Brain amino acids during hyponatremia in vivo: clinical observations and experimental studies

Associations between serum taurine concentrations in mothers and neonates and the children's anthropometrics and early neurodevelopment: Results from the Seychelles Child Development Study, Nutrition Cohort 2

BACKGROUND

High concentrations of taurine are present in the developing human brain and maternal breast milk. Taurine is thought to influence fetal growth and brain development based on experimental rodent studies. As fish is an important dietary source of taurine, we investigated associations between taurine concentrations and child outcomes in a high fish consuming population.

OBJECTIVE

To examine associations between maternal and cord serum taurine concentrations and birth anthropometric measures and cognitive development in children at 20 months of age.

METHODS

Pregnant women were recruited between 2008 and 2011 as part of Nutrition Cohort 2 (NC2) of the Seychelles Child Development Study (SCDS). Maternal taurine serum concentrations were measured at 28 week's gestation and in cord serum. Child weight, length and head circumference were measured at birth and neurodevelopment was assessed using Bayley Scales of Infant Development II (BSID-II) at 20 months of age. Associations between taurine status, birth measures and neurodevelopmental outcomes were examined (n = 300) using regression models and adjusted for relevant covariates.

RESULTS

Mean (SD) maternal and cord taurine concentrations were 124.9 (39.2) µmol/L (range 28.2-253.9 µmol/L) and 187.6 (60.0) µmol/L (range 55.0-417.4 µmol/L) respectively. We found no associations between maternal taurine concentrations and child anthropometric and neurodevelopmental measures (weight β = -0.001, SE=0.001; length β = -0.006, SE=0.006; head circumference β = -0.002, SE=0.002; MDI β = -0.005, SE=0.015; PDI β = -0.004, SE=0.016; all P > 0.05), or between cord taurine concentrations and outcomes (weight β = -0.001, SE<0.000; length β = -0.001, SE=0.004; head circumference β < 0.000, SE=0.002; MDI β = 0.004, SE=0.010; PDI β = -0.015, SE=0.012; all P > 0.05).

CONCLUSION

The Seychellois population have high maternal and cord taurine concentrations owing to their high fish intake and may be considered taurine replete compared to individuals who consume a Westernised diet. This high taurine status may explain why there were no significant associations between maternal and cord taurine concentrations and outcomes after adjusting for covariates.

Cognitive Impairment in End Stage Renal Disease Patients Undergoing Hemodialysis: Markers and Risk Factors

(1) Background: Cognitive impairment (CI) is common in chronic kidney disease (CKD) and patients treated with hemodialysis. (2) Methods: The systematic review was prepared following the PRISMA statement (2013). The biomedical electronic databases MEDLINE and SCOPUS were searched. (3) Results: out of 1093 studies, only 30, which met problem and population criteria, were included in this review. The risk factors for CI can be divided into three groups: traditional risk factors (present in the general population), factors related to dialysis sessions, and nontraditional risk factors occurring more frequently in the HD group. (4) Conclusions: the methods of counteracting CI effective in the general population should also be effective in HD patients. However, there is a need to develop unique anti-CI approaches targeting specific HD risk factors, i.e., modified hemodialysis parameters stabilizing cerebral saturation and blood flow.

Serum sodium in relation to various domains of cognitive function in the elderly US population

Background

Recent evidence suggests that sodium imbalances may be associated with cognitive impairment; however, the association between specific domains of cognition remains unclear. This study examines the association between serum sodium levels and immediate and delayed verbal memory as measured by the CERAD Word Learning Test (CERAD WLT), executive function as measured by the Animal Fluency test (AFT), and sustained attention, working memory, and processing speed as measured by the Digit Symbol Substitution test (DSST) in the elderly population of the US aged 60 and older who participated in the 2011–2014 National Health and Nutrition Examination Surveys (n = 2,541).

Methods

Cognitive function tests were performed by trained interviewers and sodium levels were measured using indirect ion selective electrode methodology.

Results

After adjusting for all covariates, quintiles of CERAD WLT scores showed significant positive associations with log-transformed sodium levels (Immediate recall (IR) β = 4.25 (SE = 1.83, p-value 0.027); Delayed recall (DR) β = 6.54 (SE = 1.82, p-value 0.001)). Compared to normal sodium levels, hyponatremia was significantly associated with lower CERAD WLT-IR (β = -0.34, SE = 0.15, p-value 0.035) and CERAD WLT-DR scores (β -0.48, SE = 0.10, p-value < 0.001) and showed borderline significance with AFT scores (β = = -0.38, SE = 0.19, p-value 0.052). Hypernatremia did not show any significant relationships with cognitive test scores, compared to normal sodium levels.

