Prevalence and Impact of Hyponatremia in Patients With Coronavirus Disease 2019 in New York City

CT semi-quantitative score used as risk factor for hyponatremia in patients with COVID-19: a cross-sectional study

Purpose

Chest computed tomography (CT) is used to determine the severity of COVID-19 pneumonia, and pneumonia is associated with hyponatremia. This study aims to explore the predictive value of the semi-quantitative CT visual score for hyponatremia in patients with COVID-19 to provide a reference for clinical practice.

Methods

In this cross-sectional study, 343 patients with RT-PCR confirmed COVID-19, all patients underwent CT, and the severity of lung lesions was scored by radiologists using the semi-quantitative CT visual score. The risk factors of hyponatremia in COVID-19 patients were analyzed and combined with laboratory tests. The thyroid function changes caused by SARS-CoV-2 infection and their interaction with hyponatremia were also analyzed.

Results

In patients with SARS-CoV-2 infection, the total severity score (TSS) of hyponatremia was higher [M(range), 3.5(2.5-5.5) vs 3.0(2.0-4.5) scores, P=0.001], implying that patients with hyponatremia had more severe lung lesions. The risk factors of hyponatremia in the multivariate regression model included age, vomiting, neutrophils, platelet, and total severity score. SARS-CoV-2 infection impacted thyroid function, and patients with hyponatremia showed a lower free triiodothyronine (3.1 ± 0.9 vs 3.7 ± 0.9, P=0.001) and thyroid stimulating hormone level [1.4(0.8-2.4) vs 2.2(1.2-3.4), P=0.038].

Conclusion

Semi-quantitative CT score can be used as a risk factor for hyponatremia in patients with COVID-19. There is a weak positive correlation between serum sodium and free triiodothyronine in patients with SARS-CoV-2 infection.

Prognostic value of initial serum sodium level in predicting disease severity in patients with COVID-19: A multicenter retrospective study

INTRODUCTION

Early prediction of coronavirus disease (COVID-19) severity is crucial. Hyponatremia has been linked to poor outcomes in hospitalized COVID-19 patients, but its association with mild cases is unclear. This study aimed to investigate whether initial serum sodium level is a risk factor for COVID-19 severity in patients with mild-to-moderate disease.

METHODS

A multicenter retrospective cohort study was conducted in 10 hospitals in Fukui City, Japan, from July 1, 2020, to October 31, 2021. The study included 1055 adult patients with asymptomatic, mild, or moderate COVID-19 confirmed by a positive RT-PCR test. The primary outcome was the need for oxygen therapy after hospitalization, and the secondary outcome was the composite of in-hospital death and critical care interventions. The association between initial serum sodium level (at the emergency department or on admission) and outcomes was examined, adjusting for age, sex, hypertension, and pneumonia presence.

RESULTS

Of the 1267 patients diagnosed with COVID-19 during the study period, 1055 were eligible (median age: 45 years; 54 % male). Hyponatremia was observed in 5.2 % of patients upon admission. A lower initial serum sodium level was associated with an increased risk of the need for oxygen therapy after hospitalization (adjusted odds ratio [OR] per 1 mmol/L lower, 1.12 [95 % confidence interval {CI}, 1.05-1.19]) and the composite of critical care and in-hospital death (adjusted OR per 1 mmol/L lower, 1.09 [95 % CI, 0.99-1.20]).

CONCLUSIONS

Among patients with mild COVID-19, lower initial serum sodium level was a risk factor for COVID-19 progression.

Risk Factors for COVID-19 Infection in Adult Patients: A Retrospective Observational Study in Japan

Purpose

The aim of the study was to identify the characteristics of patients infected with coronavirus disease 2019 (COVID-19) and to determine risk factors for COVID-19 infection in Japanese patients.

Patients and Methods

We conducted a single-center retrospective observational study in Japanese adult patients (≥20 years) who visited Kenwakai Hospital (Nagano Japan). We analyzed data of 378 patients (mean age, 75 ± 14 years; men, 54%) from the hospital's electronic information system. COVID-19 was diagnosed by polymerase-chain reaction. Patients were divided into 2 groups based on diagnosis of COVID-19.

Results

Patients infected with COVID-19 showed significantly higher rates of men (69.8 vs 51.6%, P = 0.025) than uninfected control patients. After adjustment for possible confounding factors, COVID-19 infection was significantly associated with BUN (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.01-1.03) and serum creatinine (Scr) (OR, 1.14; 95% CI, 1.05-1.24). This association was observed in men (BUN, P = 0.012; Scr, P = 0.012), but not in women (BUN, P = 0.43; Scr, P = 0.54).

Conclusion

BUN and Scr are potential risk factors for infection of COVID-19 in Japanese patients, particularly in men. Our results suggest that renal parameters might be important in Japanese male patients for the early detection of COVID-19 infection.

What is the aetiology of dysnatraemia in COVID-19 and how is this related to outcomes in patients admitted during earlier and later COVID-19 waves? A multicentre, retrospective observational study in 11 Dutch hospitals

OBJECTIVES

To evaluate the relationship among dysnatraemia at hospital presentation and duration of admission, risk of intensive care unit (ICU) admission and all-cause mortality and to assess the underlying pathophysiological mechanism of hyponatraemia in patients with COVID-19. Our hypothesis is that both hyponatraemia and hypernatraemia at presentation are associated with adverse outcomes.

DESIGN

Observational study.

SETTING

Secondary care; 11 Dutch hospitals (2 university and 9 general hospitals).

PARTICIPANTS

An analysis was performed within the retrospective multicentre cohort study COVIDPredict. 7811 patients were included (60% men, 40% women) between 24 February 2020 and 9 August 2022. Patients who were ≥18 years with PCR-confirmed COVID-19 or CT with COVID-19 reporting and data system score≥4 and alternative diagnosis were included. Patients were excluded when serum sodium levels at presentation were not registered in the database or when they had been transferred from another participating hospital.

OUTCOME MEASURES

We studied demographics, medical history, symptoms and outcomes. Patients were stratified according to serum sodium concentration and urinary sodium excretion.

RESULTS

Hyponatraemia was present in 2677 (34.2%) patients and hypernatraemia in 126 (1.6%) patients. Patients with hyponatraemia presented more frequently with diarrhoea, lower blood pressure and tachycardia. Hyponatraemia was, despite a higher risk for ICU admission (OR 1.27 (1.11-1.46; p<0.001)), not associated with mortality or the risk for intubation. Patients with hypernatraemia had higher mortality rates (OR 2.25 (1.49-3.41; p<0.001)) and were at risk for ICU admission (OR 2.89 (1.83-4.58)) and intubation (OR 2.95 (1.83-4.74)).

CONCLUSIONS

Hypernatraemia at presentation was associated with adverse outcomes in patients with COVID-19. Hypovolaemic hyponatraemia was found to be the most common aetiology of hyponatraemia. Hyponatraemia of unknown aetiology was associated with a higher risk for ICU admission and intubation and longer duration of admission.

Hyponatremia causing factors and its association with disease severity and length of stay in COVID-19 patients: A retrospective study from tertiary care hospital

The coronavirus disease-2019 (COVID-19) infection has taken the world by storm within a few months. Evidence has suggested that patients with electrolyte imbalances at baseline may have a longer duration of hospital stay. We aimed to determine the factors associated with hyponatremia on admission in COVID-19 patients and its impact on the length of stay. We conducted a retrospective study including 521 patients who tested positive for COVID-19 and had their electrolytes checked on admission from June 2020 to October 2020. Patients with sodium <135 mmol/l were included in the hyponatremic group and were compared against normonatremic patients. The severity of COVID-19 was found to be more prevalent in the case group as compared to control (38.3% vs 29.2%; 21.1% vs 17.7%). Hyponatremic patients stayed more than 5 days in hospital (56.3% vs 46.5%), and stayed longer in special care (23.4% vs 20.0%) as compared to controls. Hyponatremic patients as compared to control were more likely to have diabetes (47.9% vs 30.0%), hypertension (49.0% vs 38.5%), ischemic heart disease (20.7% vs 15.4%), chronic liver disease (2.7% vs 1.2%), and chronic kidney disease (9.6% vs 3.8%). Upon matching on the age, the adjusted odds of hyponatremia in COVID-19-positive patients were 1.9 times among diabetic patients. Moreover, COVID-19-positive patients suffering from CKD had a higher risk of developing hyponatremia (OR = 2.3, 95% CI: 1.1-5.6). The risk of hyponatremia among COVID-19-positive patients is statistically higher in patients with 1 comorbidity (OR = 1.9, 95%CI: 1.3-3.4). Hyponatremia on admission can be used to forecast the length of hospital stay and the severity of illness in COVID-19 patients.

