1
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Patel S, Maria-Rios J, Parikh A, Okorie ON. Diagnosis and management of elevated intracranial pressure in the emergency department. Int J Emerg Med 2023; 16:72. [PMID: 37833652 PMCID: PMC10571389 DOI: 10.1186/s12245-023-00540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 09/19/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Elevated intracranial pressure is a devastating complication of catastrophic brain injury. Intracranial hypertension is commonly seen in neurologic injury secondary to traumatic brain injuries. Uncontrolled pressures can lead to permanent neurologic damage, but acute medical management is often overlooked when pursuing surgical management options that may not always be indicated. DISCUSSION Traumatic brain injury is the leading cause of death in patients with severe neurologic injury. Diagnosing elevated intracranial pressures is imperative in initiating prompt treatment to reduce secondary central nervous system injury, morbidity, and mortality. Although the initial injury to the brain is typically irreversible, intracranial pressure control can assist in salvaging the remaining brain tissue from additional damage. We will discuss the initial medical and surgical management of traumatic brain injury to prevent further neurologic deterioration and reduce mortality. CONCLUSION Recent literature has reported several methods to detect elevated intracranial pressure easily and studies describing multiple treatment modalities. These investigations suggest that early detection and timely treatment of intracranial hypertension are beneficial in reducing mortality.
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Affiliation(s)
- Sima Patel
- Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA.
| | - Jose Maria-Rios
- Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Amay Parikh
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Okorie Nduka Okorie
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth Orlando, 601 E Rollins St, Orlando, FL, 32803, USA
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2
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Juarez A, Barr M, Golden T. Hypertonic Saline Administration via Intraosseous Access During Symptomatic Hyponatremia. Cureus 2023; 15:e41731. [PMID: 37575736 PMCID: PMC10415047 DOI: 10.7759/cureus.41731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/11/2023] [Indexed: 08/15/2023] Open
Abstract
Hyponatremia is a common lab finding. Symptomatology varies greatly and can depend on the degree of hyponatremia and its chronicity. Causes of hyponatremia are also vast and include heart failure, renal injury, liver disease, and gastrointestinal losses, or it can be induced by medication. Treatment depends on the suspected etiology. However, in life-threatening conditions such as seizures or coma, urgent 3% saline is required. Administration of 3% saline is usually through peripheral and central IV access. This case report highlights an alternative route in administering 3% saline, intraosseous vascular access, when other options have been exhausted.
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Affiliation(s)
- Angel Juarez
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | - Mitsy Barr
- Internal Medicine, Grand Strand Medical Center, Myrtle Beach, USA
| | - Thaddeus Golden
- Critical Care Medicine, Grand Strand Medical Center, Myrtle Beach, USA
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3
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Tang H, Xu C, Zhang P, Luo T, Huang Y, Yang X. A profile of SGLT-2 inhibitors in hyponatremia: The evidence to date. Eur J Pharm Sci 2023; 184:106415. [PMID: 36870579 DOI: 10.1016/j.ejps.2023.106415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/14/2023] [Accepted: 02/27/2023] [Indexed: 03/06/2023]
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice, which may lead to life-threatening complications. Several lines of evidence suggest that hyponatremia is associated not only with significant increases in length of stay, cost, and financial burden, but also with increased morbidity and mortality. Hyponatremia is also considered to be a negative prognostic factor in patients with heart failure and cancer. Although multiple therapeutic methods are available for treating hyponatremia, most have some limitations, such as poor compliance, rapid correction of serum Na+, other negative side effects and high cost. Given these limitations, identifying novel therapies for hyponatremia is essential. Recent clinical studies have shown that SGLT-2 inhibitors (SGLT 2i) significantly increased serum Na+ levels and were well tolerated by patients who underwent this treatment. Therefore, oral administration of SGLT 2i appears to be an effective treatment for hyponatremia. This article will briefly review the etiology of hyponatremia and integrated control of sodium within the kidney, current therapies for hyponatremia, potential mechanisms and efficacy of SGLT 2i for hyponatremia, and the benefits in cardiovascular, cancer, and kidney disease by regulating sodium and water balance.
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Affiliation(s)
- Hui Tang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China
| | - Changjing Xu
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Piao Zhang
- Department of Pharmacy, Ya 'an People's Hospital, Ya 'an, Sichuan 646000, China
| | - Taimin Luo
- Department of pharmacy, Chengdu Seventh People's Hospital, Chengdu, Sichuan 610000, China
| | - Yilan Huang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
| | - Xuping Yang
- Department of Pharmacy, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China; School of Pharmacy, Southwest Medical University, Luzhou 646000, China.
