepted: 12/17/2015] [Indexed: 12/15/2022]
Abstract
Hyponatraemia is the most common electrolyte imbalance in neurosurgical patients. Acute hyponatraemia is particularly common in neurosurgical patients after any type of brain insult, including brain tumours and their treatment, pituitary surgery, subarachnoid haemorrhage or traumatic brain injury. Acute hyponatraemia is an emergency condition, as it leads to cerebral oedema due to passive osmotic movement of water from the hypotonic plasma to the relatively hypertonic brain which ultimately is the cause of the symptoms associated with hyponatraemia. These include decreased level of consciousness, seizures, non-cardiogenic pulmonary oedema or transtentorial brain herniation. Prompt treatment is mandatory to prevent such complications, minimize permanent brain damage and therefore permit rapid recovery after brain insult. The infusion of 3% hypertonic saline is the treatment of choice with different rates of administration based on the severity of symptoms and the rate of drop in plasma sodium concentration. The pathophysiology of hyponatraemia in neurotrauma is multifactorial; although the syndrome of inappropriate antidiuresis (SIADH) and central adrenal insufficiency are the commonest causes encountered. Fluid restriction has historically been the classical treatment for SIADH, although it is relatively contraindicated in some neurosurgical patients such as those with subarachnoid haemorrhage. Furthermore, many cases admitted have acute onset hyponatraemia, who require hypertonic saline infusion. The recently developed vasopressin receptor 2 antagonist class of drug is a promising and effective tool but more evidence is needed in neurosurgical patients. Central adrenal insufficiency may also cause acute hyponatraemia in neurosurgical patients; this responds clinically and biochemically to hydrocortisone. The rare cerebral salt wasting syndrome is treated with large volume normal saline infusion. In this review, we summarize the current evidence based on the clinical presentation, causes and treatment of different types of hyponatraemia in neurosurgical patients.
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Affiliation(s)
- Martín Cuesta
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Mark J Hannon
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
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Hennrikus E, Ou G, Kinney B, Lehman E, Grunfeld R, Wieler J, Damluji A, Davis C, Mets B. Prevalence, Timing, Causes, and Outcomes of Hyponatremia in Hospitalized Orthopaedic Surgery Patients. J Bone Joint Surg Am 2015; 97:1824-32. [PMID: 26582612 DOI: 10.2106/jbjs.o.00103] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hyponatremia is common among orthopaedic patients and is associated with adverse clinical outcomes. We examined the prevalence, timing, causes, and outcomes of hyponatremia in adult hospitalized orthopaedic surgery patients. METHODS We evaluated the medical records of 1067 consecutive orthopaedic surgery patients admitted to a tertiary academic institution. The medical records were reviewed to investigate hyponatremia (serum sodium <135 mEq/L) that (1) had been present on hospital admission or (2) had developed postoperatively. The primary outcomes were the prevalence and timing of, and risk factors for, presentation with or development of hyponatremia. Secondary outcomes were hospital length of stay, total hospital cost, and discharge disposition. Multivariable logistic regression models were used to assess the variables associated with hyponatremia and the effects of hyponatremia on clinical outcomes. RESULTS Of the 1067 patients, seventy-one (7%) had preoperative hyponatremia and 319 (30%) developed hyponatremia postoperatively. Of the latter, 298 (93%) developed hyponatremia within forty-eight hours postoperatively. Compared with patients with normonatremia, those who presented with hyponatremia, on the average, were older (67.2 versus 60.5 years, p < 0.001), had longer hospital stays (4.6 versus 3.3 days, p < 0.001), incurred higher hospital costs ($19,200 versus $17,000, p = 0.006), and were more likely to be discharged to an extended-care facility (odds ratio [OR] = 2.87, p < 0.001). Developing hyponatremia postoperatively resulted, on average, in a longer hospital stay (3.7 versus 3.3 days, p = 0.002) and greater hospital cost ($18,800 versus $17,000, p < 0.001). Age (OR = 1.13 per decade, p = 0.012), spine surgery (OR = 2.76 versus knee, p < 0.001), hip surgery (OR = 1.76 versus knee, p < 0.001), and the amount of lactated Ringer solution used (OR = 1.16, p = 0.002) increased the risk of developing hyponatremia. CONCLUSIONS Hyponatremia in orthopaedic patients is associated with longer, costlier hospitalizations. The factors that significantly increased the risk of developing postoperative hyponatremia were an older age, spine fusion, hip arthroplasty, and the amount of lactated Ringer solution used.