Conclusions

Our cross-sectional study showed that lower sodium levels were associated with cognitive change, especially regarding memory and executive function.

Practical document on the management of hyponatremia in critically ill patients

Hyponatremia is the most prevalent electrolyte disorder in Intensive Care Units. It is associated with an increase in morbidity, mortality and hospital stay. The majority of the published studies are observational, retrospective and do not include critical patients; hence it is difficult to draw definitive conclusions. Moreover, the lack of clinical evidence has led to important dissimilarities in the recommendations coming from different scientific societies. Finally, etiopathogenic mechanisms leading to hyponatremia in the critical care patient are complex and often combined, and an intensive analysis is clearly needed. A study was therefore made to review all clinical aspects about hyponatremia management in the critical care setting. The aim was to develop a Spanish nationwide algorithm to standardize hyponatremia diagnosis and treatment in the critical care patient.

Understanding taurine CNS activity using alternative zebrafish models

Taurine is a highly abundant "amino acid" in the brain. Despite the potential neuroactive role of taurine in vertebrates has long been recognized, the underlying molecular mechanisms related to its pleiotropic effects in the brain remain poorly understood. Due to the genetic tractability, rich behavioral repertoire, neurochemical conservation, and small size, the zebrafish (Danio rerio) has emerged as a powerful candidate for neuropsychopharmacology investigation and in vivo drug screening. Here, we summarize the main physiological roles of taurine in mammals, including neuromodulation, osmoregulation, membrane stabilization, and antioxidant action. In this context, we also highlight how zebrafish models of brain disorders may present interesting approaches to assess molecular mechanisms underlying positive effects of taurine in the brain. Finally, we outline recent advances in zebrafish drug screening that significantly improve neuropsychiatric translational researches and small molecule screens.

Simplifying study of fever's dramatic relief of autistic behavior

Dramatic relief of autistic behavior by infectious fever continues to tantalize parents and practitioners, yet researchers still hesitate to study its physiology/biochemistry, fearing stress and heat of brain imaging, contagion, and fever's complexity. Yet what could be more revealing than a common event that virtually 'normalizes' autistic behavior for a time? This paper proposes study of three simplified scenarios: (1) improvements appearing hours before fever, (2) return of autistic behavior soon after fever, (3) improvements persisting long after fever. Each scenario limits some risk - and some explanation - inviting triangulation of decisive factor(s) in relief and recurrence. Return of autistic behavior after fever may be most revealing. The complex mechanisms that generated fever have all abated; simpler cooling mechanisms prevail - how many plausible explanations can there be? The decisive factor in fever's benefit is concluded to be water drawn/carried from brain myelin and astrocytes by osmolytes glutamine and taurine released from muscles and brain; the decisive factor in return of autistic behavior after fever is return of water.

Neurologic manifestations of major electrolyte abnormalities

The brain operates in an extraordinarily intricate environment which demands precise regulation of electrolytes. Tight control over their concentrations and gradients across cellular compartments is essential and when these relationships are disturbed neurologic manifestations may develop. Perturbations of sodium are the electrolyte disturbances that most often lead to neurologic manifestations. Alterations in extracellular fluid sodium concentrations produce water shifts that lead to brain swelling or shrinkage. If marked or rapid they can result in profound changes in brain function which are proportional to the degree of cerebral edema or contraction. Adaptive mechanisms quickly respond to changes in cell size by either increasing or decreasing intracellular osmoles in order to restore size to normal. Unless cerebral edema has been severe or prolonged, correction of sodium disturbances usually restores function to normal. If the rate of correction is too rapid or overcorrection occurs, however, new neurologic manifestations may appear as a result of osmotic demyelination syndrome. Disturbances of magnesium, phosphate and calcium all may contribute to alterations in sensorium. Hypomagnesemia and hypocalcemia can lead to weakness, muscle spasms, and tetany; the weakness from hypophosphatemia and hypomagnesemia can impair respiratory function. Seizures can be seen in cases with very low concentrations of sodium, magnesium, calcium, and phosphate.

Hyponatremia in the intensive care unit: How to avoid a Zugzwang situation?