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4
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Wagner B, Malhotra D, Schmidt D, Raj DS, Khitan ZJ, Shapiro JI, Tzamaloukas AH. Hypertonic Saline Infusion for Hyponatremia: Limitations of the Adrogué-Madias and Other Formulas. KIDNEY360 2023; 4:e555-e561. [PMID: 36758190 PMCID: PMC10278828 DOI: 10.34067/kid.0000000000000075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/10/2023] [Indexed: 02/11/2023]
Abstract
Hypertonic saline infusion is used to correct hyponatremia with severe symptoms. The selection of the volume of infused hypertonic saline ( VInf ) should address prevention of overcorrection or undercorrection. Several formulas computing this VInf have been proposed. The limitations common to these formulas consist of (1) failure to include potential determinants of change in serum sodium concentration ([ Na ]) including exchanges between osmotically active and inactive sodium compartments, changes in hydrogen binding of body water to hydrophilic compounds, and genetic influences and (2) inaccurate estimates of baseline body water entered in any formula and of gains or losses of water, sodium, and potassium during treatment entered in formulas that account for such gains or losses. In addition, computing VInf from the Adrogué-Madias formula by a calculation assuming a linear relation between VInf and increase in [ Na ] is a source of errors because the relation between these two variables was proven to be curvilinear. However, these errors were shown to be negligible by a comparison of estimates of VInf by the Adrogué-Madias formula and by a formula using the same determinants of the change in [ Na ] and the curvilinear relation between this change and VInf . Regardless of the method used to correct hyponatremia, monitoring [ Na ] and changes in external balances of water, sodium, and potassium during treatment remain imperative.
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Affiliation(s)
- Brent Wagner
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Research Service, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, New Mexico
- Kidney Institute of New Mexico, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Deepak Malhotra
- Division of Nephrology, University of Toledo College of Medicine, Toledo, Ohio
| | - Darren Schmidt
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Dominic S. Raj
- Division of Nephrology, George Washington University School of Medicine, Washington, DC
| | - Zeid J. Khitan
- Division of Nephrology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Joseph I. Shapiro
- Division of Nephrology, Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia
| | - Antonios H. Tzamaloukas
- Division of Nephrology, University of New Mexico School of Medicine, Albuquerque, New Mexico
- Research Service, Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, New Mexico
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5
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Chen M, Kohyama A, Watanabe K, Karasawa H, Kajiwara T, Kobayashi M, Ichikawa H, Kamei T, Ohnuma S, Unno M. Syndrome of inappropriate secretion of antidiuretic hormone after total proctocolectomy for ulcerative colitis. Clin J Gastroenterol 2023; 16:63-68. [PMID: 36280658 DOI: 10.1007/s12328-022-01725-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/16/2022] [Indexed: 02/03/2023]
Abstract
We report a case of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) after total proctocolectomy followed with ileal pouch-anal anastomosis (TPC-IPAA) for ulcerative colitis (UC). The patient was a 46-year-old woman. She was diagnosed with UC of pancolitis in 2000. High grade dysplasia was detected in the transverse colon after a surveillance colonoscopy in 2021. She underwent laparoscopy-assisted TPC-IPAA. On the sixth postoperative day, she had a decreased level of consciousness that worsened on the following day. Her laboratory data showed a serum sodium level of 108 mEq/L and the plasma osmolality was 234 mOsm/kg. We did not find any other abnormalities in the laboratory examination that could cause hyponatremia. Computed tomography scan showed no central nervous system disturbances such as a pituitary tumor, antidiuretic hormone-producing tumors, or pulmonary diseases. The patient was diagnosed with Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) caused by surgical invasion. We started to administer 3% sodium chloride slowly to improve the hyponatremia. Her serum sodium level became normal and stable. Although it is rare for SIADH to be caused by abdominal surgery, if hyponatremia is observed after surgery, the possibility of postoperative SIADH should be considered.