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Affiliation(s)
- Eileen Hennrikus
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
| | - George Ou
- Department of Internal Medicine, University of British Columbia, 2775 Laurel Street, 10th Floor, Vancouver, BC V5Z 1M9, Canada
| | - Bradley Kinney
- Senior Medical Officer, Special Boat Team 22, Stennis Space Center, MS 39520
| | - Erik Lehman
- Department of Public Health Sciences, Penn State Hershey College of Medicine, 90 Hope Drive, Hershey, PA 17033
| | - Robert Grunfeld
- Department of Orthopedics, University of Rochester, 601 Elmwood Avenue, Box 665, Rochester, NY 14642
| | - Jane Wieler
- Rocky Vista University College of Osteopathic Medicine, 8401 South Chambers Road, Parker, CO 80134
| | - Abdulla Damluji
- Cardiovascular Division Internal Medicine, University of Miami Miller School of Medicine, 1600 NW 10th Avenue, Miami, FL 33136
| | - Charles Davis
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
| | - Berend Mets
- Departments of Internal Medicine (E.H.), Orthopedics and Rehabilitation (C.D.), and Anesthesiology (B.M.), Milton S. Hershey Medical Center, Pennsylvania State University College of Medicine, 500 University Drive, MC H034, Hershey, PA 17033. E-mail address for E. Hennrikus:
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Méndez-Bailón M, Barba-Martín R, de Miguel-Yanes JM, Zapatero-Gaviria A, Calvo-Porqueras B, Osuna MFZ, Nuñez-Fernández C, Muñoz-Rivas N, Plaza Canteli S, Marco-Martínez J. Hyponatremia in hospitalised patients with heart failure in internal medicine: Analysis of the Spanish national minimum basic data set (MBDS) (2005-2011). Eur J Intern Med 2015; 26:603-6. [PMID: 26118453 DOI: 10.1016/j.ejim.2015.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 05/31/2015] [Accepted: 06/16/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Hyponatremia is the most common electrolyte disorder seen in clinical practice. Numerous studies have reported increased inhospital mortality associated to this condition, which is also an independent predictor of comorbidity in patients admitted with heart failure (HF). The objective of this study is to assess the incidence, average length of stay, associated comorbidities, readmissions and mortality caused by hyponatremia in admissions for acute heart failure from the Spanish national minimum basic data set (MBDS). MATERIALS AND METHODS Data from the Spanish national minimum basic data set (MBDS) of discharged patients who were initially diagnosed with heart failure (HF) from all internal medicine (IM) departments of Spanish National Health System (SNS) hospitals between 2005 and 2011 were analysed (ICD-9: 428; DRGs 127 and 544). A descriptive data analysis was conducted comparing the diagnosis codes and administrative variables of heart failure patients with and without hyponatremia. The chi-square test was used for qualitative variables and the Student's t test for quantitative variables. A bivariate analysis was used to detect statistical differences in the mortality of both groups, as well as mean age, Charlson index, average length of stay and readmissions. A multivariate logistic regression analysis was performed, taking intrahospital mortality and hospital readmissions as dependent variables, and age, gender, comorbidity according to the Charlson index and hyponatremia as independent variables. RESULTS A total of 504,860 patients with acute heart failure were identified, of whom 11,095 (2.2%) presented with HNa. A gradual year-on-year increase of hyponatremia codification (both primary and secondary diagnosis) was observed at discharge throughout the study period (from 1.6% in 2005 to 2.8% in 2011; p<0.0001). Overall mortality due to any cause in patients with hyponatremia was 17% (1937 patients) versus 11% in non-hyponatremic patients (53,820 patients). The probability of readmission for patients with hyponatremia was 22% versus 17% in the non-hyponatremic group. Hyponatremia was associated to a higher rate of mortality during hospitalisation for acute heart failure with an odds ratio (OR) of 1.58, 95% CI, 1.50-1.66 (p<0.05). Hyponatremia maintained statistical significance in the regression model after adjusting for gender, OR 0.919 (95% CI 0.902-0.936); age, OR 1.061 (95% CI 1.060-1.062); and Charlson index, OR 1.388 (95% CI 1.361-1.461). CONCLUSIONS Hyponatremia is associated to an increased rate of mortality and readmission in patients admitted for acute heart failure in SNS hospitals. Our study identified a statistically significant association between hyponatremia and increased intrahospital mortality independent of age, gender and the Charlson comorbidity index. During the defined follow-up period the discharge reports showed an increased codification of hyponatremia.