Hyponatremia is a common electrolyte derangement in the setting of the intensive care unit. Life-threatening neurological complications may arise not only in case of a severe (<120 mmol/L) and acute fall of plasma sodium levels, but may also stem from overly rapid correction of hyponatremia. Additionally, even mild hyponatremia carries a poor short-term and long-term prognosis across a wide range of conditions. Its multifaceted and intricate physiopathology may seem deterring at first glance, yet a careful multi-step diagnostic approach may easily unravel the underlying mechanisms and enable physicians to adopt the adequate measures at the patient’s bedside. Unless hyponatremia is associated with obvious extracellular fluid volume increase such as in heart failure or cirrhosis, hypertonic saline therapy is the cornerstone of the therapeutic of profound or severely symptomatic hyponatremia. When overcorrection of hyponatremia occurs, recent data indicate that re-lowering of plasma sodium levels through the infusion of hypotonic fluids and the cautious use of desmopressin acetate represent a reasonable strategy. New therapeutic options have recently emerged, foremost among these being vaptans, but their use in the setting of the intensive care unit remains to be clarified.

Hyponatremia and Cognitive Impairment in Patients Treated with Peritoneal Dialysis

BACKGROUND AND OBJECTIVES

Hyponatremia has been identified as a relevant factor for cognitive impairment but has not been investigated in patients receiving peritoneal dialysis (PD). This study investigated the relationship between hyponatremia and cognitive functions in PD patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

A total of 476 clinically stable patients from five PD units who were older than 18 years of age and had undergone PD for at least 3 months between March 2013 and March 2014 were enrolled in this multicenter cross-sectional study. Global cognitive function was measured using the Modified Mini-Mental State Examination (3MS); executive function, by trail making tests A (trails A) and B (trails B); and immediate memory, delayed memory, and language ability, by subtests of Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Hyponatremia was defined as serum sodium level ≤135 mmol/L, which was calculated as the mean of measurements taken over the preceding 3 months.

RESULTS

Fifty patients (10.5%) had hyponatremia; these patients tended to be older and less educated, to have less inflammation, and to have the higher prevalence of cognitive impairment. They also had lower scores on RBANS subtests. After adjustment for demographic and clinical confounders, hyponatremia was independently associated with lower 3MS score (coefficient, -5.28; 95% confidence interval [CI], -8.44 to -2.13) and longer completion time of trials A (coefficient, 22.68; 95% CI, 3.44 to 41.92) and B (coefficient, 45.56; 95% CI, 1.30 to 89.81). After additional adjustment for laboratory measures, hyponatremia was still associated with 3MS score and completion time of trails A. Hyponatremia was independently associated with CI (odds ratio, 2.17; 95% CI, 1.02 to 4.94) and executive dysfunction (odds ratio, 2.43; 95% CI, 1.01 to 5.87) using multivariate logistic regression analysis. Sensitivity analyses with multivariable models that included propensity score still supported the association between hyponatremia and cognitive impairment.

CONCLUSIONS

Hyponatremia was associated with global and specific cognitive impairment in PD patients.

Vigabatrin-associated retinal damage: potential biochemical mechanisms

Vigabatrin (VGB), an irreversible inhibitor of gamma-aminobutyric acid (GABA) transaminase, is approved as adjunct treatment of refractory partial seizures as well as infantile spasms. Although VGB has been proven to be effective, its use is limited by the risk of retinopathy and associated peripheral visual field defects. This review describes and analyzes current literature related to potential pathophysiologic mechanisms underlying VGB-mediated cellular toxicity. Animal data suggest that GABA mediates neural excitotoxicity. The amino acid taurine is concentrated in retinal cells, and deficiency of this amino acid may be involved in VGB-mediated retinal degeneration and possible phototoxicity.

Downregulation of the taurine transporter TauT during hypo-osmotic stress in NIH3T3 mouse fibroblasts

The present work was initiated to investigate regulation of the taurine transporter TauT by reactive oxygen species (ROS) and the tonicity-responsive enhancer binding protein (TonEBP) in NIH3T3 mouse fibroblasts during acute and long-term (4 h) exposure to low-sodium/hypo-osmotic stress. Taurine influx is reduced following reduction in osmolarity, keeping the extracellular Na(+) concentration constant. TonEBP activity is unaltered, whereas TauT transcription as well as TauT activity are significantly reduced under hypo-osmotic conditions. In contrast, TonEBP activity and TauT transcription are significantly increased following hyperosmotic exposure. Swelling-induced ROS production in NIH3T3 fibroblasts is generated by NOX4 and by increasing total ROS, by either exogenous application of H(2)O(2) or overexpressing NOX4, we demonstrate that TonEBP activity and taurine influx are regulated negatively by ROS under hypo-osmotic, low-sodium conditions, whereas the TauT mRNA level is unaffected. Acute exposure to ROS reduces taurine uptake as a result of modulated TauT transport kinetics. Thus, swelling-induced ROS production could account for the reduced taurine uptake under low-sodium/hypo-osmotic conditions by direct modulation of TauT.