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Affiliation(s)
- Mengge Chen
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Atsushi Kohyama
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
| | - Kazuhiro Watanabe
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hideaki Karasawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Taiki Kajiwara
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Minoru Kobayashi
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Hidetaka Ichikawa
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shinobu Ohnuma
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
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Rohrscheib M, Sam R, Raj DS, Argyropoulos CP, Unruh ML, Lew SQ, Ing TS, Levin NW, Tzamaloukas AH. Edelman Revisited: Concepts, Achievements, and Challenges. Front Med (Lausanne) 2022; 8:808765. [PMID: 35083255 PMCID: PMC8784663 DOI: 10.3389/fmed.2021.808765] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
The key message from the 1958 Edelman study states that combinations of external gains or losses of sodium, potassium and water leading to an increase of the fraction (total body sodium plus total body potassium) over total body water will raise the serum sodium concentration ([Na]S), while external gains or losses leading to a decrease in this fraction will lower [Na]S. A variety of studies have supported this concept and current quantitative methods for correcting dysnatremias, including formulas calculating the volume of saline needed for a change in [Na]S are based on it. Not accounting for external losses of sodium, potassium and water during treatment and faulty values for body water inserted in the formulas predicting the change in [Na]S affect the accuracy of these formulas. Newly described factors potentially affecting the change in [Na]S during treatment of dysnatremias include the following: (a) exchanges during development or correction of dysnatremias between osmotically inactive sodium stored in tissues and osmotically active sodium in solution in body fluids; (b) chemical binding of part of body water to macromolecules which would decrease the amount of body water available for osmotic exchanges; and (c) genetic influences on the determination of sodium concentration in body fluids. The effects of these newer developments on the methods of treatment of dysnatremias are not well-established and will need extensive studying. Currently, monitoring of serum sodium concentration remains a critical step during treatment of dysnatremias.
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Affiliation(s)
- Mark Rohrscheib
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Dominic S Raj
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Christos P Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Mark L Unruh
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Nathan W Levin
- Mount Sinai Icahn School of Medicine, New York, NY, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, NM, United States
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7
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Arzhan S, Lew SQ, Ing TS, Tzamaloukas AH, Unruh ML. Dysnatremias in Chronic Kidney Disease: Pathophysiology, Manifestations, and Treatment. Front Med (Lausanne) 2021; 8:769287. [PMID: 34938749 PMCID: PMC8687113 DOI: 10.3389/fmed.2021.769287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/04/2021] [Indexed: 12/29/2022] Open
Abstract
The decreased ability of the kidney to regulate water and monovalent cation excretion predisposes patients with chronic kidney disease (CKD) to dysnatremias. In this report, we describe the clinical associations and methods of management of dysnatremias in this patient population by reviewing publications on hyponatremia and hypernatremia in patients with CKD not on dialysis, and those on maintenance hemodialysis or peritoneal dialysis. The prevalence of both hyponatremia and hypernatremia has been reported to be higher in patients with CKD than in the general population. Certain features of the studies analyzed, such as variation in the cut-off values of serum sodium concentration ([Na]) that define hyponatremia or hypernatremia, create comparison difficulties. Dysnatremias in patients with CKD are associated with adverse clinical conditions and mortality. Currently, investigation and treatment of dysnatremias in patients with CKD should follow clinical judgment and the guidelines for the general population. Whether azotemia allows different rates of correction of [Na] in patients with hyponatremic CKD and the methodology and outcomes of treatment of dysnatremias by renal replacement methods require further investigation. In conclusion, dysnatremias occur frequently and are associated with various comorbidities and mortality in patients with CKD. Knowledge gaps in their treatment and prevention call for further studies.
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Affiliation(s)
- Soraya Arzhan
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Susie Q. Lew
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Antonios H. Tzamaloukas
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Research Service, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Medicine Service, Division of Nephrology, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
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8
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Chi C, Patel S, Cheung NW. Admission sodium levels and hospital outcomes. Intern Med J 2021; 51:93-98. [DOI: 10.1111/imj.14777] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 01/06/2020] [Accepted: 01/25/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Cecilia Chi
- Department of Diabetes and Endocrinology Westmead Hospital Sydney New South Wales Australia
| | - Shivani Patel
- Department of Endocrinology and Diabetes St Vincent's Hospital Sydney New South Wales Australia
| | - N. Wah Cheung
- Department of Diabetes and Endocrinology Westmead Hospital Sydney New South Wales Australia
- University of Sydney Sydney New South Wales Australia
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Leong XF, Cheng M, Jong B, Hwang NC, Roscoe A. Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3374-3384. [PMID: 32888797 DOI: 10.1053/j.jvca.2020.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 11/11/2022]
Abstract
Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.