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Affiliation(s)
- Manuel Méndez-Bailón
- Servicio de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain.
| | - Raquel Barba-Martín
- Servicio de Medicina Interna, Hospital Rey Juan Carlos I, Móstoles, Madrid, Spain
| | | | | | | | | | - Carla Nuñez-Fernández
- Servicio de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Nuria Muñoz-Rivas
- Servicio de Medicina Interna, Hospital Infanta Leonor, Madrid, Spain
| | | | - Javier Marco-Martínez
- Servicio de Medicina Interna, Hospital Universitario Clínico San Carlos, Madrid, Spain
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Ahamed S, Anpalahan M, Savvas S, Gibson S, Torres J, Janus E. Hyponatraemia in older medical patients: implications for falls and adverse outcomes of hospitalisation. Intern Med J 2015; 44:991-7. [PMID: 25039672 DOI: 10.1111/imj.12535] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/06/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Recent evidence suggests an association between hyponatraemia and falls. AIMS To determine the association of hyponatraemia with admission-associated falls (i.e. falls as part of the presenting complaint or during admission) and predefined adverse outcomes of hospitalisation. METHODS A case-control study of patients aged ≥65 years admitted with hyponatraemia during a 6-month period was conducted. The relevant data were collected by review of medical records and analysed in univariate and multivariate models. RESULTS The prevalence of hyponatraemia was 22% and more likely to be associated with the admission diagnoses of cardiovascular (P = 0.04) and metabolic disorders (P < 0.001), use of diuretics (P = 0.037) and a higher Charlson comorbidity score (P = 0.035). Hyponatraemia was independently associated with admission-associated falls (odds ratio (OR) 3.12, confidence interval (CI) 1.84-4.38, P < 0.001). The increased odds of falling were similar for mild (OR 3.15, CI 1.75-5.66) vs moderate to severe hyponatraemia (OR 3.07, CI 1.57-6.03). Although hyponatraemia had a significant independent association with increased length of stay (LOS) (OR 1.48, CI 1.22-1.79, P < 0.001) and change in residential care status to a more dependent category at discharge (OR 4.28, CI 1.68-10.859, P = 0.002), it was not associated with mortality or time to first unplanned readmission. Hyponatraemia was significantly associated with the need for inpatient rehabilitation; however, this was no longer significant when adjusted for falls. CONCLUSION Hyponatraemia is independently associated with increased risk of admission-associated falls. The degree of falls risk is similar regardless of the severity of hyponatraemia. Hyponatraemia is also an important determinant of many adverse outcomes of hospitalisation.
