Salt Toxicity: A Systematic Review and Case Reports

Poisoning with table salt while treating drug poisoning

Hypernatremia is an increase in serum sodium concentration above 145 mmol/L. There are many causes of elevated sodium levels in the blood serum. One is incorrect actions performed by medical staff. The symptoms of excessively high serum sodium levels depend on the severity of hypernatremia, the rate of its increase and the accompanying volume disorders. Severe symptoms include altered consciousness, increased muscle tone and reflexes, convulsions, psychomotor hyperactivity or drowsiness (up to coma), respiratory failure, and even death. We present the case of a 45-year-old man who took seven tablets of a blood pressure-lowering drug, and paramedics subsequently administered a concentrated solution of table salt to induce vomiting. However, vomiting did not occur, leading to hypernatremia. Ultimately, the man survived but developed persistent cognitive dysfunction, including disordered short-term memory and encoding and retrieval of information from long-term memory, weakening of attention function and fatigue, and disorders in abstract thinking. The patient's family went to the prosecutor's office to investigate the possibility of medical malpractice. Experts found that the paramedics' actions were incorrect. Although it has been known for many years that table salt solutions should not be used to induce vomiting, unfortunately, both laypeople and medical professionals are still using this technique. Iatrogenic salt poisoning may end not only in serious health complications but also in legal consequences.

Fluid management in children with volume depletion

Volume depletion is a common condition and a frequent cause of hospitalization in children. Proper assessment of the patient includes a detailed history and a thorough physical examination. Biochemical tests may be useful in selected cases. Understanding the pathophysiology of fluid balance is necessary for appropriate management. A clinical dehydration scale assessing more physical findings may help to determine dehydration severity. Most dehydrated children can be treated orally; however, intravenous therapy may be indicated in patients with severe volume depletion, in those who have failed oral therapy, or in children with altered consciousness or significant metabolic abnormalities. Proper management consists of restoring circulatory volume and electrolyte balance. In this paper, we review clinical aspects, diagnosis, and management of children with volume depletion.

Extreme Hypernatremia due to Dehydration

Hypernatremia is defined as having a serum sodium concentration exceeding 145 mmol/L (normal range is 136 - 145 mmol/L). When the serum sodium level surpasses 160 mmol/L and 190 mmol/L, it is classified as severe and extreme hypernatremia, respectively. Extreme hypernatremia is an uncommon occurrence and is associated with significant risks of mortality and morbidity. The most frequently reported causes of extreme hypernatremia are accidental or intentional salt ingestion and diabetes insipidus, while dehydration due to poor water intake as a trigger for extreme hypernatremia is rarely documented. Here, we present a case study of an elderly patient who experienced extreme hypernatremia with a serum sodium level of 191 mmol/L due to dehydration and had altered mental status and ventriculomegaly as a complication.

Toxicity evaluation of Pinus radiata D.Don bark wax for potential cosmetic application

Radiata pine bark is a widely available organic waste, requiring alternative uses due to its environmental impact on soil, fauna, and forest fires. Pine bark waxes could be used as cosmetic substitutes, but their toxicity requires evaluation since pine bark may contain toxic substances or xenobiotics, depending on the extraction process. This study evaluates the toxicity of radiata pine bark waxes obtained through various extraction methods on human skin cells grown in vitro. The assessment includes using XTT to evaluate mitochondrial activity, violet crystal dye to assess cell membrane integrity, and ApoTox-Glo triple assay to measure cytotoxicity, viability, and apoptosis signals. Pine bark waxes extracted via T3 (acid hydrolysis and petroleum ether incubation) and T9 (saturated steam cycle, alkaline hydrolysis, and petroleum ether incubation) exhibit non-toxicity up to 2% concentration, making them a potential substitute for petroleum-based cosmetic materials. Integrating the forestry and cosmetic industries through pine bark wax production under circular economy principles could promote development while replacing petroleum-based materials. Extraction methodology affects pine bark wax toxicity in human skin cells due to the retention of xenobiotic compounds including methyl 4-ketohex-5-enoate; 1-naphthalenol; dioctyl adipate; eicosanebioic acid dimethyl ester; among others. Future research will investigate whether the extraction methodology alters the molecular structure of the bark, affecting the release of toxic compounds in the wax mixture.