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Affiliation(s)
- Xin Fang Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Maureen Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Bronte Jong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Andrew Roscoe
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
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Tzamaloukas AH, Khitan ZJ, Glew RH, Roumelioti ME, Rondon-Berrios H, Elisaf MS, Raj DS, Owen J, Sun Y, Siamopoulos KC, Rohrscheib M, Ing TS, Murata GH, Shapiro JI, Malhotra D. Serum Sodium Concentration and Tonicity in Hyperglycemic Crises: Major Influences and Treatment Implications. J Am Heart Assoc 2019; 8:e011786. [PMID: 31549572 PMCID: PMC6806024 DOI: 10.1161/jaha.118.011786] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Antonios H Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | - Zeid J Khitan
- Joan C. Edwards School of Medicine Marshall University Huntington WV
| | - Robert H Glew
- University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Moses S Elisaf
- University of Ioannina School of Medicine Ioannina Greece
| | - Dominic S Raj
- George Washington University School of Medicine Washington DC
| | - Jonathan Owen
- University of New Mexico School of Medicine Albuquerque NM
| | - Yijuan Sun
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Todd S Ing
- Stritch School of Medicine Loyola University Chicago Maywood IL
| | - Glen H Murata
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM
| | - Joseph I Shapiro
- Joan C. Edwards School of Medicine Marshall University Huntington WV
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11
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Garbuzenko DV, Arefyev NO. Current approaches to the management of patients with cirrhotic ascites. World J Gastroenterol 2019; 25:3738-3752. [PMID: 31391769 PMCID: PMC6676543 DOI: 10.3748/wjg.v25.i28.3738] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/09/2019] [Accepted: 06/25/2019] [Indexed: 02/06/2023] Open
Abstract
This review describes current approaches to the management of patients with cirrhotic ascites in relation to the severity of its clinical manifestations. The PubMed database, the Google Scholar retrieval system, the Cochrane Database of Systematic Reviews, and the reference lists from related articles were used to search for relevant publications. Articles corresponding to the aim of the review were selected for 1991-2018 using the keywords: "liver cirrhosis," "portal hypertension," "ascites," "pathogenesis," "diagnostics," and "treatment." Uncomplicated and refractory ascites in patients with cirrhosis were the inclusion criteria. The literature analysis has shown that despite the achievements of modern hepatology, the presence of ascites is associated with poor prognosis and high mortality. The key to successful management of patients with ascites may be the stratification of the risk of an adverse outcome and personalized therapy. Pathogenetically based approach to the choice of pharmacotherapy and optimization of minimally invasive methods of treatment may improve the quality of life and increase the survival rate of this category of patients.
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Affiliation(s)
| | - Nikolay Olegovich Arefyev
- Department of Pathological Anatomy and Forensic Medicine, South Ural State Medical University, Chelyabinsk 454092, Russia
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12
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Ward FL, Tobe SW, Naimark DMJ. The Role of Desmopressin in the Management of Severe, Hypovolemic Hyponatremia: A Single-Center, Comparative Analysis. Can J Kidney Health Dis 2018; 5:2054358118761051. [PMID: 29593879 PMCID: PMC5865454 DOI: 10.1177/2054358118761051] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 07/28/2017] [Indexed: 12/17/2022] Open
Abstract
Background The role of desmopressin (DDAVP) to prevent or treat rapid serum sodium concentration ([Na]s) correction during hyponatremia management remains unclear. Objective To assess DDAVP use during the first 48 hours of severe, hypovolemic hyponatremia management. The primary study hypothesis was that the use of DDAVP would slow the rate of [Na]s correction compared with those not receiving DDAVP. Design A retrospective, observational, comparison study. Setting A single, Canadian, tertiary center. Patients All admitted patients referred to the nephrology service for severe, hypovolemic hyponatremia ([Na]s < 125 mmol/L) over a 12-month period from November 2015. Measurements The primary outcomes measure was the [Na]s after medical management for 48 hours. The length of hospital stay was also measured. Methods Patients were grouped based on whether they received DDAVP during the first 48 hours of treatment, and [Na]s correction was compared between groups using linear regression. An exploratory, multivariable, linear regression model was used to adjust for diabetes status, active malignancy, intensive care unit (ICU) admission, and hypertonic saline administration. Results Twenty-eight patients were identified, with baseline mean [Na]s of 112.7 ± 6.6 mmol/L versus 117 ± 4.3mmol/L (P = .06) in those receiving (n = 16) and not receiving DDAVP (n = 12), respectively. The DDAVP group had a more rapid [Na]s correction on the first day compared with those not receiving DDAVP, 7.7 ± 3.8 mmol/L/d versus 5.1 ± 2.0 mmol/L/d (P = .04). On the second day, there was a similar rate of [Na]s correction between groups: 1.3 ± 4.3 mmol/L/d versus 2.6 ± 3.2 mmol/L/d (P = .39), respectively. Overall, there was no difference in [Na]s correction after 48 hours between those who received DDAVP and those who did not: 121.7 ± 7.5 mmol/L versus 124.8 ± 5.7 mmol/L (P = .24). Patients who had experienced an overcorrection were successfully treated with DDAVP (n = 5), so that no patient had an ongoing overcorrection by 48 hours. Limitations The limited sample size and lack of randomization preclude definitive conclusion on the additional benefit of DDAVP to standard care. Conclusion DDAVP appears to be safe and effective in the management of severe, hypovolemic hyponatremia, associated with similar [Na]s correction to those who did not receive DDAVP after 48 hours, despite an initial more rapid correction. A randomized trial should examine what benefit DDAVP confers in addition to standard care in the management of severe, hypovolemic hyponatremia.
