Association of Hyponatremia and Risk of Short- and Long-Term Mortality in Patients with Stroke: A Systematic Review and Meta-Analysis

Optimizing serum electrolyte levels in stroke patients: a multimodal approach with soymilk supplementation

Introduction

Electrolyte imbalances are common in stroke patients and can significantly impact their overall health, potentially leading to severe complications and even fatal outcomes. In this study, we investigated the impact of combining multiple exercise training modalities (METM) with soymilk supplementation on serum electrolyte levels in stroke patients.

Methods

In a single-blind, four-arm randomized clinical trial, 120 stroke patients were randomly assigned to one of the following groups: (1) the METM group, (2) the soymilk group, (3) the METM plus soymilk group, and (4) the control group. Changes in serum electrolyte levels were compared both within and across groups over four consecutive weeks.

Results

Upon admission, 38.3% of the participants presented with hyponatremia, 26.7% hypokalemia, and 73.3% hypocalcemia. Over time, there was an overall improvement in serum electrolyte imbalances across all study groups compared to the baseline. Between-group comparisons revealed that the METM plus soymilk group exhibited statistically significant improvements compared to the other groups with absolute reductions in the proportion of participants with hyponatremia, hypokalemia, and hypocalcemia by 43.3%, 33.3%, and 73.4%, respectively.

Conclusions

The study findings substantiate the common occurrence of hyponatremia, hypokalemia, and hypocalcemia during the acute phase of stroke. Implementation of the METM alongside soymilk intake demonstrated potential in rectifying electrolyte imbalances among stroke patients, hinting at a promising intervention strategy.

A Stroke Mimic With Postictal Todd's Paresis and a Simplified Guide to Management of Acute Hyponatremia

Stroke mimics typically involve non-vascular disease processes, accounting for approximately half of hospital admissions for suspected stroke. These mimics may manifest as functional (conversion) disorders or indicate other neurological or medical conditions, including hypoglycemia, brain tumors, toxic poisoning, migraines, sepsis, seizures, and electrolyte imbalances, which can imitate stroke symptoms, making the diagnosis complex. In this report, we present a unique case of a man in his sixties who developed acute postoperative hyponatremia, an electrolyte abnormality frequently encountered but rarely presented with focal neurological deficits. This condition resulted in facial asymmetry and hemiparesis; however, the remarkable outcome was that these deficits were completely resolved once the hyponatremia was corrected.

Frequency of Hyponatremia and Its Impact on Prognosis in Ischemic Stroke

Background Hyponatremia, often encountered in hospitalized patients, is associated with adverse outcomes in ischemic stroke patients. In this study, we investigated the frequency of hyponatremia and its impact on prognosis and clinical outcomes in ischemic stroke patients from a tertiary care hospital. Methodology A total of 289 patients admitted to the hospital with ischemic stroke from September 2022 to February 2023 were considered in this cross-sectional study. Serum sodium level was measured on admission, and hyponatremia was defined as sodium less than 135 mmol/L. The primary outcome of the study was assessed by the National Institutes of Health Stroke Scale (NIHSS) score on admission and discharge and inpatient mortality. Data were analyzed using SPSS version 20 (IBM Corp., Armonk, NY, USA), and multivariate logistic regressions were conducted using variables identified as having a relationship with hyponatremia. Results Our study shows that among 289 patients with ischemic stroke, the mean age was 61 ± 8.53 years. Hyponatremia was observed in 101 (35%) patients, and all baseline characteristics and risk factors for stroke were similar between patients with and without hyponatremia. The patients with hyponatremia had higher NIHSS scores on admission (p = 0.041) and at discharge (p = 0.039). In the resultant multivariate analysis, hyponatremia was an independent predictor of mortality rates during the hospital stay. The cumulative incidence rates of in-hospital mortality for hyponatremia and normal sodium level were 16.8% and 10.1%, respectively. Conclusions Hyponatremia is prevalent in ischemic stroke and is independently associated with in-hospital mortality and worse NIHSS scores at admission and discharge.