Do salt cravings in children with autistic disorders reveal low blood sodium depleting brain taurine and glutamine?

Because boys are four times more likely than girls to develop autism, the role of male hormones (androgens) has received considerable scrutiny. Some researchers implicate arginine vasopressin, an androgen-dependent hormone from the pituitary gland that elicits male behavior. Elevated vasopressin is also the most common cause of low blood sodium (hyponatremia)--most serious in the brains of children. Hyponatremia causes astrocytes to swell, then release the amino acids taurine and glutamine and their water to compensate. Taurin--the brain osmolyte/inhibitory neurotransmitter that suppresses vasopressin--was the amino acid most wasted or depleted in urine of autistic children. Glutamine is a critical metabolic fuel in brain neurons, astrocytes, endothelial cells, and the intestines, especially during hypoglycemia. Because glutamine is not thought to cross the blood-brain barrier significantly, the implications of low blood glutamine in these children are not recognized. Yet children with high brain glutamine from urea cycle disorders are rarely diagnosed with autistic disorders. Other common events in autistic children that release vasopressin are gastrointestinal inflammation, hypoglycemia, and stress. Signs of hyponatremia in these children are salt cravings reported online and anecdotally, deep yellow urine revealing concentration, and relief of autistic behavior by fluid/salt diets. Several interventions offer promise: (a) taurine to suppress vasopressin and replenish astrocytes; (b) glutamine as fuel for intestines and brain; (c) arginine to spare glutamine, detoxify ammonia, and increase brain blood flow; and (d) oral rehydration salts to compensate dilutional hyponatremia. This hypothesis appears eminently testable: Does your child crave salt? Is his urine deep yellow?

The physiological implication of novel proteins in systemic osmoregulation

Maintenance of the osmobalance is important for life. In this process, in which brain and kidney act in concert, mammals have to cope with significant deviations as drinking water reduces plasma osmolality, whereas salty food increases it. To restore homeostasis, specialized nuclei within the hypothalamus play a pivotal role in detecting changes in plasma osmolality and initiating appropriate responses. These responses are accomplished by either changing the intake of water or the excretion of water by the kidney. In the past decade, several novel findings have made significant contributions to our insights in the process of systemic osmoregulation. Novel proteins have been identified in the brain as well as in the kidney that are fulfilling important roles in the process of systemic osmoregulation. In this review, recent evidence of the involvement of TRPV channels (TRPV1, TRPV2, and TRPV4) and proteins, such as sodium channels NALCN and Na(x), in neuronal osmoregulation, as well as; e.g., the purinergic P2Y2 receptor in renal osmoregulation, are discussed, and integrated with existing knowledge of systemic osmoregulation.

Hypo-osmotic swelling modifies glutamate-glutamine cycle in the cerebral cortex and in astrocyte cultures

In our previous work, we found that perfusion of the rat cerebral cortex with hypo-osmotic medium triggers massive release of the excitatory amino acid L-glutamate but decreases extracellular levels of L-glutamine (R. E. Haskew-Layton et al., PLoS ONE, 3: e3543). The release of glutamate was linked to activation of volume-regulated anion channels, whereas mechanism(s) responsible for alterations in extracellular glutamine remained unclear. When mannitol was added to the hypo-osmotic medium to reverse reductions in osmolarity, changes in microdialysate levels of glutamine were prevented, indicating an involvement of cellular swelling. As the main source of brain glutamine is astrocytic synthesis and export, we explored the impact of hypo-osmotic medium on glutamine synthesis and transport in rat primary astrocyte cultures. In astrocytes, a 40% reduction in medium osmolarity moderately stimulated the release of L-[(3) H]glutamine by ∼twofold and produced no changes in L-[(3) H]glutamine uptake. In comparison, hypo-osmotic medium stimulated the release of glutamate (traced with D-[(3) H]aspartate) by more than 20-fold. In whole-cell enzymatic assays, we discovered that hypo-osmotic medium caused a 20% inhibition of astrocytic conversion of L-[(3) H]glutamate into L-[(3) H]glutamine by glutamine synthetase. Using an HPLC assay, we further found a 35% reduction in intracellular levels of endogenous glutamine. Overall, our findings suggest that cellular swelling (i) inhibits astrocytic glutamine synthetase activity, and (ii) reduces substrate availability for this enzyme because of the activation of volume-regulated anion channels. These combined effects likely lead to reductions in astrocytic glutamine export in vivo and may partially explain occurrence of hyperexcitability and seizures in human hyponatremia.

