Changes in renal sodium transport during a systemic inflammatory response

The prevalence and prognosis of hyponatraemia in non-Hodgkin lymphoma-associated hemophagocytic lymphohistiocytosis

Non-Hodgkin lymphoma associated hemophagocytic lymphohistiocytosis (NHL-HLH) in adult secondary HLH is a common and universally highly lethal critical disorder. Hyponatraemia is the most common electrolyte disorder in the critical illness setting and acts as a negative prognostic factor. The aim of our study was to evaluate the prognostic role of hyponatraemia among patients with NHL-HLH. The results showed that 81 (52.9%) patients had hyponatraemia. After a median follow up 47 (range 14-180) days, there were 72 (88.9%) cumulative deaths in hyponatraemia group while 50 (69.4%) in normonatremia group. After adjustment for confounders, multivariate analysis revealed that hyponatraemia was an independent prognostic factor for OS (HR:1.51, 95% CI: 1.03-2.20; p = 0.033). Restricted cubic spline confirmed a linear and positive association between serum sodium and the risk of mortality. Hyponatraemia is relatively frequent in NHL-HLH. As a readily available biomarker in clinical routine, it was a promising prognostic predictor for NHL-HLH.

Systemic lupus erythematosus presenting as hyponatremia-associated rhabdomyolysis: A case report

RATIONALE

Systemic lupus erythematosus (SLE) is an autoimmune disease that involves multiple organs and causes various clinical manifestations. Cases of rhabdomyolysis as the initial presentation of SLE are rare, and there are no reported cases of SLE presenting hyponatremia-associated rhabdomyolysis as the first manifestation. Herein, we report a case of SLE with lupus nephritis in a patient with acute hyponatremia-associated rhabdomyolysis.

PATIENT CONCERNS

A 44-year-old woman was admitted with complaints of altered consciousness, myalgia, and red-brownish urine that first appeared three days prior. Peripheral blood tests revealed elevated creatine kinase (19,013 IU/L) and myoglobin (5099 U/L) levels and severe hyponatremia (111 mEq/L) with no azotemia. Urinalysis showed nephritic sediments.

DIAGNOSIS

Whole-body bone scintigraphy showed increased uptake of radiotracer in the both upper and lower extremities. Serological evaluation revealed the presence of anti-nuclear (speckled pattern, 1:640), anti-double stranded DNA, and anti-Smith antibodies and absence of anti-Jo-1 antibody. A kidney biopsy demonstrated mesangial proliferative (class II) lupus nephritis.

INTERVENTIONS

Fluid therapy, including intravenous administration of 3% NaCl, was initiated. After three consecutive days of intravenous methylprednisolone (1 g/d), oral prednisolone (1 mg/kg/d), mycophenolate mofetil, and hydroxychloroquine were administered.

OUTCOMES

On day 28, the patient was discharged with marked resolution of SLE-associated symptoms and laboratory findings. Lupus reactivation was not present during the subsequent six-month follow-up.

LESSONS

Hyponatremia-associated rhabdomyolysis can be the first manifestation of SLE. Moreover, prompt fluid therapy and timely administration of immunosuppressive agents in SLE patients presenting with hyponatremia and rhabdomyolysis can significantly help alleviate disease activity and improve clinical outcomes.

Hyponatremia in infants with community-acquired infections on hospital admission

Acute moderate to severe gastroenteritis is traditionally associated with hypernatremia but recent observations suggest that hypernatremia is currently less common than hyponatremia. The latter has sometimes been documented also in children with acute community-acquired diseases, such as bronchiolitis and pyelonephritis. We investigated the prevalence of dysnatremia in children with acute moderate severe gastroenteritis, bronchiolitis and pyelonephritis. This prospective observational study included 400 consecutive previously healthy infants ≥4 weeks to ≤24 months of age (232 males and 168 females): 160 with gastroenteritis and relevant dehydration, 160 with moderate-severe bronchiolitis and 80 with pyelonephritis admitted to our emergency department between 2009 and 2017. Circulating sodium was determined by means of direct potentiometry. For analysis, the Kruskal-Wallis test and the Fisher’s exact test were used. Hyponatremia was found in 214 of the 400 patients. It was common in gastroenteritis (43%) and significantly more frequent in bronchiolitis (57%) and pyelonephritis (68%). Patients with hyponatremia were significantly younger than those without hyponatremia (3.9 [1.6–13] versus 7.5 [3.4–14] months). The gender ratio was similar in children with and without hyponatremia. Hyponatremia was associated with further metabolic abnormalities (hypokalemia, hyperkalemia, metabolic acidosis or metabolic alkalosis) in gastroenteritis (71%) and pyelonephritis (54%), and always isolated in bronchiolitis. In conclusion, hyponatremia is common at presentation among previously healthy infants with gastroenteritis, bronchiolitis or pyelonephritis. These data have relevant consequences for the nutrition and rehydration management in these conditions.