Electrolyte Imbalance Among Patients With and With No ST-Elevation Myocardial Infarction: A Cohort Study

Electrolytes imbalances are highly prevalent and have shown a high impact on mortality in patients with acute myocardial infarction. These electrolytes imbalance have prognostic value in predicting mortality in patients with acute myocardial infarction. The purpose of this study was to assess the prognostic value of electrolyte imbalances in predicting 1-month mortality among patients with myocardial infarction with and with no ST-elevation. This cohort study was conducted in a referral hospital in the West Bank, Palestine. All patients with confirmed medical diagnosis of acute myocardial infarction and admitted to the medical coronary care unit in the hospital were eligible participants. A convenience sample of 186 participants was obtained. These participants were followed up for 1 month to assess their survival (alive or dead). Demographic and clinical data were recorded by reviewing their health records. The derived data were analyzed using SPSS version 19. About 36% of all patients were found to be hyponatremic, 15% of them have hypokalemia, and 9% of patients had hypocalcemia. There was a significant difference between STEMI and non-STEMI in sodium (t = 4.7, P < .001). A multivariate logistic regression analysis was performed to predict 1-month mortality for patients with myocardial infarction with and with no ST-elevation. The predictors that were found to be significant are sodium (odds ratio [OR] = 0.789, P = .010), calcium (OR = 0.221, P = .014), diastolic blood pressure (OR = 0.933, P = .047), and blood urea nitrogen (OR = 0.821, P = .005). Electrolyte imbalance was highly prevalent among patients with acute myocardial infarction. Hyponatremia and hypocalcemia were present and associated significantly with predicting 1-month mortality. Health care providers should take into consideration the electrolytes of patients with acute myocardial infarction from the first moment of admission and correct them early to maximize the clinical outcomes and survival for patients.

An interpretable machine learning approach for predicting 30-day readmission after stroke

BACKGROUND

Stroke is the second leading cause of death worldwide and has a significantly high recurrence rate. We aimed to identify risk factors for stroke recurrence and develop an interpretable machine learning model to predict 30-day readmissions after stroke.

METHODS

Stroke patients deposited in electronic health records (EHRs) in Xuzhou Medical University Hospital between February 1, 2021, and November 30, 2021, were included in the study, and deceased patients were excluded. We extracted 74 features from EHRs, and the top 20 features (chi-2 value) were used to build machine learning models. 80% of the patients were used for pre-training. Subsequently, a 20% holdout dataset was used for verification. The Shapley Additive exPlanations (SHAP) method was used to explore the interpretability of the model.

RESULTS

The cohort included 6,558 patients, of whom the mean (SD) age was 65 (11) years, 3,926 were males (59.86 %), and 132 (2.01 %) were readmitted within 30 days. The area under the receiver operating characteristic curve (AUROC) for the optimized model was 0.80 (95 % CI 0.68-0.80). We used the SHAP method to identify the top 10 risk factors (i.e., severe carotid artery stenosis, weak, homocysteine, glycosylated hemoglobin, sex, lymphocyte percentage, neutrophilic granulocyte percentage, urine glucose, fresh cerebral infarction, and red blood cell count). The AUROC of a model with the 10 features was 0.80 (95 % CI 0.69-0.80) and was not significantly different from that of the model with 20 risk factors.

CONCLUSIONS

Our methods not only showed good performance in predicting 30-day readmissions after stroke but also revealed risk factors that provided valuable insights for treatments.