Incidence of Hyponatremia Among Critically Ill Patients With and Without COVID-19 Infection at a Community Teaching Hospital

Background: Various studies have demonstrated the incidence of hyponatremia in patients with Coronavirus Disease 2019 (COVID-19); however, to our knowledge, no study has assessed the difference in the incidence of hyponatremia in patients with and without COVID-19. Purpose: To compare the incidence of hyponatremia in patients requiring intensive care unit (ICU) admission with and without COVID-19 infection. Methods: This was a single-center, retrospective cohort study of patients with a diagnosis of pneumonia from February 2019 to January 2020, or a diagnosis of COVID-19 from June 2020 to May 2021. Included patients were matched on age and sex. The primary outcome was the incidence of hyponatremia within 72 h of admission. Secondary endpoints collected included severity of hyponatremia, symptomatic hyponatremia, and lowest serum sodium. Results: There were 99 and 104 patients included in pneumonia and COVID-19 arms, respectively. Twenty-nine patients in the pneumonia group and 56 patients in the COVID-19 group had a sodium level <134 mEq/L (29% vs 56%, RR 1.84, P < .01). The mean lowest serum sodium within 72 h of admission was 136.9 mEq/L in the pneumonia group and 134.5 mEq/L in the COVID-19 group (P < .01). Other notable findings included days of mechanical ventilation (3 days vs 8 days, respectively; P < .01), downgrade from the ICU (74.8% vs 59.6%, P = .02), ICU length of stay (4 days vs 10 days, P < .01), hospital length of stay (6 days vs 14 days, P < .01), and mortality (16.2% vs 39.4%, P < .01). Conclusion: Among critically ill patients with COVID-19, the risk of hyponatremia was significantly greater than the risk in critically ill patients with pneumonia.

The prevalence and outcomes of hyponatremia in children with COVID-19 and multisystem inflammatory syndrome in children (MIS-C)

Introduction

To assess the prevalence of hyponatremia among pediatric patients with coronavirus disease 2019 (COVID-19) and Multisystem Inflammatory Syndrome in Children (MIS-C) and determine if pediatric hyponatremia was associated with an increased length of stay, higher rates of mechanical ventilation, and/or elevated inflammatory markers on admission as compared to eunatremic patients.

Methods

Electronic health records were retrospectively analyzed for 168 children less than 18 years old with COVID-19 or MIS-C who were admitted to pediatric units within the Northwell Health system. The primary exposure was hyponatremic status (serum sodium <135 mEq/L) and the primary outcomes were length of stay, mechanical ventilation usage and increased inflammatory markers.

Results

Of the 168 children in the study cohort, 95 (56%) were admitted for COVID-19 and 73 (43.5%) for MIS-C. Overall, 60 (35.7%) patients presented with hyponatremia on admission. Patients with hyponatremia had higher rates of intensive care unit admission when compared to eunatremic patients (32/60 [53.3%] vs. 39/108 [36.1%], p = 0.030). In regression models, hyponatremia was not significantly associated with increased length of stay or mechanical ventilation rates. After adjustment for relevant confounders, hyponatremia remained associated with an increased square root CRP (β = 1.79: 95% CI: 0.22-3.36) and lower albumin levels (β = -0.22: 95% CI: -0.42--0.01).

Conclusion

Hyponatremia is common in pediatric COVID-19 and MIS-C. Hyponatremia was associated with a lower albumin and higher square root CRP levels. This may suggest an association of inflammation with lower serum sodium levels.

Inappropriate therapy of euvolemic hyponatremia, the most frequent type of hyponatremia in SARS-CoV-2 infection, is associated with increased mortality in COVID-19 patients

Introduction

Admission hyponatremia, frequent in patients hospitalized for COVID-19, has been associated with increased mortality. However, although euvolemic hyponatremia secondary to the Syndrome of Inappropriate Antidiuresis (SIAD) is the single most common cause of hyponatremia in community-acquired pneumonia (CAP), a thorough and rigorous assessment of the volemia of hyponatremic COVID-19 subjects has yet to be described. We sought to identify factors contributing to mortality and hospital length-of-stay (LOS) in hospitalized COVID-19 patients admitted with hyponatremia, taking volemia into account.

Method

Retrospective study of 247 patients admitted with COVID-19 to a tertiary hospital in Madrid, Spain from March 1st through March 30th, 2020, with a glycemia-corrected serum sodium level (SNa) < 135 mmol/L. Variables were collected at admission, at 2nd-3rd day of hospitalization, and ensuing days when hyponatremia persisted. Admission volemia (based on both physical and analytical parameters), therapy, and its adequacy as a function of volemia, were determined.

Results

Age: 68 years [56-81]; 39.9% were female. Median admission SNa was 133 mmol/L [131- 134]. Hyponatremia was mild (SNa 131-134 mmol/L) in 188/247 (76%). Volemia was available in 208/247 patients; 57.2% were euvolemic and the rest (42.8%) hypovolemic. Hyponatremia was left untreated in 154/247 (62.3%) patients. Admission therapy was not concordant with volemia in 43/84 (51.2%). In fact, the majority of treated euvolemic patients received incorrect therapy with isotonic saline (37/41, 90.2%), whereas hypovolemics did not (p=0.001). The latter showed higher mortality rates than those receiving adequate or no therapy (36.7% vs. 19% respectively, p=0.023). The administration of isotonic saline to euvolemic hyponatremic subjects was independently associated with an elevation of in-hospital mortality (Odds Ratio: 3.877, 95%; Confidence Interval: 1.25-12.03).

Conclusion

Hyponatremia in COVID-19 is predominantly euvolemic. Isotonic saline infusion therapy in euvolemic hyponatremic COVID-19 patients can lead to an increased mortality rate. Thus, an exhaustive and precise volemic assessment of the hyponatremic patient with CAP, particularly when due to COVID-19, is mandatory before instauration of therapy, even when hyponatremia is mild.

Elevated Serum Urea-to-Creatinine Ratio and In-Hospital Death in Patients with Hyponatremia Hospitalized for COVID-19

Hyponatremia is associated with adverse outcomes in hospitalized patients. An elevated value of the serum urea-to-creatinine ratio (UCR) has been proposed as a proxy of hypovolemia. The aim of this study was to investigate the relationship between the UCR and in-hospital death in patients hospitalized with COVID-19 and hyponatremia. We studied 258 patients admitted for COVID-19 between January 2020 and May 2021 with serum sodium at < 135 mmol/L. The primary end-point was all-cause mortality. A 5-unit increase in the serum UCR during hospital stays was associated with an 8% increase in the hazard of all-cause death (HR = 1.08, 95% CI: 1.03-1.14, p = 0.001) after adjusting for potential confounders. In patients with a UCR > 40 at baseline, a > 10 mmol/L increase in serum sodium values within the first week of hospitalization was associated with higher odds of in-hospital death (OR = 2.93, 95% CI: 1.03-8.36, p = 0.044) compared to patients who experienced a < 10 mmol/L change. This was not observed in patients with a UCR < 40. Hypovolemia developing during hospital stays in COVID-19 patients with hyponatremia detected at hospital admission bears an adverse prognostic impact. Moreover, in hypovolemic patients, a > 10 mmol/L increase in serum sodium within the first week of hospital stays may further worsen the in-hospital prognosis.

Post-COVID-19-associated multiorgan complications or "long COVID" with literature review and management strategy discussion: A meta-analysis

Objective

To investigate the post-COVID-19 long-term complications or long COVID of various organ systems in patients after 3 months of the infection, specifically before the Omicron variant, with comparative literature analysis.

Methods

A systemic literature search and meta-analysis were conducted using multiple electronic databases (PubMed, Scopus, Cochrane library) with predefined search terms to identify eligible articles. Eligible studies reported long-term complications of COVID-19 infection before the Omicron variant infection. Case reports, case series, observational studies with cross-sectional or prospective research design, case-control studies, and experimental studies that reported post-COVID-19 complications were included. The complications reported after 3 months after the recovery from COVID-19 infection were included in the study.