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Affiliation(s)
- S Ahamed
- General Medicine Unit, Western Health, Melbourne, Victoria, Australia
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Dasta J, Waikar SS, Xie L, Boklage S, Baser O, Chiodo J, Badawi O. Patterns of treatment and correction of hyponatremia in intensive care unit patients. J Crit Care 2015. [PMID: 26209428 DOI: 10.1016/j.jcrc.2015.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE The goal of this study was to examine the real-world patterns of care and interventions among intensive care unit (ICU) patients with hypervolemic and euvolemic hyponatremia using a large clinical database. MATERIALS AND METHODS The Phillips eICU Research Institute database was used to investigate hyponatremia treatment patterns and trends, mortality, and ICU and hospital length of stay. Demographics, clinical characteristics, and outcome variables were compared in patients corrected for hyponatremia using both a more strict and a less strict definition. RESULTS At admission, 35%, 55%, and 10% of patients had mild, moderate, and severe hyponatremia, respectively. At the end of an ICU stay, the percentage of patients who did not have corrected serum sodium concentration was 48% (using a more strict definition) and 24% (using a less strict definition). Using either definition of correction, patients with serum sodium correction had lower mortality and longer survival than did patients without corrected serum sodium concentration. CONCLUSIONS A significant proportion of hyponatremia is not corrected during an ICU stay. Critically ill patients with hyponatremia who have their serum sodium corrected have lower mortality and longer survival, highlighting the need for more attention to hyponatremia and its correction in critically ill patients.
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Affiliation(s)
- Joseph Dasta
- The Ohio State University College of Pharmacy, Columbus, OH; University of Texas College of Pharmacy, Austin, TX.
| | | | - Lin Xie
- STATinMED Research, Ann Arbor, MI
| | | | - Onur Baser
- STATinMED Research, Ann Arbor, MI; Columbia University, New York, NY; MEF University, Istanbul, Turkey
| | | | - Omar Badawi
- Philips Healthcare, Baltimore, MD; University of Maryland School of Pharmacy, Baltimore, MD; Massachusetts Institute of Technology, Cambridge, MA
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Frangeskou M, Lopez-Valcarcel B, Serra-Majem L. Dehydration in the Elderly: A Review Focused on Economic Burden. J Nutr Health Aging 2015; 19:619-27. [PMID: 26054498 DOI: 10.1007/s12603-015-0491-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Dehydration is the most common fluid and electrolyte problem among elderly patients. It is reported to be widely prevalent and costly to individuals and to the health care system. The purpose of this review is to summarize the literature on the economic burden of dehydration in the elderly. METHOD A comprehensive search of several databases from database inception to November 2013, only in English language, was conducted. The databases included Pubmed and ISI Web of Science. The search terms «dehydration» / "hyponaremia" / "hypernatremia" AND «cost» AND «elderly» were used to search for comparative studies of the economic burden of dehydration. A total of 15 papers were identified. RESULTS Dehydration in the elderly is an independent factor of higher health care expenditures. It is directly associated with an increase in hospital mortality, as well as with an increase in the utilization of ICU, short and long term care facilities, readmission rates and hospital resources, especially among those with moderate to severe hyponatremia. CONCLUSIONS Dehydration represents a potential target for intervention to reduce healthcare expenditures and improve patients' quality of life.