Receptor regulation of osmolyte homeostasis in neural cells

The capacity of cells to correct their volume in response to hyposmotic stress via the efflux of inorganic and organic osmolytes is well documented. However, the ability of cell-surface receptors, in particular G-protein-coupled receptors (GPCRs), to regulate this homeostatic mechanism has received much less attention. Mechanisms that underlie the regulation of cell volume are of particular importance to cells in the central nervous system because of the physical restrictions of the skull and the adverse impact that even small increases in cell volume can have on their function. Increases in brain volume are seen in hyponatraemia, which can arise from a variety of aetiologies and is the most frequently diagnosed electrolyte disorder in clinical practice. In this review we summarize recent evidence that the activation of GPCRs facilitates the volume-dependent efflux of osmolytes from neural cells and permits them to more efficiently respond to small, physiologically relevant, reductions in osmolarity. The characteristics of receptor-regulated osmolyte efflux, the signalling pathways involved and the physiological significance of receptor activation are discussed. In addition, we propose that GPCRs may also regulate the re-uptake of osmolytes into neural cells, but that the influx of organic and inorganic osmolytes is differentially regulated. The ability of neural cells to closely regulate osmolyte homeostasis through receptor-mediated alterations in both efflux and influx mechanisms may explain, in part at least, why the brain selectively retains its complement of inorganic osmolytes during chronic hyponatraemia, whereas its organic osmolytes are depleted.

Organic osmolytes in hyponatremia and ammonia toxicity

Hyperammonemia (HA) is a major and commonly observed feature of hepatic encephalopathy. Furthermore, hyponatremia is an important pathogenetic factor in patients with hepatic encephalopathy. Both conditions have some features in common, such as the release of organic osmolytes, which might be an adaptive mechanism against cell swelling. However, the consequence of a possible relationship between osmoregulatory response in hyperammonemia and hyponatremia is not completely understood. This review gives a short introduction into the pathogenesis of hepatic encephalopathy and hyponatremia. For a comparison of both pathological events, some basics on cellular osmo- and volume regulation are explained, in particular as the mechanisms involved in the adaption of the cell to volume changes can be different under both pathological conditions. The role of brain glutamine and organic osmolytes in hyponatremia and hyperammonemia and their combination are discussed based on findings in experimental animal models, and finally on data obtained from primary astrocytes in culture. The observations that the decrease of brain organic osmolytes in astrocytes not adequately compensate for an increased intracellular osmolarity caused by glutamine are consistent with results obtained after chronic hyponatremia in rats, in which the release of osmolytes does not protect from ammonia-induced brain edema. Furthermore, a decrease in intracellular osmolarity is attributed both to the release and a reduced de novo synthesis of amino acids.

Muscarinic receptor regulation of osmosensitive taurine transport in human SH-SY5Y neuroblastoma cells

The ability of G protein-coupled receptors to regulate osmosensitive uptake of the organic osmolyte, taurine, into human SH-SY5Y neuroblastoma cells has been examined. When monitored under isotonic conditions and in the presence of physiologically relevant taurine concentrations (1-100 microM), taurine influx was mediated exclusively by a Na(+)-dependent, high-affinity (K(m) = 2.5 microM) saturable transport mechanism (V(max) = 0.087 nmol/mg protein/min). Reductions in osmolarity of > 20% (attained under conditions of a constant NaCl concentration) resulted in an inhibition of taurine influx (> 30%) that could be attributed to a reduction in V(max), whereas the K(m) for uptake remained unchanged. Inclusion of the muscarinic cholinergic agonist, oxotremorine-M (Oxo-M), also resulted in an attenuation of taurine influx (EC(50) approximately 0.7 microM). Although Oxo-M-mediated inhibition of taurine uptake could be observed under isotonic conditions (approximately 25-30%), the magnitude of inhibition was significantly enhanced by hypotonicity (approximately 55-60%), a result that also reflected a reduction in the V(max), but not the K(m), for taurine transport. Oxo-M-mediated inhibition of taurine uptake was dependent upon the availability of extracellular Ca(2+) but was independent of protein kinase C activity. In addition to Oxo-M, inclusion of either thrombin or sphingosine 1-phosphate also attenuated volume-dependent taurine uptake. The ability of Oxo-M to inhibit the influx of taurine was attenuated by 4-[(2-butyl-6,7-dichloro-2-cyclopentyl-2,3-dihydro-1-oxo-1H-inden-5-yl)oxy]butanoic acid, an inhibitor of the volume-sensitive organic osmolyte and anion channel. 4-[(2-Butyl-6,7-dichloro-2-cyclopentyl-2,3-dihydro-1-oxo-1H-inden-5-yl)oxy]butanoic acid also prevented receptor-mediated changes in the efflux and influx of K(+) under hypoosmotic conditions. The results suggest that muscarinic receptor activation can regulate both the volume-dependent efflux and uptake of taurine and that these events may be functionally coupled.