Downregulation of inflammatory erectile dysfunction by Mantisa religiosa egg-cake through NO-cGMP-PKG dependent NF-kB signaling cascade activated by mixture of salt intake

We hypothesized whether 10% praying-mantis-egg-cake (10% PMEC) can be applied against inflammatory-erectile-dysfunction and whether it could be linked to NO-cGMP-dependent PKG signaling cascade. Ninety male albino-rats were randomly distributed into nine (n = 10) groups. Group I was given distilled water. Group II and III were pre-treated with 80 mg/kg NaCl and 75 mg/kg MSG, respectively. Group IV was pre-treated with 80 mg/kg NaCl + 75 mg/kg MSG. Group V was administered with 80 mg/kg NaCl+ 3 mg/kg Amylopidin. Group VI was given 80 mg/kg NaCl + 10% PMEC. Group VII was treated with 75 mg/kg MSG + 10% PMEC. Group VIII was treated with 80 mg/kg NaCl+ 75 mg/kg MSG + 10% PMEC. Group IX was post-treated with 10% PMEC for 14 days. Penile PDE-5¹, arginase, ATP hydrolytic, cholinergic, dopaminergic (MAO-A) and adenosinergic (ADA) enzymes were hyperactive on intoxication with NaCl and MSG. The erectile dysfunction caused by inflammation was linked to alteration of NO-cGMP-dependent PKG signaling cascade via up-regulation of key cytokines and chemokine (MCP-1). These lesions were prohibited by protein-rich-cake (10% PMEC). Thus, protein-rich-cake (10% PMEC) by a factor of 4 (25%) inhibited penile cytokines/MCP-1 on exposure to mixture of salt-intake through NO-cGMP-PKG dependent-NF-_KB signaling cascade in rats.

Sex Differences in Salt Appetite: Perspectives from Animal Models and Human Studies

Salt ingestion by animals and humans has been noted from prehistory. The search for salt is largely driven by a physiological need for sodium. There is a large body of literature on sodium intake in laboratory rats, but the vast majority of this work has used male rats. The limited work conducted in both male and female rats, however, reveals sex differences in sodium intake. Importantly, while humans ingest salt every day, with every meal and with many foods, we do not know how many of these findings from rodent studies can be generalized to men and women. This review provides a synthesis of the literature that examines sex differences in sodium intake and highlights open questions. Sodium serves many important physiological functions and is inextricably linked to the maintenance of body fluid homeostasis. Indeed, from a motivated behavior perspective, the drive to consume sodium has largely been studied in conjunction with the study of thirst. This review will describe the neuroendocrine controls of fluid balance, mechanisms underlying sex differences, sex differences in sodium intake, changes in sodium intake during pregnancy, and the possible neuronal mechanisms underlying these differences in behavior. Having reviewed the mechanisms that can only be studied in animal experiments, we address sex differences in human dietary sodium intake in reproduction, and with age.

Hypertension, Anxiety and Obstructive Sleep Apnea in Cardiovascular Disease and COVID-19: Mediation by Dietary Salt