A step-by-step guide for the diagnosis and management of hyponatraemia in patients with stroke

Hyponatraemia is common in patients with stroke and associated with adverse outcomes and increased mortality risk. The present review presents the underlying causes and provides a thorough algorithm for the diagnosis and management of hyponatraemia in stroke patients. Concomitant diseases and therapies, such as diabetes, chronic kidney disease and heart failure, along with diuretics, antidepressants and proton pump inhibitors are the most common causes of hyponatraemia in community. In the setting of acute stroke, the emergence of hyponatraemia might be attributed to the administration of hypotonic solutions and drugs (ie. mannitol and antiepileptics), poor solute intake, infections, as well as stroke-related conditions or complications, such as the syndrome of inappropriate secretion of antidiuretic hormone, cerebral salt wasting syndrome and secondary adrenal insufficiency. Diagnostically, the initial step is to differentiate hypotonic from non-hypotonic hyponatraemia, usually caused by hyperglycaemia or recent mannitol administration in patients with stroke. Determining urine osmolality, urine sodium level and volume status are the following steps in the differentiation of hypotonic hyponatraemia. Of note, specific parameters, such as fractional uric acid and urea excretion, along with plasma copeptin concentration, may further improve the diagnostic yield. Therapeutic options are based on the duration and symptoms of hyponatremia. In the case of acute or symptomatic hyponatraemia, hypertonic saline administration is recommended. Hypovolaemic chronic hyponatremia is treated with isotonic solution administration. Although fluid restriction remains the first-line treatment for the rest forms of chronic hyponatraemia, therapies increasing renal free water excretion may be necessary. Loop diuretics and urea serve this purpose in patients with stroke, whereas sodium-glucose transport protein-2 inhibitors appear to be a promising therapy. Nevertheless, it is yet unclear whether the appropriate restoration of sodium level improves outcomes in such patients. Randomized trials designed to compare therapeutic strategies in managing hyponatraemia in patients with stroke are required.

Hyponatremia Is Associated With Post-thrombolysis Hemorrhagic Transformation and Poor Clinical Outcome in Ischemic Stroke Patients

Objective

Hyponatremia is the most common electrolyte disorder encountered in patients with neurological conditions, such as stroke. Studies have shown that it is associated with worse clinical outcomes and increased mortality in acute ischemic stroke (AIS). However, the role of hyponatremia has not been elucidated in patients with AIS who received intravenous thrombolysis (IVT) therapy. Therefore, this study aimed to investigate the effect of serum sodium levels on the clinical outcome and hemorrhagic transformation (HT) in patients with AIS who received thrombolytic therapy.

Methods

Patients diagnosed with AIS who received IVT therapy between May 2015 and December 2020 were included in this study. All patients were screened for serum sodium levels immediately after hospital admission, before IVT therapy. The occurrence of HT was evaluated using computed tomography (CT) 24 ± 2 h after thrombolysis. Then, 3-month clinical outcomes were obtained by telephone calls or outpatient visits, and poor 3-month clinical outcomes were defined as modified Rankin Scale scores ≥3. The effects of serum sodium levels on the clinical outcome and HT were assessed using the multivariate logistic regression analysis.

Results

Of the 963 included patients, 82 (8.5%) had hyponatremia, 157 (16.3%) developed HT, and 333 (34.6%) had poor 3-month outcomes. Of the 82 patients with hyponatremia, 21 (25.6%) developed HT, and 39 (47.6%) had poor 3-month outcomes. Patients with hyponatremia had a higher incidence of post-thrombolysis HT (25.6 vs. 15.4%, p = 0.017) and worse clinical outcome (47.6 vs. 33.4%, p = 0.01) than those with normal serum sodium levels. Patients had significantly lower serum sodium levels in those with HT [138.4 (136.4–140.3, IQR) vs. 139.0 (137.2–140.7, IQR) mmol/L, p = 0.019] and poor 3 month outcome [139.0 (137.2–140.7) vs. 138.4 (136.7–140.3) mmol/L, p = 0.005] than those without. After adjusting for major covariates, the multivariate logistic regression analysis revealed that lower serum sodium levels were independently associated with an increased risk of HT [odds ratio (OR) = 1.804; 95% CI: 1.048–3.105] and poor 3-month outcome (OR = 1.647; 95% CI: 1.012–2.679).

Conclusion

Lower serum sodium level was an independent risk factor for post-thrombolysis HT and poor clinical outcome in patients with AIS who received thrombolytic therapy.