Hyponatremia in patients with systemic lupus erythematosus

The aim of this study was to determine whether decreased serum sodium concentration could be associated with the disease activity in SLE. We retrospectively analyzed the data of the two independent cohorts of children and adults with SLE in two centers. Hyponatremia was associated with serum chloride (p = 0.004), albumin (p = 0.002) and SLE disease activity index (SLEDAI) (p = 0.026) in children with SLE. Serum sodium levels were correlated negatively with ESR (p =0.001) and positively with serum albumin levels (p < 0.0001) and C3 (p = 0.008) in children with SLE and those levels were correlated negatively with serum interleukin-6 levels (p = 0.003) in adults with SLE. Independent risk factors for the development of hyponatremia were the decreased serum C3 levels (OR 1.069, p = 0.031), the decreased serum chloride levels (OR 2.054, p = 0.006) and increased erythrocyte sedimentation rate (ESR) (OR 1.066, p = 0.03) in children with SLE and increased C-reactive protein (CRP) (OR 1.480, p = 0.023) in combined cohorts with SLE by multiple logistic regression analyses. Our study firstly showed that hyponatremia could reflect a disease activity and severe inflammation of SLE.

Hyponatremia and osteoporosis: insights from the Danish National Patient Registry

The association between hyponatremia and osteoporosis was evaluated in humans. A significant association was found between low sodium levels, lower bone mineralization in the hip, and with several common conditions. Hyponatremia could be used as a marker of osteoporosis and systemic disease.

INTRODUCTION

The objective of this study was to evaluate the association between hyponatremia and osteoporosis in humans through a cross-sectional study.

METHODS

Patient information was gathered from regional and national Danish patient databases, both in- and outpatient settings, from 2004 to 2011. Patients with dual-energy x-ray absorptiometry (DXA) scans performed within this time were included if accompanied [Na+] was measured within 14 days prior or past the scan date. A total of 1575 patients were included.

RESULTS

A total of 104 patients were hyponatremic (6.6 %). Total hip and lumbar spine bone mineral content (BMC) and densities (BMD) and T-scores were all significantly lower with hyponatremia. The odds ratio (OR) of osteoporosis significantly increased among hyponatremic patients at both total hip (unadjusted OR = 2.17, 95% CI = [1.40-3.34], p < .05) and lumbar spine (unadjusted OR = 1.83, 95% CI = [1.20-2.80], p < .05) regions. Dose-response found between increasing [Na+] and increasing total hip BMC (slope .174, adjusted p < .05), BMD (slope .004, adjusted p < .05), and T-score (slope .034, adjusted p < .05). Systemic disease was more prevalent in hyponatremia.

CONCLUSION

The presence of hyponatremia increases the risk of concurrent osteoporosis at both the total hip and lumbar spine in humans. Hyponatremia could be used a screening tool and marker of secondary osteoporosis.

Hyponatremia influences the outcome of patients with acute-on-chronic liver failure: an analysis of the CANONIC study

Introduction

Hyponatremia is a marker of poor prognosis in patients with cirrhosis. This analysis aimed to assess if hyponatremia also has prognostic value in patients with acute-on-chronic liver failure (ACLF), a syndrome characterized by acute decompensation of cirrhosis, organ failure(s) and high short-term mortality.

Methods

We performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,341 consecutive patients admitted to 29 European centers with acute decompensation of cirrhosis (including ascites, gastrointestinal bleeding, hepatic encephalopathy, or bacterial infections, or any combination of these), both with and without associated ACLF (301 and 1,040 respectively).

Results

Of the 301 patients with ACLF, 24.3% had hyponatremia at inclusion compared to 12.3% of 1,040 patients without ACLF (P <0.001). Model for end-stage liver disease, Child-Pugh and chronic liver failure-SOFA scores were significantly higher in patients with ACLF and hyponatremia compared to those without hyponatremia. The presence of hyponatremia (at inclusion or during hospitalization) was a predictive factor of survival both in patients with and without ACLF. The presence of hyponatremia and ACLF was found to have an independent effect on 90-day survival after adjusting for the potential confounders. Hyponatremia in non-ACLF patients nearly doubled the risk (hazard ratio (HR) 1.81 (1.33 to 2.47)) of dying at 90 days. However, when considering patients with both factors (ACLF and hyponatremia) the relative risk of dying at 90 days was significantly higher (HR 6.85 (3.85 to 12.19) than for patients without both factors. Patients with hyponatremia and ACLF had a three-month transplant-free survival of only 35.8% compared to 58.7% in those with ACLF without hyponatremia (P <0.001).

Conclusions

The presence of hyponatremia is an independent predictive factor of survival in patients with ACLF. In cirrhosis, outcome of patients with ACLF is dependent on its association with hyponatremia.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-014-0700-0) contains supplementary material, which is available to authorized users.