This perspective paper used a grounded theory method to synthesize evidence proposing that sodium toxicity from excessive dietary salt intake is a potential common pathophysiological mechanism that mediates the association of hypertension, obstructive sleep apnea, and anxiety with cardiovascular disease and COVID-19. Increased anxiety in these conditions may be linked to a high-salt diet through stimulation of the sympathetic nervous system, which increases blood pressure while releasing catecholamines, causing a "fight or flight" response. A rostral shift of fluid overload from the lower to the upper body occurs in obstructive sleep apnea associated with COVID-19 and cardiovascular disease, and may be related to sodium and fluid retention triggered by hypertonic dehydration. Chronic activation of the renin-angiotensin-aldosterone system responds to salt-induced dehydration by increasing reabsorption of sodium and fluid, potentially exacerbating fluid overload. Anxiety may also be related to angiotensin II that stimulates the sympathetic nervous system to release catecholamines. More research is needed to investigate these proposed interrelated mechanisms mediated by dietary salt. Furthermore, dietary interventions should use a whole-food plant-based diet that eliminates foods processed with salt to test the effect of very low sodium intake levels on hypertension, anxiety, and obstructive sleep apnea in cardiovascular disease and COVID-19.

Sudden Infant Death Syndrome, Pulmonary Edema, and Sodium Toxicity: A Grounded Theory

Sudden Infant Death Syndrome (SIDS) occurs unexpectedly in an otherwise healthy infant with no identifiable cause of death following a thorough investigation. A general hypervolemic state has been identified in SIDS, and fluid in the lungs suggests the involvement of pulmonary edema and hypoxia as the cause of death. The present perspective paper reviews pathophysiological, epidemiological, and dietary evidence in SIDS. A grounded theory is presented that proposes an association of SIDS with sodium toxicity from excessive sodium chloride intake, mediated by noncardiogenic pulmonary edema, hypoxia, and alveolar damage. The peak of SIDS cases occurs in infants 2-4 months of age, who are less efficient in excreting excessive dietary sodium load. Evidence implicating sodium toxicity in SIDS includes increased levels of sodium associated with fever and with inflammatory/immune responses in the lungs. Conditions in near-miss SIDS cases are linked to dysregulated sodium, and increased sodium dietary intake suggests that sodium toxicity from a high-salt diet potentially mediates the association of seasonality and socioeconomic status with SIDS incidence. In addition, exposure to sodium toxicity meets three main criteria of the triple risk model of SIDS. The proposed pathophysiological effects of pulmonary edema related to sodium toxicity in SIDS merit further investigations.

Histological Identification and Quantification of Eosinophils and Ascites in Leghorn Chickens Treated with High Oral Concentrations of NaCl-Pilot Study

The purpose of this pilot study was to determine the role played by eosinophils in NaCl poisoning and right cardiac hypertrophy (ascitic syndrome) in Leghorn chickens, as well as the histological findings in the central nervous system (CNS), liver, and kidney. Moreover, the hypertrophy of the right ventricle index (HRVI) as an indicator of ascites was evaluated. Male SPF Leghorn birds at 28 days of age were submitted to two experiments. Food and water (FW) experiment: birds were treated with food plus 3.3% NaCl for the next 27 days and 1% NaCl in their drinking water from days 22 to 27. Water experiment (W): birds were treated with 1% NaCl in their drinking water for 5 days. In both experiments, the chickens exhibited loss of appetite, diuresis, and watery, green diarrhea during treatment days; at 24−27 td-FW and experiment W, the birds showed nervous signology (prostration, running movements, tremors, and comatose state). In the leukogram at 28 td-FW, an increase (p < 0.05) in heterophiles and basophils was observed. CNS eosinophilia was not observed in birds intoxicated with NaCl, though they did present demyelination in the brain and spinal cord, hepatic degeneration, mesangial proliferative glomerulopathy, and acute proximal renotubular necrosis.

Case Report: Severe Hypernatremia From Ingestion of One's Own Urine

An often unrecognized cause of hypernatremia is the ingestion of fluids or substances with high osmolality. We hereby report a case of severe hypernatremia with acute kidney injury in a severely debilitated patient with acute gouty arthritis who resorted to ingesting his own urine. Hypernatremia induced by drinking urine could be attributed to many underlying mechanisms, one of the important possible causes is the resultant high serum urea that leads to significant osmotic diuresis and a further increase in free water clearance. To the best of our knowledge this is the first case report that describes this unique cause of hypernatremia.