Volume-dependent osmolyte efflux from neural tissues: regulation by G-protein-coupled receptors

The CNS is particularly vulnerable to reductions in plasma osmolarity, such as occur during hyponatremia, the most commonly encountered electrolyte disorder in clinical practice. In response to a lowered plasma osmolarity, neural cells initially swell but then are able to restore their original volume through the release of osmolytes, both inorganic and organic, and the exit of osmotically obligated water. Given the importance of the maintenance of cell volume within the CNS, mechanisms underlying the release of osmolytes assume major significance. In this context, we review recent evidence obtained from our laboratory and others that indicates that the activation of specific G-protein-coupled receptors can markedly enhance the volume-dependent release of osmolytes from neural cells. Of particular significance is the observation that receptor activation significantly lowers the osmotic threshold at which osmolyte release occurs, thereby facilitating the ability of the cells to respond to small, more physiologically relevant, reductions in osmolarity. The mechanisms underlying G-protein-coupled receptor-mediated osmolyte release and the possibility that this efflux can result in both physiologically beneficial and potentially harmful pathophysiological consequences are discussed.

Central mechanisms of osmosensation and systemic osmoregulation

Systemic osmoregulation is a vital process whereby changes in plasma osmolality, detected by osmoreceptors, modulate ingestive behaviour, sympathetic outflow and renal function to stabilize the tonicity and volume of the extracellular fluid. Furthermore, changes in the central processing of osmosensory signals are likely to affect the hydro-mineral balance and other related aspects of homeostasis, including thermoregulation and cardiovascular balance. Surprisingly little is known about how the brain orchestrates these responses. Here, recent advances in our understanding of the molecular, cellular and network mechanisms that mediate the central control of osmotic homeostasis in mammals are reviewed.

Activation of muscarinic cholinergic receptors on human SH-SY5Y neuroblastoma cells enhances both the influx and efflux of K+ under conditions of hypo-osmolarity

The ability of receptor activation to regulate osmosensitive K+ fluxes (monitored as 86Rb+) in SH-SY5Y neuroblastoma has been examined. Incubation of SH-SY5Y cells in buffers rendered increasingly hypotonic by a reduction in NaCl concentration resulted in an enhanced basal efflux of Rb+ (threshold of release, 200 mOsM) but had no effect on Rb(+) influx. Addition of the muscarinic cholinergic agonist, oxotremorine-M (Oxo-M), potently enhanced Rb+ efflux (EC50 = 0.45 microM) and increased the threshold of release to 280 mOsM. Oxo-M elicited a similarly potent, but osmolarity-independent, enhancement of Rb+ influx (EC50 = 1.35 microM). However, when incubated under hypotonic conditions in which osmolarity was varied by the addition of sucrose to a fixed concentration of NaCl, basal- and Oxo-M-stimulated Rb+ influx and efflux were demonstrated to be dependent upon osmolarity. Basal- and Oxo-M-stimulated Rb+ influx (but not Rb+ efflux) were inhibited by inclusion of ouabain or furosemide. Both Rb+ influx and efflux were inhibited by removal of intracellular Ca2+ and inhibition of protein kinase C activity. In addition to Oxo-M, agonists acting at other cell surface receptors previously implicated in organic osmolyte release enhanced both Rb+ efflux and influx under hypotonic conditions. Oxo-M had no effect on cellular K+ concentration in SH-SY5Y cells under physiologically relevant reductions in osmolarity (0-15%) unless K+ influx was blocked. Thus, although receptor activation enhances the osmosensitive efflux of K+, it also stimulates K+ influx, and the latter permits retention of K+ by the cells.

Effect of taurine supplementation on growth and development in preterm or low birth weight infants

BACKGROUND

Taurine is the most abundant free amino acid in breast milk. Evidence exists that taurine has important roles in intestinal fat absorption, hepatic function, and auditory and visual development in preterm or low birth weight infants. Observational data suggest that relative taurine deficiency during the neonatal period is associated with adverse long-term neurodevelopmental outcomes in preterm infants. Current standard practice is to supplement formula milk and parenteral nutrition solutions with taurine.

OBJECTIVES

To assess the effect of providing supplemental taurine for enterally or parenterally fed preterm or low birth weight infants on growth and development.