Results

The total number of studies available for analysis was 34. The effect size (ES) for neurological complications was 29% with 95% confidence interval (CI): 19%-39%. ES for psychiatric complications was 24% with 95% CI: 7%-41%. ES was 9% for cardiac outcomes, with a 95% CI of 1%-18%. ES was 22%, 95% CI: 5%-39% for the gastrointestinal outcome. ES for musculoskeletal symptoms was 18% with 95% CI: 9%-28%. ES for pulmonary complications was 28% with 95% CI: 18%-37%. ES for dermatological complications was 25%, with a 95% CI of 23%-26%. ES for endocrine outcomes was 8%, with a 95% CI of 8%-9%. ES size for renal outcomes was 3% with a 95% CI of 1%-7%. At the same time, other miscellaneous uncategorized outcomes had ES of 39% with 95% CI of 21%-57%. Apart from analyzing COVID-19 systemic complications outcomes, the ES for hospitalization and intensive care unit admissions were found to be 4%, 95% CI: 0%-7%, and 11% with 95% CI: 8%-14%.

Conclusion

By acquiring the data and statistically analyzing the post-COVID-19 complications during the prevalence of most virulent strains, this study has generated a different way of understanding COVID-19 and its complications for better community health.

Electrolyte imbalances as poor prognostic markers in COVID-19: a systemic review and meta-analysis

PURPOSE

Serum electrolyte imbalances are highly prevalent in COVID-19 patients. However, their associations with COVID-19 outcomes are inconsistent, and of unknown prognostic value. We aim to systematically clarify the associations and prognostic accuracy of electrolyte imbalances (sodium, calcium, potassium, magnesium, chloride and phosphate) in predicting poor COVID-19 clinical outcome.

METHODS

PubMed, Embase and Cochrane Library were searched. Odds of poor clinical outcome (a composite of mortality, intensive-care unit (ICU) admission, need for respiratory support and acute respiratory distress syndrome) were pooled using mixed-effects models. The associated prognostic sensitivity, positive and negative likelihood ratios (LR + , LR-) and predictive values (PPV, NPV; assuming 25% pre-test probability), and area under the curve (AUC) were computed.

RESULTS

We included 28 observational studies from 953 records with low to moderate risk-of-bias. Hyponatremia (OR = 2.08, 95% CI = 1.48-2.94, I² = 93%, N = 8), hypernatremia (OR = 4.32, 95% CI = 3.17-5.88, I² = 45%, N = 7) and hypocalcemia (OR = 3.31, 95% CI = 2.24-4.88, I² = 25%, N = 6) were associated with poor COVID-19 outcome. These associations remained significant on adjustment for covariates such as demographics and comorbidities. Hypernatremia was 97% specific in predicting poor outcome (LR + 4.0, PPV = 55%, AUC = 0.80) despite no differences in CRP and IL-6 levels between hypernatremic and normonatremic patients. Hypocalcemia was 76% sensitive in predicting poor outcome (LR- 0.44, NPV = 87%, AUC = 0.71). Overall quality of evidence ranged from very low to moderate.

CONCLUSION

Hyponatremia, hypernatremia and hypocalcemia are associated with poor COVID-19 clinical outcome. Hypernatremia is 97% specific for a poor outcome, and the association is independent of inflammatory marker levels. Further studies should evaluate if correcting these imbalances help improve clinical outcome.

Consensus Clinical Guidance for Diagnosis and Management of Adult COVID-19 Encephalopathy Patients

Encephalopathy, a common condition among patients hospitalized with COVID-19, can be a challenge to manage and negatively affect prognosis. While encephalopathy may present clinically as delirium, subsyndromal delirium, or coma and may be a result of systemic causes such as hypoxia, COVID-19 has also been associated with more prolonged encephalopathy due to less common but nevertheless severe complications, such as inflammation of the brain parenchyma (with or without cerebrovascular involvement), demyelination, or seizures, which may be disproportionate to COVID-19 severity and require specific management. Given the large number of patients hospitalized with severe acute respiratory syndrome coronavirus-2 infection, even these relatively unlikely complications are increasingly recognized and are particularly important because they require specific management. Therefore, the aim of this review is to provide pragmatic guidance on the management of COVID-19 encephalopathy through consensus agreement of the Global COVID-19 Neuro Research Coalition. A systematic literature search of MEDLINE, medRxiv, and bioRxiv was conducted between January 1, 2020, and June 21, 2021, with additional review of references cited within the identified bibliographies. A modified Delphi approach was then undertaken to develop recommendations, along with a parallel approach to score the strength of both the recommendations and the supporting evidence. This review presents analysis of contemporaneous evidence for the definition, epidemiology, and pathophysiology of COVID-19 encephalopathy and practical guidance for clinical assessment, investigation, and both acute and long-term management.

Risk factors for Hyponatremia in COVID-19 hospitalised patients

Objectives

To determine the risk factors for Hyponatremia in Coronavirus disease 2019 (COVID-19) patients.

Methods

Medical records of all patients admitted in COVID-19 Isolation Intensive Care Unit of Farooq Hospital Westwood Branch, Lahore from 1st July to 30th September, 2020 were retrospectively reviewed. Patients with confirmed diagnosis of COVID-19 by Real Time Polymerase Chain Reaction (RT-PCR) and having Hyponatremia (serum Sodium (s/Na+ <135mEq/L) were included, patients with Eunatremia (s/Na+ within 135 - 145mEq/L) were taken as control while subjects with Hypernatremia (s/Na+ >145mEq/L) at admission, incomplete medical records and pregnant females were excluded from the study. Demographic, clinical and laboratory data at time of admission in hospital was extracted.

Results

Of 182 included patients, 79.1% (n=144) were male 40.7% (n=74) had Diabetes Mellitus (DM) and 44.5% (n=81) were hypertensive. Forty seven percent (n=86) patients had Hyponatremia while 52.7% (n=96) were eunatremic. Forty nine percent (n=90) patients had Acute Kidney Injury (AKI) and 4.9% (n=9) patients died. Risk factors for Hyponatremia were age >60 years (OR=2.52, p=0.006); DM (OR=2.79, p=0.001); Hypoxemia (OR=3.74, p<0.001); Lymphopenia (OR=7.62, p<0.009); Hypoalbuminemia (OR=9.15, p<0.001); high serum Ferritin (OR=4.46, p<0.001), high Neutrophil to Lymphocyte Ratio (NLR) (OR=3.58, p<0.001) and AKI (OR=3.40, p<0.001).

Conclusions

Hyponatremia was common in COVID-19 hospitalized patients. Increasing age, DM, Hypoxemia, Hypoalbuminemia, high serum Ferritin and AKI were the most significant risk factors for Hyponatremia. Hyponatremic patients had comparatively higher mortality than Eunatremic patients.

The Evolution of Hypovolemic and Euvolemic Hyponatremia Coincides with an Inflammatory Status in Patients with COVID-19: An Observational Cohort Study

We evaluated the hospital evolution of hyponatremia and inflammation markers in patients with coronavirus disease 2019 (COVID-19). The hospital evolutions of a cohort of adult patients with COVID-19 pneumonia and hyponatremia were retrospectively analyzed. Data of the admission day, 2nd–3rd and 7th–10th day of hospitalization, and of the discharge day were collected. Comparative and multivariate analyzes were developed, and Hazzard ratio (HR) with 95% confidence intervals (95% CI) were calculated. Of the 172 hospitalized patients with COVID-19, 49 of them (28.5%) had hyponatremia, which were analyzed. A total of 32/49 (65.3%) patients were male, and 22/49 (44.9%) euvolemic. Mean age: 69.9 ± 14.7 years. All patients had high inflammatory markers at admission. Of the total patients with hyponatremia at admission, only 26.2% remained hyponatremic at the 7th–10th day of hospitalization. Improvement in serum sodium (SNa) coincided with improvement in inflammatory markers during hospitalization, in both euvolemic and hypovolemic hyponatremic patients. A higher serum creatinine at admission was independently associated with mortality (HR: 12.23, 95% CI: 2 to 25.6) in hyponatremic COVID-19 patients. In conclusion, both hypovolemic and euvolemic hyponatremia in COVID-19 patients occurred in an inflammation status, and improved as inflammation decreased.

Role of Micronutrients and Gut Microbiota-Derived Metabolites in COVID-19 Recovery

A balanced and varied diet provides diverse beneficial effects on health, such as adequate micronutrient availability and a gut microbiome in homeostasis. Besides their participation in biochemical processes as cofactors and coenzymes, vitamins and minerals have an immunoregulatory function; meanwhile, gut microbiota and its metabolites coordinate directly and indirectly the cell response through the interaction with the host receptors. Malnourishment is a crucial risk factor for several pathologies, and its involvement during the Coronavirus Disease 2019 pandemic has been reported. This pandemic has caused a significant decline in the worldwide population, especially those with chronic diseases, reduced physical activity, and elder age. Diet and gut microbiota composition are probable causes for this susceptibility, and its supplementation can play a role in reestablishing microbial homeostasis and improving immunity response against Coronavirus Disease 2019 infection and recovery. This study reviews the role of micronutrients and microbiomes in the risk of infection, the severity of disease, and the Coronavirus Disease 2019 sequelae.