Diagnosis and management of hypernatraemia in children

Hypernatraemia is most commonly caused by excessive loss of solute-free water or decreased fluid intake; less often, the aetiology is salt intoxication. Especially infants, young children and individuals with a lack of access to water are at risk of developing hypernatraemia. Diagnosis is based on detailed history, physical examination and basic laboratory tests. Correction of hypernatraemia must be slow to prevent cerebral oedema and irreversible brain damage. This article reviews the aetiology, differential diagnosis and management of conditions associated with paediatric hypernatraemia. Distinguishing states with water deficiency from states with salt excess is important for proper management of hypernatraemic patients.

Dietary Reference Intakes of sodium for Koreans: focusing on a new DRI component for chronic disease risk reduction

Sodium is a physiologically essential nutrient, but excessive intake is linked to the increased risk of various chronic diseases, particularly cardiovascular. It is, therefore, necessary to accomplish an evidence-based approach and establish the Korean Dietary Reference Intakes (KDRIs) index, to identify both the nutritional adequacy and health effects of sodium. This review presents the rationale for and the process of revising the KDRIs for sodium and, more importantly, establishing the sodium Chronic Disease Risk Reduction Intake (CDRR) level, which is a new specific set of values for chronic disease risk reduction. To establish the 2020 KDRIs for dietary sodium, the committee conducted a systematic literature review of the intake–response relationships between the selected indicators for sodium levels and human chronic diseases. In this review, 43 studies published from January 2014 to December 2018, using databases of PubMed and Web of Science, were finally included for evaluating the risk of bias and strength of evidence (SoE). We determined that SoE of the relationship between dietary sodium and cardiovascular diseases, cerebrovascular disease, and hypertension, was moderate to strong. However, due to insufficient scientific evidence, we were unable to establish the estimated average requirement and the recommended nutrient intake for dietary sodium. Therefore, the adequate intake of sodium for adults was established to be 1,500 mg/day, whereas the CDRR for dietary sodium was established at 2,300 mg/day for adults. Intake goal for dietary sodium established in the 2015 KDRIs instead of the tolerable upper intake level was not presented in the 2020 KDRIs. For the next revision of the KDRIs, there is a requirement to pursue further studies on nutritional adequacy and toxicity of dietary sodium, and their associations with chronic disease endpoint in the Korean population.

Sodium Toxicity in the Nutritional Epidemiology and Nutritional Immunology of COVID-19

Dietary factors in the etiology of COVID-19 are understudied. High dietary sodium intake leading to sodium toxicity is associated with comorbid conditions of COVID-19 such as hypertension, kidney disease, stroke, pneumonia, obesity, diabetes, hepatic disease, cardiac arrhythmias, thrombosis, migraine, tinnitus, Bell's palsy, multiple sclerosis, systemic sclerosis, and polycystic ovary syndrome. This article synthesizes evidence from epidemiology, pathophysiology, immunology, and virology literature linking sodium toxicological mechanisms to COVID-19 and SARS-CoV-2 infection. Sodium toxicity is a modifiable disease determinant that impairs the mucociliary clearance of virion aggregates in nasal sinuses of the mucosal immune system, which may lead to SARS-CoV-2 infection and viral sepsis. In addition, sodium toxicity causes pulmonary edema associated with severe acute respiratory syndrome, as well as inflammatory immune responses and other symptoms of COVID-19 such as fever and nasal sinus congestion. Consequently, sodium toxicity potentially mediates the association of COVID-19 pathophysiology with SARS-CoV-2 infection. Sodium dietary intake also increases in the winter, when sodium losses through sweating are reduced, correlating with influenza-like illness outbreaks. Increased SARS-CoV-2 infections in lower socioeconomic classes and among people in government institutions are linked to the consumption of foods highly processed with sodium. Interventions to reduce COVID-19 morbidity and mortality through reduced-sodium diets should be explored further.