SEARCH STRATEGY

The standard search strategy of the Cochrane Neonatal Review Group was used. This included searches of the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 - June 2007), EMBASE (1980 - June 2007), conference proceedings, and previous reviews.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared taurine supplementation versus no supplementation in preterm or low birth weight newborn infants.

DATA COLLECTION AND ANALYSIS

Data were extracted using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by two review authors, and synthesis of data using relative risk, risk difference and weighted mean difference.

MAIN RESULTS

Nine small trials were identified. In total, 189 infants participated. Most participants were greater than 30 weeks gestational age at birth and were clinically stable. In eight of the studies, taurine was given enterally with formula milk. Only one small trial assessed parenteral taurine supplementation. Taurine supplementation increased intestinal fat absorption [weighted mean difference 4.0 (95% confidence interval 1.4, 6.6) percent of intake]. However, meta-analyses did not reveal any statistically significant effects on growth parameters assessed during the neonatal period or until three to four months chronological age [rate of weight gain: weighted mean difference -0.25 (95% confidence interval -1.16, 0.66) grams/kilogram/day; change in length: weighted mean difference 0.37 (95% confidence interval -0.23, 0.98) millimetres/week; change in head circumference: weighted mean difference 0.15 (95% confidence interval -0.19, 0.50) millimeters/week]. There are very limited data on the effect on neonatal mortality or morbidities, and no data on long-term growth or neurological outcomes.

AUTHORS' CONCLUSIONS

Despite that lack of evidence of benefit from randomised controlled trials, it is likely that taurine will continue to be added to formula milks and parenteral nutrition solutions used for feeding preterm and low birth weight infants given the putative association of taurine deficiency with various adverse outcomes. Further randomised controlled trials of taurine supplementation versus no supplementation in preterm or low birth weight infants are unlikely to be viewed as a research priority, but there may be issues related to dose or duration of supplementation in specific subgroups of infants that merit further research.

Inadvertent hyponatremia leading to acute cerebral edema and early evidence of herniation

INTRODUCTION

For years, the maintenance of normal or supranormal serum sodium (Na) concentrations has been believed to be beneficial in brain injuries. Recently published guidelines for cerebral trauma recommend the use of hypertonic saline to achieve hypernatremia for the management of increased intracranial pressure and these standards are generally practiced across most diseases in neurocritical care including stroke, hemorrhage and tumors. Severe hyponatremia has long been known to be detrimental, but objective evidence for the harm of mild hyponatremia as a secondary injury has been scarce.

DESCRIPTION OF CASE

In this case report, we describe a child with aneurysmal subarachnoid hemorrhage who had a sudden, inadvertent decrease in serum Na (128 meq/l) that was associated with a deterioration of her neurological examination and evidence of early transtentorial herniation on emergent brain CT scan. These findings were quickly reversed after the serum Na was corrected.

DISCUSSION

This report emphasizes that close monitoring of serum Na and osmolarity in acute head injured children is important, and provides evidence that alterations of these parameters is a substantial risk for cerebral edema in children with evolving brain injuries and briefly reviews the literature regarding the risks of hyponatremia in children.

Acute and chronic changes in aquaporin 4 expression after spinal cord injury

The effect of spinal cord injury (SCI) on the expression levels and distribution of water channel aquaporin 4 (AQP4) has not been studied. We have found AQP4 in gray and white matter astrocytes in both uninjured and injured rat spinal cords. AQP4 was detected in astrocytic processes that were tightly surrounding neurons and blood vessels, but more robustly in glia limitans externa and interna, which were forming an interface between spinal cord parenchyma and cerebrospinal fluid (CSF). Such spatial distribution of AQP4 suggests a critical role that astrocytes expressing AQP4 play in the transport of water from blood/CSF to spinal cord parenchyma and vice versa. SCI induced biphasic changes in astrocytic AQP4 levels, including its early down-regulation and subsequent persistent up-regulation. However, changes in AQP4 expression did not correlate well with the onset and magnitude of astrocytic activation, when measured as changes in GFAP expression levels. It appears that reactive astrocytes began expressing increased levels of AQP4 after migrating to the wound area (thoracic region) two weeks after SCI, and AQP4 remained significantly elevated for months after SCI. We also showed that increased levels of AQP4 spread away from the lesion site to cervical and lumbar segments, but only in chronically injured spinal cords. Although overall AQP4 expression levels increased in chronically-injured spinal cords, AQP4 immunolabeling in astrocytic processes forming glia limitans externa was decreased, which may indicate impaired water transport through glia limitans externa. Finally, we also showed that SCI-induced changes in AQP4 protein levels correlate, both temporally and spatially, with persistent increases in water content in acutely and chronically injured spinal cords. Although correlative, this finding suggests a possible link between AQP4 and impaired water transport/edema/syringomyelia in contused spinal cords.