Real-world effectiveness and protection of SARS-CoV-2 vaccine among patients hospitalized for COVID-19 in Xi’an, China, December 8, 2021, to January 20, 2022: A retrospective study

Introduction

In December 2021, a large-scale epidemic broke out in Xi’an, China, due to SARS-CoV-2 infection. This study reports the effect of vaccination on COVID-19 and evaluates the impact of different vaccine doses on routine laboratory markers.

Methods

The laboratory data upon admission, of 231 cases with COVID-19 hospitalized from December 8, 2021 to January 20, 2022 in Xi’an, including blood routine, lymphocyte subtypes, coagulative function tests, virus specific antibodies and blood biochemical tests were collected and analyzed.

Results

Of the 231 patients, 21 were not vaccinated, 158 were vaccinated with two doses and 52 with three doses. Unvaccinated patients had a higher proportion of moderate and severe symptoms than vaccinated patients, while two-dose vaccinated patients had a higher proportion than three-dose vaccinated patients. SARS-CoV-2 specific IgG levels were significantly elevated in vaccinated patients compared with unvaccinated patients. Particularly, unvaccinated patients had lower counts and percentages of lymphocytes, eosinophils and CD8⁺ T-lymphocytes, and elevated coagulation-related markers. In addition, vaccination had no effect on liver and kidney function.

Conclusions

Vaccination against SARS-CoV-2, inducing high IgG level and increased CD8⁺ T cells and eosinophils, and regulating coagulation function, can significantly attenuate symptoms of COVID-19, suggesting that the vaccine remains protective against SARS-CoV-2.

Hyponatremia in horses with septic pneumopathy

Background

Hyponatremia is common in horses with bacterial pleuropneumonia, but no further characterization of this abnormality has been reported.

Objectives

Describe admission plasma sodium concentration ([Na]) in horses with septic pneumopathy and evaluate any association of plasma [Na] with markers of systemic inflammation.

Animals

Medical records of horses >1 month of age that between 2008 and 2021 had a transtracheal aspirate (TTA) performed, abnormal TTA cytology, positive TTA culture, pulmonary disease on ultrasonography, radiography or both, and plasma [Na] assessed by direct ion‐selective‐electrode (dISE). Horses with concurrent diarrhea or azotemia were excluded.

Methods

Clinical and clinicopathological variables of interest between hypo‐ and normonatremic horses were compared. Spearman correlation and Fisher exact tests were used to identify significant associations (P < .05).

Results

Twenty of 35 horses had hyponatremia (median, 132 mmol/L; 25‐75th interquartile range [IQR], 129.7‐133.1 mmol/L; reference range, 134.2‐138.4 mmol/L). A higher proportion of horses with systemic inflammatory response syndrome (SIRS) had hyponatremia (P = .01). Hyponatremic patients had higher mean plasma fibrinogen concentration (461 ± 160.5 mg/dL; P = .01) and higher rectal temperature (38.8 ± 0.7°C; P = .02) than normonatremic horses. Negative correlations were found between plasma [Na] and fibrinogen (P = .001; ρ = −0.57) concentrations and between plasma [Na] and rectal temperature (P = .001; ρ = −0.51). Presence or absence of pleural effusion did not influence severity of hyponatremia. Mean duration of hospitalization was longer (P = .04) in hyponatremic horses (9.8 ± 6.6 days).

Conclusions and Clinical Importance

Hyponatremia at admission is associated with the presence of inflammation, SIRS, and with longer duration of hospitalization.

The Mutual Relationship among Cardiovascular Diseases and COVID-19: Focus on Micronutrients Imbalance

Micronutrients are ions and vitamins humbly required by the human body. They play a main role in several physiological mechanisms and their imbalance is strongly associated with potentially-fatal complications. Micronutrient imbalance is associated with many cardiovascular diseases, such as arrythmias, heart failure, and ischemic heart disease. It has been also observed in coronavirus disease 2019 (COVID-19), particularly in most severe patients. The relationship between cardiovascular diseases and COVID-19 is mutual: the latter triggers cardiovascular disease onset and worsening while patients with previous cardiovascular disease may develop a more severe form of COVID-19. In addition to the well-known pathophysiological mechanisms binding COVID-19 and cardiovascular diseases together, increasing importance is being given to the impact of micronutrient alterations, often present during COVID-19 and able to affect the balance responsible for a good functioning of the cardiovascular system. In particular, hypokalemia, hypomagnesemia, hyponatremia, and hypocalcemia are strongly associated with worse outcome, while vitamin A and D deficiency are associated with thromboembolic events in COVID-19. Thus, considering how frequent the cardiovascular involvement is in patients with COVID-19, and how it majorly affects their prognosis, this manuscript provides a comprehensive review on the role of micronutrient imbalance in the interconnection between COVID-19 and cardiovascular diseases.

Treatment of hyponatremia in children with acute bacterial meningitis

Purpose

Few studies have evaluated hyponatremia management in children with bacterial meningitis (BM). Thus, we aimed to describe variations in clinical practice, the effectiveness of sodium management, and adverse outcomes in children with BM and hyponatremia.

Methods

This retrospective cross-sectional study conducted at a tertiary institution analyzed participants' demographic, clinical, and sodium-altering treatment data. The sodium trigger for treatment was defined as pretreatment sodium level, with response and overcorrection defined as increments of ≥5 and &gt;10 mmol/L after 24 h, respectively.

Results

This study enrolled 364 children with BM (age: &lt;16 years; 215 boys). Hyponatremia occurred in 62.1% of patients, among whom 25.7% received sodium-altering therapies; 91.4% of those individuals had moderate/severe hyponatremia. Monotherapy was the most common initial hyponatremia treatment. After 24 h of treatment initiation, 82.4% of the patients responded. Logistic regression analyses revealed that ΔNa24 &lt;5 mmol/L [odds ratio (OR) 15.52, 95% CI 1.71–141.06, p = 0.015] and minimum Glasgow Coma Scale (GCS) score ≤ 8 (OR 11.09, 95% CI 1.16–105.73, p = 0.036) predicted dysnatremia at 48 h after treatment initiation. Although rare, persistent moderate/severe hyponatremia or hypernatremia at 48 h after treatment initiation was associated with a high mortality rate (57.1%).

Conclusion

This study found that most cases of hyponatremia responded well to various treatments. It is important to identify and institute appropriate treatment early for moderate or severe hyponatremia or hypernatremia in children with BM. This study was limited by its non-randomized nature.

Sosa S, Mateu-Rogell P, Ortega-Castillo V, Tolentino-Dolores M, Perichart-Perera O, Franco-Gallardo JO, Carranco-Martínez JA, Prieto-Rodríguez S, Guzmán-Huerta M, Missirlis F, Estrada-Gutierrez G. Inflammatory-Metal Profile as a Hallmark for COVID-19 Severity During Pregnancy

Pregnancy makes women more susceptible to infectious agents; however, available data on the effect of SARS-CoV-2 on pregnant women are limited. To date, inflammatory responses and changes in serum metal concentration have been reported in COVID-19 patients, but few associations between metal ions and cytokines have been described. The aim of this study was to evaluate correlations between inflammatory markers and serum metal ions in third-trimester pregnant women with varying COVID-19 disease severity. Patients with severe symptoms had increased concentrations of serum magnesium, copper, and calcium ions and decreased concentrations of iron, zinc, and sodium ions. Potassium ions were unaffected. Pro-inflammatory cytokines IL-6, TNF-α, IL-8, IL-1α, anti-inflammatory cytokine IL-4, and the IP-10 chemokine were induced in the severe presentation of COVID-19 during pregnancy. Robust negative correlations between iron/magnesium and zinc/IL-6, and a positive correlation between copper/IP-10 were observed in pregnant women with the severe form of the disease. Thus, coordinated alterations of serum metal ions and inflammatory markers – suggestive of underlying pathophysiological interactions—occur during SARS-CoV-2 infection in pregnancy.