Etiology Analysis and Diagnosis and Treatment Strategy of Traumatic Brain Injury Complicated With Hyponatremia

Objective

To explore the etiology and diagnosis and treatment strategy of traumatic brain injury complicated with hyponatremia.

Methods

90 patients with traumatic brain injury admitted to our hospital from December 2019 to December 2020 were retrospectively analyzed and divided into hyponatremic group (50 patients) and non-hyponatremic group (40 patients) according to the patients' concomitant hyponatremia, and the clinical data of the two groups were collected and compared. In addition, patients in the hyponatremia group were divided into a control group and an experimental group of 25 patients each according to their order of admission, with the control group receiving conventional treatment and the experimental group using continuous renal replacement therapy (CRRT). Hemodynamic indices, mortality and serum neuron-specific enolase (NSE) indices before and after treatment were compared between the control and experimental groups. The Glasgow coma scale (GCS) was used to assess the degree of coma before and after the treatment in the two groups, and the patients' disease status was assessed using the Acute Physiological and Chronic Health Evaluation Scoring System (APACHE II).

Results

The etiology of traumatic brain injury complicated with hyponatremia is related to the degree of brain injury, ventricular hemorrhage, cerebral edema, and skull base fracture (P < 0.05). After the treatment, the hemodynamic indexes, APACHE II scores, death rate, and NSE levels of the experimental group were significantly lower than those of the control group (P < 0.001); The experimental group yielded remarkably higher GAC scores as compared to the control group (P < 0.001).

Conclusion

The degree of brain injury, ventricular hemorrhage, cerebral edema, and skull base fracture were considered to be the main factors for traumatic brain injury complicated with hyponatremia. Continuous renal replacement therapy can effectively improve the clinical indicators of the patients with a promising curative effect, which merits promotion and application.

Impact of Sodium Levels on Functional Outcomes in Patients With Stroke - A Swiss Stroke Registry Analysis

CONTEXT

Correction of hyponatremia might represent an additional treatment for improving stroke patients' clinical outcomes.

OBJECTIVE

Admission hyponatremia is associated with worse clinical outcome in stroke patients, but whether normalization of hyponatremia improves outcome is unknown. We investigated whether normalization of hyponatremia affects patients' disability, mortality, and stroke recurrence within 3 months; length of hospitalization; and discharge destination.

DESIGN

This was a registry-based analysis of data collected between January 2016 and December 2018. We linked data from Swiss Stroke Registry (SSR) with electronic patients' records for extracting sodium values.

SETTING

We analyzed data of hospitalized patients treated at University Hospital of Basel.

PATIENTS

Stroke patients whose data and informed consent were available.

MAIN OUTCOME MEASURE

Modified Rankin Scale (mRS) score at 3 months. The tested hypothesis was formulated after SSR data collection but before linkage with electronic patients' records.

RESULTS

Of 1995 patients, 144 (7.2%) had hyponatremia on admission; 102 (70.8%) reached normonatremia, and 42 (29.2%) remained hyponatremic at discharge. An increase of initial sodium was associated with better functional outcome at 3 months (odds ratio [OR] 0.94; 95% CI, 0.90-0.99, for a shift to higher mRS per 1 mmol/L sodium increase). Compared with normonatremic patients, patients who remained hyponatremic at discharge had a worse functional outcome at 3 months (odds ratio 2.46; 95% CI, 1.20-5.03, for a shift to higher mRS). No effect was found on mortality, recurrence, or length of hospitalization.

CONCLUSIONS

In hospitalized acute stroke patients, persistent hyponatremia is associated with worse functional outcome. Whether active correction of hyponatremia improves outcome remains to be determined in prospective studies.