Hyponatremia and anti-diuretic hormone in Legionnaires' disease

Background

Medical textbooks often list Legionnaires’ disease as a differential diagnosis of the syndrome of inappropriate secretion of anti-diuretic hormone (ADH) (SIADH), but evidence supporting this association is largely lacking. We tested the hypothesis whether hyponatremia in patients with Legionnaires’ disease would be caused by increased CT-ProVasopressin.

Methods

We measured CT-ProVasopressin and sodium levels in a prospective cohort of 873 pneumonia patients from a previous multicentre study with 27 patients having positive antigen tests for Legionella pneumophila.

Results

Patients with Legionnaires’ disease more frequently had low sodium levels (Na < 130 mmol/L) (44.4% vs 8.2%, p < 0.01), but similar mean CT-ProVasopressin levels (pmol/l) (39.4 [±7] vs 51.2 [±2.7], p = 0.43) as compared to patients with pneumonia of other etiologies. In patients with Legionnaires’ disease, CT-ProVasopressin levels showed a positive correlation with sodium (r = 0.42, p < 0.05). Independent of pneumonia etiology, CT-ProVasopressin correlated significantly with the pneumonia severity index (r = 0.56, p < 0.05), ICU admission (adjusted odds ratio per decile, 95% CI) (1.6, 1.2 - 2.0), and 30-day-mortality (1.8, 1.3 - 2.4).

Conclusion

While Legionnaires’ disease was associated with hyponatremia, no concurrent increase in CT-ProVasopressin levels was found, which argues against elevated ADH levels as the causal pathway to hyponatremia. Rather, Vasopressin precursors were upregulated as response to stress in severe disease, which seems to overrule the osmoregulatory regulation of ADH.

Hyponatremia may reflect severe inflammation in children with febrile urinary tract infection

BACKGROUND

Hyponatremia is the most common electrolyte abnormality in clinical practice, but little is known about the association between febrile urinary tract infection (UTI) and hyponatremia or its significance to clinical outcomes.

METHODS

Data from 140 children with febrile UTI between 2000 and 2010 were retrospectively analyzed. Laboratory examinations [white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and serum sodium concentration], renal ultrasonography, (99m)Technetium-dimercaptosuccinic acid (DMSA) scintigraphy, and voiding cystourethrogram were performed. Culture growing >50,000 colonies of one single bacterial species on a urine sample obtained by catheter or >100,000 colonies on two clean-catch samples was required to establish diagnosis of UTI.

RESULTS

In children with renal cortical defects diagnosed after DMSA scintigraphy (group 1), duration of fever was significantly longer (P = 0.038) and WBC (P = 0.047) and CRP (P < 0.0001) levels significantly higher than in those without renal cortical defects (group 2). However, serum sodium levels were significantly lower in group 1 than group 2 (135.9 ± 2.4 vs 137.4 ± 2.7 mEq/L, P = 0.007). Hyponatremia (serum sodium ≤ 135 mEq/L) was also more frequent in group 1 than in group 2 (74.1 % vs 45.3 %, P = 0.012). Serum sodium concentration was negatively correlated with WBC count (r = -0.156, P = 0.011) and CRP levels (r = -0.160, P= 0.028).

CONCLUSIONS

Our study indicates that hyponatremia may be a substantial inflammatory marker and is significantly and independently associated with the degree of inflammation in children with febrile UTI.

Hyponatremia and syndrome of inappropriate antidiuretic hormone secretion in kawasaki disease

Background and Objectives

The pathogenesis of hyponatremia (serum sodium <135 mEq/L) in Kawasaki disease (KD) remains unclear. We investigated the clinical significance of hyponatremia, and the role of interleukin (IL)-6 and IL-1β in the development of hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (SIADH) in KD.

Subjects and Methods

Fifty KD patients were prospectively enrolled and analyzed for clinical and laboratory variables according to the presence of hyponatremia or SIADH.

Results

Thirteen KD patients (26%) had hyponatremia and 6 of these had SIADH. In patients with hyponatremia, the percentage of neutrophils (% neutrophils), C-reactive protein (CRP), and N-terminal pro-brain natriuretic peptide (NT-proBNP) were higher than in those without hyponatremia, while serum triiodothyronine (T3) and albumin were lower. Patients with hyponatremia had a higher incidence of intravenous immunoglobulin-resistance but this was not statistically significant. No differences existed between patients with and without SIADH with regard to clinical or laboratory variables and the incidence of IVIG-resistance. Serum sodium inversely correlated with % neutrophils, CRP, and NT-proBNP, and positively correlated with T3 and albumin. Serum IL-6 and IL-1β levels increased in KD patients and were higher in patients with hyponatremia. Plasma antidiuretic hormone increased in patients with SIADH, which tended to positively correlate with IL-6 and IL-1β levels.

Conclusion

Hyponatremia occurs in KD patients with severe inflammation, while increased IL-6 and IL-1β may activate ADH secretion, leading to SIADH and hyponatremia in KD.