[Pituitary and COVID-19: review]

A severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread around the world since was first scientifically described in December 2019. At present approximately 400 million people have suffered from the disease, almost 6 million people have died.SARS-CoV-2 uses the angiotensin-converting enzyme 2 (ACE2) and the serine protease TMPRSS2 for S protein priming. ACE2 and TMPRSS2 are expressed in several endocrine glands, including the pituitary, pancreas, thyroid, ovaries, and testes. Thus, the endocrine glands may be a direct target for SARS-CoV-2. The main risk factors for severity of the COVID-19 are obesity, arterial hypertension, diabetes mellitus (DM), vertebral fractures, which potentially predisposes patients to a severe course of COVID-19.In this review, we present current data on the course of COVID-19 in patients with hypothalamic-pituitary diseases, and also discuss treatment for endocrinopathies during to COVID-19.

The impact of the correction of hyponatremia during hospital admission on the prognosis of SARS-CoV-2 infection

Background

SARS-CoV-2 infection is frequently associated with hyponatremia (plasma sodium <135 mmol/L), being associated with a worse prognosis. The incidence of hyponatremia is estimated to be 20-37% according to the series, but there are no data on the prognosis after correction of hyponatremia. Therefore, our objectives were: to analyse the incidence and severity of hyponatremia at hospital admission, and to determine the association of this hyponatremia with the prognosis of COVID-19.

Methods

Observational and retrospective cohort study. Patients who were admitted with a diagnosis of COVID-19 infection and hyponatremia, in the period March-May 2020, were included. We recorded epidemiological, demographic, clinical, biochemical, and radiological variables of SARS-CoV-2 infection and hyponatremia at the time of diagnosis and during hospitalization. The clinical follow-up ranged from admission to death or discharge.

Results

91 patients (21.8%) of the 414 admitted for SARS-CoV-2 infection presented hyponatremia (81.32% mild hyponatremia, 9.89% moderate and 8.79% severe). The absence of correction of hyponatremia 72-96 h after hospital admission was associated with higher mortality in patients with COVID-19 (Odds Ratio 0.165; 95% confidence interval: 0.018-0.686; p = 0.011). 19 patients (20.9%) died. An increase in mortality was observed in patients with severe hyponatremia compared with moderate and mild hyponatremia during hospital admission (37.5% versus 11.1% versus 8.1%, p = 0.041).

Conclusion

We conclude that persistence of hyponatremia at 72-96 h of hospital admission was associated with higher mortality in patients with SARS-Cov-2.

Hypertonic Solution in Severe COVID-19 Patient: A Potential Adjuvant Therapy

Coronavirus disease 2019 (COVID-19) features hyper-inflammation, cytokine storm, neutrophil function changes, and sodium chloride (NaCl) homeostasis disruption, while the treatment with NaCl hypertonic solutions (HS) controls electrolytic body homeostasis and cell functions. HS treatment is a simple, popular, economic, and feasible therapy to regulate leukocyte function with a robust anti-inflammatory effect in many inflammatory diseases. The purpose of this narrative review is to highlight the knowledge on the use of HS approaches against viral infection over the past years and to describe the mechanisms involved in the release of neutrophil extracellular traps (NETs) and production of cytokine in severe lung diseases, such as COVID-19. We reported the consequences of hyponatremia in COVID-19 patients, and the immunomodulatory effects of HS, either in vitro or in vivo. We also described the relationship between electrolyte disturbances and COVID-19 infection. Although there is still a lack of clinical trials, hypertonic NaCl solutions have marked effects on neutrophil function and NETs formation, emerging as a promising adjuvant therapy in COVID-19.

Predictors and outcome of hyponatremia in patients with COVID 19: a single-center experience

Introduction/Aim: Hyponatremia (serum sodium 0.001) were the independent predictors of hyponatremia at the time of admission. The median length of hospital stay (LOS) was longer in patients with hyponatremia than patients with normonatremia (10 days vs. 8 days, p < 0.001). In multivariate analysis, hyponatremia was significantly associated with ICU admission or the need for mechanical ventilation (adjusted OR, 1.72; 95% confidence interval [95% CI], 1.03 to 2.85; p = 0.036). The severity of pneumonia, hemoglobin and lactate dehydrogenase levels, neutrophil-to-lymphocyte ratio (NLR), and body temperature were also associated with ICU admission or the need for mechanical ventilation. The oxygen saturation, male sex, serum albumin, NLR, and the ICU admission but not the hyponatremia on admission were significantly related to mortality. Conclusion: Hyponatremia on admission, even when mild, predicts a worse outcome in COVID-19 patients, and it should be considered in risk stratification.

Heterogeneity and Risk of Bias in Studies Examining Risk Factors for Severe Illness and Death in COVID-19: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis synthesized the evidence on the impacts of demographics and comorbidities on the clinical outcomes of COVID-19, as well as the sources of the heterogeneity and publication bias of the relevant studies. Two authors independently searched the literature from PubMed, Embase, Cochrane library, and CINAHL on 18 May 2021; removed duplicates; screened the titles, abstracts, and full texts by using criteria; and extracted data from the eligible articles. The variations among the studies were examined by using Cochrane, Q.; I2, and meta-regression. Out of 11,975 articles that were obtained from the databases and screened, 559 studies were abstracted, and then, where appropriate, were analyzed by meta-analysis (n = 542). COVID-19-related severe illness, admission to the ICU, and death were significantly correlated with comorbidities, male sex, and an age older than 60 or 65 years, although high heterogeneity was present in the pooled estimates. The study design, the study country, the sample size, and the year of publication contributed to this. There was publication bias among the studies that compared the odds of COVID-19-related deaths, severe illness, and admission to the ICU on the basis of the comorbidity status. While an older age and chronic diseases were shown to increase the risk of developing severe illness, admission to the ICU, and death among the COVID-19 patients in our analysis, a marked heterogeneity was present when linking the specific risks with the outcomes.

[Hyponatraemia in elderly patient - significance, clarification and therapy]

In the general population, the prevalence of mild, usually asymptomatic hyponatremia ranges from 1,7-7,7 %. With increasing age, it rises to 11,6 % in > 75-year-olds. The prevalence is much higher in nursing home residents and hospital patients. Hyponatremia thus represents the most common electrolyte disturbance in the elderly. Despite the existing evidence on the acute as well as chronic effects of hyponatremia, too little attention is paid to it in clinical practice. An algorithm has proven to be useful for the diagnosis of hyponatremia, which enables the cause to be identified in a few simple steps and at the same time leads to the correct therapeutic steps. The goal must be a serum sodium within the normal range. This is the only way to improve the prognosis and functionality of elderly patients. For SIADH, we have a potent substance available in tolvaptan. In order to be able to recognize the danger of overcorrection in time, the adjustment should take place in the inpatient setting.

Hyponatremia in COVID‐19 patients: Experience from Bangladesh

Background

The purpose of the study was to measure the prevalence of hyponatremia and its association with clinical and laboratory characteristics of hospitalized coronavirus disease 2019 (COVID‐19) patients at Dhaka Medical College and Hospital (DMCH).

Methods

This retrospective study was conducted in COVID‐19 dedicated wards at DMCH from June to August 2020. Demographic, clinical, and laboratory data were collected from patient treatment sheets. Two groups of COVID‐19 patients were retrospectively screened on the basis of plasma sodium level at admission: hyponatremic (sodium < 135 mM, n = 84) or normonatremic (sodium ≥ 135 mM, n = 48) patients. Severity was assessed using World Health Organization classification for COVID‐19 disease severity. To compare the two groups, Pearson's χ² (qualitative variables) and Student's T tests (quantitative variables) were applied. The link between patients' clinical data and outcomes was investigated using logistic regression model.

Results

A total of 132 patients were included in the study, with a mean age of 51.41 (±14.13) years. Hyponatremia was found in 84 patients (63.6%) and the remaining 48 patients (36.4%) had normal plasma Na⁺ values. Among them, 74 (56.06%) presented with severe disease and 53 (40.15%) with moderate disease. At presentation, patients with moderate COVID‐19 disease had 2.15 (1.04–4.5) times higher odds of suffering from hyponatremia. Besides, hyponatremia was independently associated with on admission SpO₂ (p = 0.038), hemoglobin (p = 0.004), and C‐reactive protein (p = 0.001).

Conclusions

The authors suggest that patients' serum electrolytes be measured during initial hospital admission and then monitored throughout the hospital stay to predict the probability for referral for invasive ventilation and for better management.