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Affiliation(s)
- M Frangeskou
- Dr. Lluis Serra Majem, Research Institute of Biomedical and Health Sciencies, University of Las Palmas de Gran Canaria, PO Box 550; 35080-Las Palmas de Gran Canaria, Spain. Telephone:+34 928 453476 Fax:+34 928 453475 E-mail address:
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Current treatment practice and outcomes. Report of the hyponatremia registry. Kidney Int 2015; 88:167-77. [PMID: 25671764 PMCID: PMC4490559 DOI: 10.1038/ki.2015.4] [Citation(s) in RCA: 120] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Revised: 11/24/2014] [Accepted: 12/05/2014] [Indexed: 01/16/2023]
Abstract
Current management practices for hyponatremia (HN) are incompletely understood. The HN Registry has recorded diagnostic measures, utilization, efficacy, and outcomes of therapy for eu- or hypervolemic HN. To better understand current practices, we analyzed data from 3087 adjudicated adult patients in the registry with serum sodium concentration of 130 mEq/l or less from 225 sites in the United States and European Union. Common initial monotherapy treatments were fluid restriction (35%), administration of isotonic (15%) or hypertonic saline (2%), and tolvaptan (5%); 17% received no active agent. Median (interquartile range) mEq/l serum sodium increases during the first day were as follows: no treatment, 1.0 (0.0–4.0); fluid restriction, 2.0 (0.0–4.0); isotonic saline, 3.0 (0.0–5.0); hypertonic saline, 5.0 (1.0–9.0); and tolvaptan, 4.0 (2.0–9.0). Adjusting for initial serum sodium concentration with logistic regression, the relative likelihoods for correction by 5 mEq/l or more (referent, fluid restriction) were 1.60 for hypertonic saline and 2.55 for tolvaptan. At discharge, serum sodium concentration was under 135 mEq/l in 78% of patients and 130 mEq/l or less in 49%. Overly rapid correction occurred in 7.9%. Thus, initial HN treatment often uses maneuvers of limited efficacy. Despite an association with poor outcomes and availability of effective therapy, most patients with HN are discharged from hospital still hyponatremic. Studies to assess short- and long-term benefits of correction of HN with effective therapies are needed.
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Gray JR, Morbitzer KA, Liu-DeRyke X, Parker D, Zimmerman LH, Rhoney DH. Hyponatremia in Patients with Spontaneous Intracerebral Hemorrhage. J Clin Med 2014; 3:1322-32. [PMID: 26237605 PMCID: PMC4470185 DOI: 10.3390/jcm3041322] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/28/2014] [Accepted: 10/31/2014] [Indexed: 12/04/2022] Open
Abstract
Hyponatremia is the most frequently encountered electrolyte abnormality in critically ill patients. Hyponatremia on admission has been identified as an independent predictor of in-hospital mortality in patients with spontaneous intracerebral hemorrhage (sICH). However, the incidence and etiology of hyponatremia (HN) during hospitalization in a neurointensive care unit following spontaneous intracerebral hemorrhage (sICH) remains unknown. This was a retrospective analysis of consecutive patients admitted to Detroit Receiving Hospital for sICH between January 2006 and July 2009. All serum Na levels were recorded for patients during the ICU stay. HN was defined as Na <135 mmol/L. A total of 99 patients were analyzed with HN developing in 24% of sICH patients. Patients with HN had an average sodium nadir of 130 ± 3 mmol/L and an average time from admission to sodium <135 mmol/L of 3.9 ± 5.7 days. The most common cause of hyponatremia was syndrome of inappropriate antidiuretic hormone (90% of HN patients). Patients with HN were more likely to have fever (50% vs. 23%; p = 0.01), infection (58% vs. 28%; p = 0.007) as well as a longer hospital length of stay (14 (8–25) vs. 6 (3–9) days; p < 0.001). Of the patients who developed HN, fifteen (62.5%) patients developed HN in the first week following sICH. This shows HN has a fairly high incidence following sICH. The presence of HN is associated with longer hospital length of stays and higher rates of patient complications, which may result in worse patient outcomes. Further study is necessary to characterize the clinical relevance and treatment of HN in this population.
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Affiliation(s)
- Jaime Robenolt Gray
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - Kathryn A Morbitzer
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
| | - Xi Liu-DeRyke
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, MI 48201, USA.
| | - Dennis Parker
- Department of Pharmacy, Detroit Receiving Hospital, Detroit, MI 48201, USA.