Sodium and water perturbations in patients who had an acute stroke: clinical relevance and management strategies for the neurologist

Sodium and water perturbations, manifesting as hyponatraemia and hypernatraemia, are common in patients who had an acute stroke, and are associated with worse outcomes and increased mortality. Other non-stroke-related causes of sodium and water perturbations in these patients include underlying comorbidities and concomitant medications. Additionally, hospitalised patients who had an acute stroke may receive excessive intravenous hypotonic solutions, have poor fluid intake due to impaired neurocognition and consciousness, may develop sepsis or are administered drugs (eg, mannitol); factors that can further alter serum sodium levels. Sodium and water perturbations can also be exacerbated by the development of endocrine consequences after an acute stroke, including secondary adrenal insufficiency, syndrome of inappropriate antidiuretic hormone secretion and diabetes insipidus. Recently, COVID-19 infection has been reported to increase the risk of development of sodium and water perturbations that may further worsen the outcomes of patients who had an acute stroke. Because there are currently no accepted consensus guidelines on the management of sodium and water perturbations in patients who had an acute stroke, we conducted a systematic review of the literature published in English and in peer-reviewed journals between January 2000 and December 2020, according to PRISMA guidelines, to assess on the current knowledge and clinical practices of this condition. In this review, we discuss the signs and symptoms of hyponatraemia and hypernatraemia, the pathogenesis of hyponatraemia and hypernatraemia, their clinical relevance, and we provide our recommendations for effective treatment strategies for the neurologist in the management of sodium and water perturbations in commonly encountered aetiologies of patients who had an acute stroke.

Electrolytes and clinical outcomes in patients with acute ischemic stroke or transient ischemic attack

Background

Abnormal electrolytes were closely related to the prognosis of various diseases, the prognostic role of electrolytes in stroke has not been investigated well. We aimed to investigate the association between electrolytes and clinical outcomes in patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA).

Methods

Data were recruited from the China National Stroke Registry III study. Patients were classified into three groups according to tertiles and the normal range of each electrolyte. Multivariable logistic and Cox proportional hazards regressions were adopted to explore the associations of electrolytes with poor functional outcomes [modified Rankin Scale (mRS) 3–6/2–6] and all-cause death at 3 months and 1 year.

Results

A total of 10,299 eligible patients were enrolled. After adjusted for confounding factors, the first tertile electrolytes were associated with increased risk of poor functional outcome (mRS score 3–6) at 1 year, the adjusted odds ratios (95% confidence intervals) were 1.33 (1.14–1.55) for potassium, 1.41 (1.20–1.60) for sodium, 1.27 (1.08–1.48) for chloride, compared with the second tertile. Similar results were found when poor functional outcome was defined as mRS score 2–6 and all-cause death. However, almost no significant association was present of calcium with these outcomes. All results were consistent when each electrolyte was classified into three groups according to the normal range and the outcomes timepoint was set at 3 months.

Conclusions

Lower levels of potassium, sodium, chloride but not calcium were associated with higher risk of poor functional outcomes and death in patients with AIS or TIA.

The Survival Status and Predictors of Mortality Among Stroke Patients at North West Ethiopia

INTRODUCTION

Stroke is one of the commonest non-communicable disease types that has a great public health impact both in developed and developing countries. However, in Ethiopia, the long-term survival status of stroke patients is not very understood. This study aimed at assessing survival status and predictors of mortality among stroke patients at Felege Hiwot comprehensive specialized hospital from September 1, 2014, to August 31, 2019, Bahirdar, North West Ethiopia.

METHODS

An institutional-based retrospective cohort study was conducted using 368 registered stroke patients between September 1, 2014, and August 31, 2019. We used Kaplan-Meier together with a Log-rank test to compare the survival rate of the study participants using categorical variables and to compare covariate and both bi-variable and multivariable Cox proportional hazards regression analysis model was conducted to identify predictors of mortality among stroke patients. The association between outcome and independent variables was expressed using an adjusted hazard ratio (AHR) with a 95% confidence interval and statistical significances were declared at P-value of <0.05.