Psychological Symptoms in COVID-19 Patients: Insights into Pathophysiology and Risk Factors of Long COVID-19

There is growing evidence of studies associating COVID-19 survivors with increased mental health consequences. Mental health implications related to a COVID-19 infection include both acute and long-term consequences. Here we discuss COVID-19-associated psychiatric sequelae, particularly anxiety, depression, and post-traumatic stress disorder (PTSD), drawing parallels to past coronavirus outbreaks. A literature search was completed across three databases, using keywords to search for relevant articles. The cause may directly correlate to the infection through both direct and indirect mechanisms, but the underlying etiology appears more complex and multifactorial, involving environmental, psychological, and biological factors. Although most risk factors and prevalence rates vary across various studies, being of the female gender and having a history of psychiatric disorders seem consistent. Several studies will be presented, demonstrating COVID-19 survivors presenting higher rates of mental health consequences than the general population. The possible mechanisms by which the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enters the brain, affecting the central nervous system (CNS) and causing these psychiatric sequelae, will be discussed, particularly concerning the SARS-CoV-2 entry via the angiotensin-converting enzyme 2 (ACE-2) receptors and the implications of the immune inflammatory signaling on neuropsychiatric disorders. Some possible therapeutic options will also be considered.

Serum Sodium, Patient Symptoms, and Clinical Outcomes in Hospitalized Patients with COVID-19

Introduction:

Disorders of serum sodium (SNa) are common in hospitalized patients with COVID-19 and may reflect underlying disease severity. However, the association of SNa with patient-reported outcomes is not clear.

Methods:

The Brigham and Women’s Hospital COVID-19 Registry is a prospective cohort study of consecutively admitted adult patients with confirmed SARS-CoV-2 infection (n = 809). We examined the associations of SNa (continuous and tertiles) on admission with: (1) patient symptoms obtained from detailed chart review; and (2) in-hospital mortality, length of stay, and intensive care unit (ICU) admission using unadjusted and adjusted logistic regression models. Covariates included demographic data and comorbidities.

Results:

Mean age was 60 years, 48% were male, and 35% had diabetes. The most frequent symptoms were cough (64%), fever (60%), and shortness of breath (56%). In adjusted models, higher SNa (per mmol/L) was associated with lower odds of GI symptoms (OR 0.96; 95% CI 0.92-0.99), higher odds of confusion (OR 1.08; 95% CI 1.04-1.13), in-hospital mortality (OR 1.06; 95% CI 1.02-1.11), and ICU admission (OR 1.09; 95% CI 1.05-1.13). The highest sodium tertile (compared with the middle tertile) showed similar associations, in addition to lower odds of either anosmia or ageusia (OR 0.30; 95% CI 0.12-0.74).

Conclusion:

In this prospective cohort study of hospitalized patients with COVID-19, hypernatremia was associated with higher odds of confusion and in-hospital mortality. These findings may aid providers in identifying high-risk patients who warrant closer attention, thereby furthering patient-centered approaches to care.

COVID-19 and Dementia; Hard to Forget Yet Haunting Forgetfulness!

The current pandemic has affected almost everyone worldwide. Although the majority of people survive the illness, bad cognitive repercussions might last a long time, resulting in a lower quality of life and disability, particularly in severe cases. We tried to understand and bring together the various possible mechanisms leading to dementia in COVID-19. The link between COVID-19 and dementia will help public health workers plan and allocate resources to provide better care for a community suffering from sickness and improve quality of life. A conceptual framework for care of infected people in the older age group and care of dementia people is proposed.

Prevalence and outcomes of hyponatremia among COVID-19 patients: A systematic review and meta-analysis

Objectives

On March 2020, the WHO declared coronavirus disease 2019 (COVID-19) pandemic. COVID-19 is associated with various clinical syndromes, with electrolytes imbalances involved. This review aims to quantify the prevalence and outcomes of hyponatremia among COVID-19 patients, as well as to review the underlying pathophysiological mechanisms of hyponatremia among these patients.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines, we conducted a systematic literature search using the electronic databases of Google Scholar, MEDLINE (PubMed), WHO Virtual Health Library, and ScienceDirect, without limitations regarding gender, geographical area, race or publication date, up until December 13, 2021. Primary outcomes measured were mortality, intensive care unit (ICU) admission, assisted ventilation need, and length of hospital stay (LOS). Secondary outcome was the mechanism underlying hyponatremia among COVID-19 patients.

Results

From a total of 52 included studies, 23 underwent quantitative analysis. For the primary outcomes; proportions, odds ratios (OR), and standardized mean difference (SMD) were calculated using random effects model. The prevalence of hyponatremia was found to be 25.8%. Hyponatremia was found to be significantly associated with increased odds for mortality (OR = 1.97[95% CI, 1.50-2.59]), ICU admission (OR = 1.91 [95% CI, 1.56-2.35]), assisted ventilation need (OR = 2.04 [95% CI, 1.73-2.38]), and with increased LOS (SMD of 5.74 h [95% CI, 0.092-0.385]). Regarding the mechanisms underlying hyponatremia, syndrome of inappropriate anti-diuretic hormone secretion (SIADH) was most commonly reported, followed by adrenal insufficiency, and finally hypovolemic hyponatremia due to gastrointestinal losses.

Conclusion

Hyponatremia among COVID-19 patients is generally associated with poor outcomes, with SIADH being the most common underlying mechanism.

Prior fluid and electrolyte imbalance is associated with COVID-19 mortality

Background

The COVID-19 pandemic represents a major public health threat. Risk of death from the infection is associated with age and pre-existing comorbidities such as diabetes, dementia, cancer, and impairment of immunological, hepatic or renal function. It remains incompletely understood why some patients survive the disease, while others do not. As such, we sought to identify novel prognostic factors for COVID-19 mortality.

Methods

We performed an unbiased, observational retrospective analysis of real world data. Our multivariable and univariable analyses make use of U.S. electronic health records from 122,250 COVID-19 patients in the early stages of the pandemic.

Results

Here we show that a priori diagnoses of fluid, pH and electrolyte imbalance during the year preceding the infection are associated with an increased risk of death independently of age and prior renal comorbidities.

Conclusions

We propose that future interventional studies should investigate whether the risk of death can be alleviated by diligent and personalized management of the fluid and electrolyte balance of at-risk individuals during and before COVID-19.

Correlation of biochemical profile at admission with severity and outcome of COVID-19

Background

COVID-19 was detected in China in December 2019. The rapid dissemination and novelty of the disease resulted in an epidemic. This study aimed to identify biochemical parameters at admission that can be used to categorize severity and outcome of COVID -19 infection.

Materials and Methods

This cross-sectional study was conducted at Allied Hospitals of RMU from April 2020 to July 2020. It included 128 randomly selected confirmed COVID-19 patients. At admission, biochemical profile (total bilirubin, alanine aminotransferases {ALT}, aspartate aminotransferases {AST}, urea, creatinine, uric acid, sodium, potassium, and chloride were correlated with severity and outcome of COVID-19 by employing t-tests and ANOVA where required. Cut-off values to predict disease severity and outcome were calculated using ROC curve.

Results

The study comprised 46.1% non-severe, 29.7% severe, and 24.2% critical COVID-19 patients. 84.4% patients improved and 15.6% expired. Urea was increased in critical disease patients (p < 0.000). Higher ALT (p 0.030) and AST (p 0.004) levels were noted in severe and critical disease. Sodium (p 0.001) and chloride (p 0.026) were decreased in critical disease. Patients who expired had increased urea (p 0.000), ALT (p 0.040) and AST (p 0.002). At admission, urea >42.7 mg (sensitivity of 64.7%, specificity of 87.5%), AST >43.5 IU/L (64% sensitivity, 60% specificity), and sodium <136.9 mmol/L (sensitivity of 70.6%, specificity of 71.2%) predicted critical COVID-19 infection.

Conclusion

At admission, increased urea, AST, and ALT along with decreased sodium can help in identifying COVID-19 patients with severe illness and poor outcome.

Prevalence, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19

Hyponatraemia is frequently encountered in adults with coronavirus disease 2019 (COVID-19) and is associated with poor prognosis. This review aims to describe for the first time the prevalence, aetiology, prognostic value, pathophysiology, and management of hyponatraemia in children and adolescents with COVID-19, taking into account all relevant studies published in PubMed and Cochrane Library studies until 26th September 2021. Literature search did not detect any studies evaluating the prevalence and prognostic value of sodium disorders in paediatric patients with COVID-19. A broader literature review showed a high prevalence of hyponatraemia in children with bacterial pneumonia, while some studies have reported that hyponatraemia is relatively common in Multisystem Inflammatory Syndrome in Children (MIS-C). In adults with COVID-19, an inverse association between sodium and interleukin-6 levels has been found, indicating that hyponatraemia could be used as a surrogate marker for the risk of cytokine storm and may facilitate the identification of patients who could benefit from immunomodulatory agents. Studies are urgently needed to evaluate the frequency and prognostic impact of electrolyte abnormalities in children with COVID-19. In the meantime, clinicians are urged to consider hyponatraemia in children with COVID-19 as a potential red flag, investigate the cause and administer fluids and other therapies accordingly.