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI 48201, USA.
| | - Lisa Hall Zimmerman
- Department of Pharmacy, New Hanover Regional Medical Center, Wilmington, NC 28401, USA.
| | - Denise H Rhoney
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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Hannon MJ, Thompson CJ. Neurosurgical Hyponatremia. J Clin Med 2014; 3:1084-104. [PMID: 26237593 PMCID: PMC4470172 DOI: 10.3390/jcm3041084] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Revised: 09/11/2014] [Accepted: 09/22/2014] [Indexed: 02/08/2023] Open
Abstract
Hyponatremia is a frequent electrolyte imbalance in hospital inpatients. Acute onset hyponatremia is particularly common in patients who have undergone any type of brain insult, including traumatic brain injury, subarachnoid hemorrhage and brain tumors, and is a frequent complication of intracranial procedures. Acute hyponatremia is more clinically dangerous than chronic hyponatremia, as it creates an osmotic gradient between the brain and the plasma, which promotes the movement of water from the plasma into brain cells, causing cerebral edema and neurological compromise. Unless acute hyponatremia is corrected promptly and effectively, cerebral edema may manifest through impaired consciousness level, seizures, elevated intracranial pressure, and, potentially, death due to cerebral herniation. The pathophysiology of hyponatremia in neurotrauma is multifactorial, but most cases appear to be due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Classical treatment of SIADH with fluid restriction is frequently ineffective, and in some circumstances, such as following subarachnoid hemorrhage, contraindicated. However, the recently developed vasopressin receptor antagonist class of drugs provides a very useful tool in the management of neurosurgical SIADH. In this review, we summarize the existing literature on the clinical features, causes, and management of hyponatremia in the neurosurgical patient.
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Affiliation(s)
- Mark J Hannon
- Department of Endocrinology, St. Bartholomew's Hospital, London, EC1A 7BE, UK.
| | - Christopher J Thompson
- Academic Department of Endocrinology, Beaumont Hospital/RCSI Medical School, Dublin, Ireland.
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Moritz ML, Ayus JC. Management of hyponatremia in various clinical situations. Curr Treat Options Neurol 2014; 16:310. [PMID: 25099180 DOI: 10.1007/s11940-014-0310-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OPINION STATEMENT Hyponatremia is the most common electrolyte abnormality in both inpatient and outpatient settings. The condition primarily results from the combination of impaired free water excretion due to elevated vasopressin levels in conjunction with a source of free water intake. Recent studies have revealed that even mild and asymptomatic hyponatremia is associated with deleterious consequences. It is an independent risk factor for mortality and is also associated with increased length of hospitalization and hospital costs. Even mild chronic hyponatremia can result in subtle neurologic impairment and bone demineralization, leading to falls and associated bone fractures in the elderly. Hyponatremia can be a difficult condition to treat, with varying therapeutic strategies based on the etiology, severity, duration, and extent of neurologic symptoms. The ideal magnitude of correction is also controversial, as both inadequate therapy and overly aggressive therapy can result in neurologic injury. Formulas that have been devised to aid in the treatment of hyponatremia can be inaccurate in that they fail to adequately account for the renal response to therapy. Hyponatremic encephalopathy is the most serious complication of hyponatremia, and can result in permanent neurologic impairment or death if left untreated. Individuals most at risk for developing hyponatremic encephalopathy are postmenarchal women, children under 16 years of age, patients with central nervous system disease or hypoxemia, and patients in the postoperative setting. The preferred therapy for hyponatremic encephalopathy is a 100-ml bolus of 3 % sodium chloride (513 mEq/L) administered in repeated doses until symptoms reverse, with the goal of increasing the serum sodium 5-6 mEq/L. Vasopressin (V2) antagonists (vaptans) are not appropriate for the management of acute hyponatremic encephalopathy, as the onset of action is not sufficiently rapid and the increase in sodium is not predictable. Vaptans are primarily indicated for the treatment of asymptomatic hyponatremia due to SIAD that is refractory to conventional measures.