Hyponatremia in neurologic patients: consequences and approaches to treatment

BACKGROUND

Hyponatremia is a common fluid-electrolyte disturbance, particularly in patients with neurologic disorders, in part because of the major role the central nervous system (CNS) plays in the regulation of sodium and water homeostasis.

REVIEW SUMMARY

The classification of hyponatremia is based on an assessment of serum sodium concentration ([Na+]), serum and urine osmolality, and body volume status. In most cases, hyponatremia is associated with hypotonicity, which causes water to move into the brain. Adaptive responses limit the impact of cerebral edema in chronic hyponatremia, but CNS symptoms and death may occur in response to rapid or large decreases in serum [Na+]. The prompt correction of serum [Na+] is mandatory in symptomatic patients, but overly rapid correction must be avoided to limit the risk of myelinolysis. In neurologic disorders, euvolemic hyponatremia (usually caused by the syndrome of inappropriate secretion of antidiuretic hormone) must be distinguished from hypovolemic states such as cerebral salt wasting because the treatment of the 2 conditions differs. Vasopressin antagonists represent a new approach to the treatment of euvolemic and hypervolemic hyponatremia secondary to arginine vasopressin dysregulation.

CONCLUSION

The optimal treatment of hyponatremia is controversial, but appropriate treatment must be determined according to the osmolality and volume status of the patient. If left untreated, serious CNS complications and adverse outcomes, including an increased risk of death, can occur.

Neurological impact of vasopressin dysregulation and hyponatremia

Hyponatremia is frequently associated with neurological disease, neurosurgical procedures, and use of psychoactive drugs. Arginine vasopressin (AVP), or antidiuretic hormone, is the principal physiological regulator of water and electrolyte balance, and disruption of the normal AVP response to osmotic stimuli is a common cause of dilutional hyponatremia in neurological disorders. The hyponatremia-induced shift in water from the extracellular to the intracellular compartment can lead to cerebral edema and serious neurological complications, especially if the decrease in serum sodium concentration ([Na+]) is large or rapid. Overly rapid correction of the serum [Na+] may lead to osmotic demyelination and irreversible brain injury. Fluid restriction is considered first-line treatment and pharmacological agents currently used in the treatment of hyponatremia are limited by inconsistent response and adverse side effects. AVP receptor antagonists represent a new approach to the treatment of hyponatremia by blocking tubular reabsorption of water by binding to V2 receptors in the renal collecting ducts, resulting in aquaresis. Initial clinical experience with AVP receptor antagonists for hyponatremia has shown that these agents augment free water clearance, decrease urine osmolality, and correct serum [Na+] and serum osmolality. Controlled clinical trials now underway will help elucidate the role of AVP receptor antagonism in the treatment of hyponatremia.

Exercise-Associated Hyponatraemia

In 1958, Edelman and colleagues empirically showed plasma sodium concentration ([Na+]p) to be primarily a function of the sum of exchangeable sodium and potassium (E) divided by total body water (TBW). Based on Edelman's equation, Nguyen and Kurtz derived an equation to show how [Na+]p changes as a function of TBW, change in TBW (DeltaTBW), and change in the sum of exchangeable sodium and potassium (DeltaE). Using the Nguyen-Kurtz equation, the present study examines the sensitivity of [Na+]p to these parameters: [Na+]p is very sensitive to DeltaTBW and moderately sensitive to DeltaE, and is modulated by TBW. For example, for a person with 50 L TBW, a net increase of 1L water lowers [Na+]p by 3.2 mEq/L, but for a person with 25 L TBW it lowers [Na+]p by 6.3 mEq/L (assuming initial [Na+]p is 140 mEq/L). In each case, a loss of 159 mEq of sodium plus potassium (roughly equivalent to 1.5 teaspoons of table salt) would be required to produce the same effect as the net increase of 1 L water. The present review demonstrates why fluid overload predominates over electrolyte loss in the aetiology of exercise-associated hyponatraemia (EAH), and why the excretion of electrolyte-dilute urine is highly effective in correcting EAH (nonetheless, loss of sodium and potassium is significant in long events in warm weather). Sports drinks will, if overconsumed, result in hyponatraemia. Administration of a sports drink to an athlete with fluid overload hyponatraemia further lowers [Na+]p and increases fluid overload. Administration of either a sports drink or normal (0.9%) saline increases fluid overload.