Sodium alterations impair the prognosis of hospitalized patients with COVID-19 pneumonia

OBJECTIVE

Dysnatremia is common in hospitalized patients, often worsening the prognosis in pneumopathies and critical illnesses. Information on coronavirus disease-19 (COVID-19)-related hyponatremia is partially conflicting, whereas data on hypernatremia in this context are scarce. We assessed, in a cohort of COVID-19 inpatients: the prevalence of sodium alterations at admission and throughout their hospitalization; their association with inflammation/organ damage indexes; their short-term prognostic impact.

STUDY DESIGN AND METHODS

117 patients (81 males, 64 ± 13 years) hospitalized for COVID-19 between 1 March and 30 April 2020 were retrospectively followed-up for their first 21 days of stay by collecting all serum sodium measurements, basal CRP and serum lactate levels, maximum IL-6 and information on care setting, required ventilation, length of hospitalization, in-hospital death.

RESULTS

At admission, 26.5% patients had hyponatremia, and 6.8% had hypernatremia. During their hospitalization, 13.7% patients experienced both disorders ('mixed dysnatremia'). Lower sodium levels at admission were correlated with higher C reactive protein (CRP) (P = 0.039) and serum lactate levels (P = 0.019), but not interleukin-6 (IL-6). Hypernatremia and a wider sodium variability were associated with maximum required ventilation, need for ICU assistance and duration of the hospitalization. Mean estimated time to Intensive Care Unit (ICU) admission was 20 days shorter in patients exposed to sodium alterations at any time of their hospital course (log-rank test P = 0.032).

CONCLUSIONS

Sodium alterations frequently affect hospitalized COVID-19 patients. Hyponatremia could indicate pulmonary involvement, whereas hypernatremia is associated to prolonged hospitalization and the need for intensive care/mechanical ventilation, particularly when resulting from prior hyponatremia. Optimizing in-hospital sodium balance is crucial to improve patients' prognosis.

Hypernatraemia and low eGFR at hospitalization in COVID-19 patients: a deadly combination

Background

The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the general population and the burden of pre-existing comorbidities has heavily affected the outcome of the infection. Hyponatraemia has been frequently described. Conversely, hypernatraemia has rarely been described in COVID-19.

Methods

The studied cohort encompasses all COVID-19 patients consecutively admitted to the Messina Hospital, Italy, during the first wave of the epidemic. Since healthcare structures were not overwhelmed at that time, indications for hospitalization were homogeneous throughout the study period. Serum sodium levels, kidney function [estimated glomerular filtration rate (eGFR)], demographic and clinical characteristics were recorded at admission. Correlation between mortality, sodium and eGFR was evaluated by survival curves and univariate and multivariate regression models.

Results

Baseline biochemical and clinical data at the time of admission were available for 115 COVID-19-confirmed patients. The median age at admission was 73 years (48% men), with a median Charlson Comorbidity Index of 4. A total of 23.5% of patients presented with a sodium level ≥146 mmol/L, while 7.8% had sodium <135 mmol/L. Hypernatraemic patients were older, with higher comorbidity. Age, hypernatraemia and reduced eGFR were associated with increased mortality in both univariate and multivariate regression models (P < 0.001). The combination of hypernatraemia and reduced renal function at admission had an odds ratio of 47.67 (95% confidence interval 10.08–225.43) of dying compared with patients with an eGFR ≥60 mL/min and sodium <145 mmol/L.

Conclusions

Our study suggests that the association between hypernatraemia and reduced eGFR at referral is a highly relevant prognostic marker for death during hospitalization. The role of this association should be further tested in larger, multicentre cohorts.

MANAGEMENT OF ENDOCRINE DISEASE: Dysnatraemia in COVID-19: prevalence, prognostic impact, pathophysiology, and management

This review examines the prevalence, aetiology, pathophysiology, prognostic value, and investigation of dysnatraemia in hospitalised COVID-19 patients, taking into account all relevant studies published in PubMed and Cochrane Library studies until March 2021. Hyponatraemia is commonly observed in patients with bacterial pneumonia and is an independent predictor for excess mortality and morbidity. However, it remains unknown whether this association applies to coronavirus disease-2019 (COVID-19). Several studies reported a 20-35% prevalence for hyponatraemia and 2-5% for hypernatraemia in patients admitted with COVID-19. In addition, hyponatraemia on admission was a risk factor for progression to severe disease, being associated with an increased likelihood for the need for invasive mechanical ventilation, with an odds ratio (OR) of 1.83-3.30. Hyponatraemia seems to be an independent risk factor for mortality, with an OR of 1.40-1.50 compared to normonatraemia, while hypernatraemia is related to even worse outcomes than hyponatraemia. Furthermore, preliminary data show an inverse association between serum sodium and interleukin-6 levels, suggesting that hyponatraemia might be used as a surrogate marker for the risk of a cytokine storm and the need for treatment with interleukin antagonists. In conclusion, dysnatraemia is common and carries a poor prognosis in COVID-19 patients, indicating that it may play a future role in risk stratification and individualising therapy.

Interplay between endocrinology, metabolism and COVID-19 infection

There are more than 170 million confirmed cases of COVID-19 worldwide, yet its effects on the endocrine system remain under-reported due to lack of awareness by the public, primary care givers and specialists. This is a narrative review using up-to-date literature discussing the consequences that infection with SARS-CoV-2 can have on diabetes and the endocrine glands including the adrenals, thyroid and pituitary, as well as hyponatremia and hypogonadism. Endocrinologists, internists and primary care physicians need to be aware of the involvement of the endocrine organs when dealing with people recovering from COVID-19 and actively manage any complications to reduce mortality and improve the quality of life of those affected.

ENDOCRINOLOGY IN THE TIME OF COVID-19-2021 UPDATES: The management of diabetes insipidus and hyponatraemia

COVID-19 has changed the nature of medical consultations, emphasizing virtual patient counselling, with relevance for patients with diabetes insipidus (DI) or hyponatraemia. The main complication of desmopressin treatment in DI is dilutional hyponatraemia. Since plasma sodium monitoring is not always possible in times of COVID-19, we recommend to delay the desmopressin dose once a week until aquaresis occurs allowing excess retained water to be excreted. Patients should measure their body weight daily. Patients with DI admitted to the hospital with COVID-19 have a high risk for mortality due to volume depletion. Specialists must supervise fluid replacement and dosing of desmopressin. Patients after pituitary surgery should drink to thirst and measure their body weight daily to early recognize the development of postoperative SIAD. They should know hyponatraemia symptoms. Hyponatraemia in COVID-19 is common with a prevalence of 20-30% and is mostly due to SIAD or hypovolaemia. It mirrors disease severity and is an early predictor of mortality. Hypernatraemia may also develop in COVID-19 patients, with a prevalence of 3-5%, especially in ICU, and derives from different multifactorial reasons, for example, due to insensible water losses from pyrexia, increased respiration rate and use of diuretics. Hypernatraemic dehydration may contribute to the high risk of acute kidney injury in COVID-19. IV fluid replacement should be administered with caution in severe cases of COVID-19 because of the risk of pulmonary oedema.

The impact of the correction of hyponatremia during hospital admission on the prognosis of SARS-CoV-2 infection

INTRODUCTION

SARS-CoV-2 infection is frequently associated with hyponatremia (plasma sodium<135mmol/L), being associated with a worse prognosis. The incidence of hyponatremia is estimated to be 20-37% according to the series, but there are no data on the prognosis after correction of hyponatremia. Therefore, our objectives were: to analyze the incidence and severity of hyponatremia at hospital admission, and to determine the association of this hyponatremia with the prognosis of COVID-19.

MATERIAL AND METHOD

Observational and retrospective cohort study. Patients who were admitted with a diagnosis of COVID-19 infection and hyponatremia, in the period March-May 2020, were included. We recorded epidemiological, demographic, clinical, biochemical, and radiological variables of SARS-CoV-2 infection and hyponatremia at the time of diagnosis and during hospitalization. The clinical follow-up ranged from admission to death or discharge.