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Affiliation(s)
- Michael L Moritz
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
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Makam AN, Boscardin WJ, Miao Y, Steinman MA. Risk of thiazide-induced metabolic adverse events in older adults. J Am Geriatr Soc 2014; 62:1039-45. [PMID: 24823661 DOI: 10.1111/jgs.12839] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To evaluate the risk and predictors of thiazide-induced adverse events (AEs) in multimorbid older adults in real-world clinical settings. DESIGN Observational cohort study. SETTING National Veterans Affairs data from 2007 to 2008. PARTICIPANTS Veterans aged 65 and older newly prescribed a thiazide (N = 1,060) compared with propensity-matched nonusers of antihypertensive medications (N = 1,060). MEASUREMENTS The primary outcome was a composite of metabolic AEs defined as sodium less than 135 mEq/L, potassium less than 3.5 mEq/L, or a decrease in the estimated glomerular filtration rate (eGFR) of more than 25% from the baseline rate. Secondary outcomes included sev-ere AEs (sodium <130 mEq/L, potassium <3.0 mEq/L, or a decrease in eGFR of more than 50%). RESULTS Over 9 months of follow-up, 14.3% of new thiazide users developed an AE, compared with 6.0% of nonusers (number needed to harm (NNH) 12, 95% confidence interval (CI) = 9-17, P < .001); 1.8% of new users developed a severe AE, compared with 0.6% of nonusers (NNH = 82, P = .008), and 3.8% of new users had an emergency department visit or hospitalization with an AE, compared with 2.0% of nonusers (NNH = 56, P = .02). Risk of AEs did not vary according to age, but having five or more comorbidities was associated with 3.0 times the odds (95% CI = 1.4-6.2) of developing an AE as having one comorbidity (hypertension). Low-normal and unmeasured baseline sodium and potassium values were among the strongest predictors of hyponatremia and hypokalemia, respectively. Only 42% of thiazide users had laboratory monitoring within 90 days after initiation. CONCLUSION Thiazide-induced AEs are common in older adults. Greater attention should be paid to potential complications in prescribing thiazides to older adults, including closer laboratory monitoring before and after initiation of thiazides.
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Affiliation(s)
- Anil N Makam
- Division of General Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Deitelzweig S, Amin A, Christian R, Friend K, Lin J, Lowe TJ. Health care utilization, costs, and readmission rates associated with hyponatremia. Hosp Pract (1995) 2013; 41:89-95. [PMID: 23466971 DOI: 10.3810/hp.2013.02.1014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
PURPOSE Hyponatremia is associated with higher morbidity and mortality rates among hospitalized patients. Our study evaluated health care utilization and associated costs of patients hospitalized with a primary diagnosis of hyponatremia. METHODS Hospitalized patients with a primary discharge diagnosis of hyponatremia (aged ≥ 18 years) were identified from the Premier Perspective™ database (January 1, 2007-March 31, 2010) and matched to non-hyponatremic (non-HN) patients using a combination of exact patient characteristic matching and propensity score matching. Univariate and multivariate statistics were used to compare hospital resource usage, costs, and 30-day readmission rates between cohorts. RESULTS Hospital length of stay (LOS) (± standard deviation) (3.78 ± 3.19 vs 3.54 ± 3.26 days; P < 0.001) and cost ($5396 ± $6500 vs $4979 ± $6152; P < 0.001 for the hyponatremic [HN] and non-HN patient cohorts, respectively) were greater for the HN cohort, but intensive care unit (ICU) costs ($3554 ± $6463 vs $3484 ± $8510; P = 0.828) and ICU LOS (2.37 ± 3.47 vs 2.52 ± 3.87; P = 0.345) did not differ between cohorts. The ICU admission rate (7.9% vs 4.4%; P < 0.001), as well as the 30-day readmission rate (12.1% vs 2.9%; P < 0.001) were greater for the HN cohort. After adjustment for key patient characteristics, hyponatremia was associated with a 7.6% increase in hospital LOS, an 8.9% increase in hospital costs, and a 9% increase in ICU costs. Hyponatremia was associated with an increased risk of ICU admission (odds ratio, 1.89, confidence limits, 1.72, 2.07; P < 0.001) and 30-day hospital readmission for hyponatremia (odds ratio, 4.76; confidence limits, 4.31, 5.26; P < 0.001). CONCLUSION Compared with non-HN patients, patients with a primary diagnosis of hyponatremia use a greater amount of hospital resources and represent a challenge to hospital profitability due to the increased likelihood of 30-day readmission.
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