RESULTS

Fifty-six (15.2%) of the 368 stroke patients included in the study died, and 312 (84.8%) were correctly censored. The overall survival rate was 72.2% at 51 months of follow-up with a median survival time of 0.26 months. Age greater than 65 (AHR 6.31, 95% CI 1.75-22.74), body temperature >7.1 degree centigrade (AHR = 7.14, 95% CI: 2.76-18.5), potassium level below <2 mmol/l (AHR = 2, 95% CI: 1.9-23.53) and creatinine level >1.2 mg/dl (AHR = 7.85, 95% CI: 2.7-22.6) were predictive predictors of mortality.

CONCLUSIONS

In the follow-up of 51 months, significant mortality occurred. Important predictive predictors of survival status were identified. Interventions should be focused on health education and awareness creation of the community for the early management of stroke.

Hyponatremia as a prognostic factor in non-small cell lung cancer: a systematic review and meta-analysis

Background

Hyponatremia is a common electrolyte disorder in cancer patients and has been evaluated as a negative prognostic factor in several cancer types, especially in small cell lung cancer (SCLC). However, the prognostic value of hyponatremia is less studied in non-small cell lung cancer (NSCLC) patients. Therefore, we conducted a systematic review and meta-analysis to investigate the prognostic value of pretreatment hyponatremia in NSCLC patients.

Methods

The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting checklist. The databases PubMed, Embase, Scopus, and Web of Science were searched on March 26th 2020 without time restrictions. The protocol was submitted to the PROSPERO database (ID 184612). Studies were included if they evaluated sodium level as a prognostic factor in NSCLC patients and contained original data published in English. Hazard ratios (HRs) for overall survival (OS) were pooled in a random-effects model.

Results

Of 10,888 identified titles, 14 articles were included in the review including a total of 4,364 NSCLC patients. In 13 of the 14 articles, hyponatremia was found to be significantly correlated to a shorter OS. Ten articles were included in the meta-analysis. Here, patients with hyponatremia had a significantly shorter OS compared with patients with normal sodium level {pooled HR =2.02 [95% confidence interval (CI): 1.65-2.47]}. Two out of four studies found hyponatremia to be associated with a reduced progression free survival (PFS). Normalization of the sodium level during treatment was found to be associated with a prolonged PFS and OS in one study.

Conclusions

This meta-analysis indicates that hyponatremia is a relative common condition in NSCLC patients associated with an increased mortality. Hence, sodium level could be a useful biomarker for stratifying NSCLC patients and thereby for preparing individual treatment plans.

Predictors of hyponatremia following elective primary unilateral knee arthroplasty at a tertiary centre: A retrospective observational cohort and predictive model

Introduction

Hyponatremia is a common electrolyte disorder. This can be associated with nausea, disorientation and in more serious cases a decreased level of consciousness or neurological deficits. These symptoms may lead to increases in the cost of hospital care and significant morbidity. The purpose of this retrospective, observational cohort study is to investigate the impact of hyponatremia on patient and systems specific outcome measures in those undergoing elective, unilateral total knee arthroplasty (TKA) at two hospitals in Auckland, New Zealand over a twelve-month period.

Materials and methods

Patients were stratified into two groups based on the presence or absence of post-operative hyponatremia (defined as a blood sodium of <135 mmol/L with a concurrent decrease of ≥5 mmol/L between the pre- and post-operative recordings). Outcomes collected included Quality of Recovery - 15 (QOR) scores, time to assisted mobilisation, discharge ICD-10 complication codes and hospital length of stay.

Results

During the study period 236 patients underwent surgery. Eighty-six (36.4%) patients met criteria for post-operative hyponatremia. This finding was associated with prolongation of the hospital length of stay (4.17 (3.26-5.18) versus 4.28 (3.31-5.45) days, p = 0.031) and a reduction in the QOR score on the second post-operative day (113.0 (99.5-126.5) versus 105.0 (94.0-118.0), p = 0.039). There was no difference in the time to assisted mobilisation.

Conclusions

Hyponatremia is a common finding following TKA. This abnormality is associated with small changes in patient specific outcome measures. These implications of these findings may become more significant in settings where same day or rapid discharge from hospital is targeted.