RESULTS

91 patients (21.8%) of the 414 admitted for SARS-CoV-2 infection presented hyponatremia (81.32% mild hyponatremia, 9.89% moderate and 8.79% severe). The absence of correction of hyponatremia 72-96h after hospital admission was associated with higher mortality in patients with COVID-19 (Odds Ratio .165; 95% confidence interval: .018-.686; P=.011). 19 patients (20.9%) died. An increase in mortality was observed in patients with severe hyponatremia compared with moderate and mild hyponatremia during hospital admission (37.5% versus 11.1% versus 8.1%, P=.041).

CONCLUSIONS

We conclude that persistence of hyponatremia at 72-96h of hospital admission was associated with higher mortality in patients with SARS-CoV-2.

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.

Prevalence and Predictors of Prolonged Cognitive and Psychological Symptoms Following COVID-19 in the United States

Background/Objectives

Little is known regarding the prevalence and predictors of prolonged cognitive and psychological symptoms of COVID-19 among community-dwellers. We aimed to quantitatively measure self-reported metrics of fatigue, cognitive dysfunction, anxiety, depression, and sleep and identify factors associated with these metrics among United States residents with or without COVID-19.

Methods

We solicited 1000 adult United States residents for an online survey conducted February 3–5, 2021 utilizing a commercial crowdsourcing community research platform. The platform curates eligible participants to approximate United States demographics by age, sex, and race proportions. COVID-19 was diagnosed by laboratory testing and/or by exposure to a known positive contact with subsequent typical symptoms. Prolonged COVID-19 was self-reported and coded for those with symptoms ≥ 1 month following initial diagnosis. The primary outcomes were NIH PROMIS/Neuro-QoL short-form T-scores for fatigue, cognitive dysfunction, anxiety, depression, and sleep compared among those with prolonged COVID-19 symptoms, COVID-19 without prolonged symptoms and COVID-19 negative subjects. Multivariable backwards step-wise logistic regression models were constructed to predict abnormal Neuro-QoL metrics.

Results

Among 999 respondents, the average age was 45 years (range 18–84), 49% were male, 76 (7.6%) had a history of COVID-19 and 19/76 (25%) COVID-19 positive participants reported prolonged symptoms lasting a median of 4 months (range 1–13). Prolonged COVID-19 participants were more often younger, female, Hispanic, and had a history of depression/mood/thought disorder (all P < 0.05). They experienced significantly higher rates of unemployment and financial insecurity, and their symptoms created greater interference with work and household activities compared to other COVID-19 status groups (all P < 0.05). After adjusting for demographics, past medical history and stressor covariates in multivariable logistic regression analysis, COVID-19 status was independently predictive of worse Neuro-QoL cognitive dysfunction scores (adjusted OR 11.52, 95% CI 1.01–2.28, P = 0.047), but there were no significant differences in quantitative measures of anxiety, depression, fatigue, or sleep.

Conclusion

Prolonged symptoms occurred in 25% of COVID-19 positive participants, and NeuroQoL cognitive dysfunction scores were significantly worse among COVID-19 positive subjects, even after accounting for demographic and stressor covariates. Fatigue, anxiety, depression, and sleep scores did not differ between COVID-19 positive and negative respondents.

The Prognostic Value of Hyponatremia for Predicting Poor Outcome in Patients With COVID-19: A Systematic Review and Meta-Analysis

Background: This meta-analysis aimed to assess the prognostic value of hyponatremia in patients with COVID-19.

Methods: We performed a systematic literature search on PubMed, Scopus, ScienceDirect, and Wiley up until January 26, 2021. The key exposure was hyponatremia, defined as sodium level below the reference level. The outcome of interest was poor outcome, which was a composite of mortality, severe COVID-19, and prolonged hospitalization. Severe COVID-19 was defined severe CAP or needing ICU care or IMV. The pooled effect estimate was odds ratio (OR). Sensitivity, specificity, positive and negative likelihood ratio (PLR and NLR), diagnostic OR (DOR), and area under curve (AUC) were generated.

Results: There were 11,493 patients from eight studies included in this systematic review and meta-analysis. The incidence of hyponatremia was 24%, and incidence of poor outcome was 20%. Hyponatremia was associated with poor outcome in COVID-19 (OR 2.65 [1.89, 3.72], p < 0.001; I²: 67.2%). Meta-regression analysis showed that the association between hyponatremia and poor outcome was reduced by age (OR 0.94 [0.90, 0.98], p = 0.006) and hypertension (OR 0.96 [0.93, 0.94], p < 0.001). Hyponatremia has a sensitivity of 0.37 [0.27, 0.48], specificity of 0.82 [0.72, 0.88], PLR of 2.0 [1.5, 2.7], NLR of 0.77 [0.69, 0.87], DOR of 3 [2, 4], and AUC of 0.62 [0.58, 0.66] for predicting poor outcome. In this pooled analysis, hyponatremia has a 33% posttest probability for poor outcome, and absence of hyponatremia confers to a 16% posttest probability.

Conclusion: Hyponatremia was associated with poor outcome in patients with COVID-19.

Systematic Review Registration: PROSPERO, CRD42021233592.

Serum sodium alterations in SARS CoV-2 (COVID-19) infection: impact on patient outcome

OBJECTIVE

Hyponatremia is the most common electrolyte disorder in hospitalized patients and occurs in about 30% of patients with pneumonia. Hyponatremia has been associated with a worse outcome in several pathologic conditions The main objective of this study was to determine whether serum sodium alterations may be independent predictors of the outcome of hospitalized COVID-19 patients.

DESIGN AND METHODS

In this observational study, data from 441 laboratory-confirmed COVID-19 patients admitted to a University Hospital were collected. After excluding 61 patients (no serum sodium at admission available, saline solution infusion before sodium assessment, transfer from another hospital), data from 380 patients were analyzed.

RESULTS

274 (72.1%) patients had normonatremia at admission, 87 (22.9%) patients had hyponatremia and 19 (5%) patients had hypernatremia. We found an inverse correlation between serum sodium and IL-6, whereas a direct correlation between serum sodium and PaO2/FiO2 ratio was observed. Patients with hyponatremia had a higher prevalence of non-invasive ventilation and ICU transfer than those with normonatremia or hypernatremia. Hyponatremia was an independent predictor of in-hospital mortality (2.7-fold increase vs normonatremia) and each mEq/L of serum sodium reduction was associated with a 14.4% increased risk of death.

CONCLUSIONS

These results suggest that serum sodium at admission may be considered as an early prognostic marker of disease severity in hospitalized COVID-19 patients.

Dysnatremia is a Predictor for Morbidity and Mortality in Hospitalized Patients with COVID-19

CONTEXT

Dysnatremia is an independent predictor of mortality in patients with bacterial pneumonia. There is paucity of data about the incidence and prognostic impact of abnormal sodium concentration in patients with coronavirus disease 2019 (COVID-19).

OBJECTIVE

This work aimed to examine the association of serum sodium during hospitalization with key clinical outcomes, including mortality, need for advanced respiratory support and acute kidney injury (AKI), and to explore the role of serum sodium as a marker of inflammatory response in COVID-19.

METHODS

This retrospective longitudinal cohort study, including all adult patients who presented with COVID-19 to 2 hospitals in London over an 8-week period, evaluated the association of dysnatremia (serum sodium < 135 or > 145 mmol/L, hyponatremia, and hypernatremia, respectively) at several time points with inpatient mortality, need for advanced ventilatory support, and AKI.

RESULTS

The study included 488 patients (median age, 68 years). At presentation, 24.6% of patients were hyponatremic, mainly due to hypovolemia, and 5.3% hypernatremic. Hypernatremia 2 days after admission and exposure to hypernatremia at any time point during hospitalization were associated with a 2.34-fold (95% CI, 1.08-5.05; P = .0014) and 3.05-fold (95% CI, 1.69-5.49; P < .0001) increased risk of death, respectively, compared to normonatremia. Hyponatremia at admission was linked with a 2.18-fold increase in the likelihood of needing ventilatory support (95% CI, 1.34-3.45, P = .0011). Hyponatremia was not a risk factor for in-hospital mortality, except for the subgroup of patients with hypovolemic hyponatremia. Sodium values were not associated with the risk for AKI and length of hospital stay.

CONCLUSION

Abnormal sodium levels during hospitalization are risk factors for poor prognosis, with hypernatremia and hyponatremia being associated with a greater risk of death and respiratory failure, respectively. Serum sodium values could be used for risk stratification in patients with COVID-19.