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Affiliation(s)
- Frank L Ward
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Sheldon W Tobe
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - David M J Naimark
- Division of Nephrology, Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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13
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Roumelioti ME, Ing TS, Rondon-Berrios H, Glew RH, Khitan ZJ, Sun Y, Malhotra D, Raj DS, Agaba EI, Murata GH, Shapiro JI, Tzamaloukas AH. Principles of quantitative water and electrolyte replacement of losses from osmotic diuresis. Int Urol Nephrol 2018; 50:1263-1270. [PMID: 29511980 DOI: 10.1007/s11255-018-1822-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/04/2018] [Indexed: 02/08/2023]
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14
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Meng L, Nguyen CM, Patel S, Mlynash M, Caulfield AF. Association between continuous peripheral i.v. infusion of 3% sodium chloride injection and phlebitis in adults. Am J Health Syst Pharm 2018; 75:284-291. [PMID: 29472509 DOI: 10.2146/ajhp161028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE One institution's experience with use of peripheral i.v. (PIV) catheters for prolonged infusions of 3% sodium chloride injection at rates up to 100 mL/hr is described. METHODS A prospective, observational, 13-month quality assurance project was conducted at an academic medical center to evaluate frequencies of patient and catheter phlebitis among adult inpatients who received both an infusion of 3% sodium chloride injection for a period of ≥4 hours through a dedicated PIV catheter and infusions of routine-care solutions (RCSs) through separate PIV catheters during the same hospital stay. RESULTS Sixty patients received PIV infusions through a total of 291 catheters during the study period. The majority of patients (78%) received infusions of 3% sodium chloride injection for intracranial hypertension, with 30% receiving such infusions in the intensive care unit. Phlebitis occurred in 28 patients (47%) during infusions of 3% sodium chloride and 26 patients (43%) during RCS infusions (p = 0.19). Catheter phlebitis occurred in 73 catheters (25%), with no significant difference in the frequencies of catheter phlebitis with infusion of 3% sodium chloride versus RCSs (30% [32 of 106 catheters]) versus 22% [41 of 185 catheters]), p = 0.16). CONCLUSION Patient and catheter phlebitis rates were not significantly different with infusions of 3% sodium chloride injection versus RCSs, suggesting that an osmolarity cutoff value of 900 mOsm/L for peripheral infusions of hypertonic saline solutions may not be warranted.
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Affiliation(s)
| | | | | | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Health Care, Stanford, CA
| | - Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Health Care, Stanford, CA
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Lee A, Jo YH, Kim K, Ahn S, Oh YK, Lee H, Shin J, Chin HJ, Na KY, Lee JB, Baek SH, Kim S. Efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe symptomatic hyponatremia: study protocol for a randomized controlled trial (SALSA trial). Trials 2017; 18:147. [PMID: 28356136 PMCID: PMC5372334 DOI: 10.1186/s13063-017-1865-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/24/2017] [Indexed: 12/15/2022] Open
Abstract
Background Hyponatremia is the most common electrolyte imbalance encountered in clinical practice, associated with increased mortality and length of hospital stay. However, no high-quality evidence regarding whether hypertonic saline is best administered as a continuous infusion or a bolus injection has been found to date. Therefore, in the current study, we will evaluate the efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe symptomatic hyponatremia. Methods/design This is a prospective, investigator-initiated, multicenter, open-label, randomized controlled study with two experimental therapy groups. A total of 178 patients with severe symptomatic hyponatremia will be enrolled and randomly assigned to receive either rapid intermittent bolus or slow continuous infusion management with hypertonic saline. The primary outcome is the incidence of overcorrection at any given period over 2 days. The secondary outcomes will include the efficacy and safety of two other approaches to the treatment of hyponatremia with 3% hypertonic saline. Discussion This is the first clinical trial to investigate the efficacy and safety of rapid intermittent correction compared with slow continuous correction with hypertonic saline in patients with moderately severe or severe hyponatremia. Trial registration ClinicalTrials.gov, identifier number: NCT02887469. Registered on 1 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1865-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anna Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Soyeon Ahn
- Department of Medical Research Collaborating Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Yun Kyu Oh
- Department of Internal Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Huijai Lee
- Department of Emergency Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Jonghwan Shin
- Department of Emergency Medicine, Seoul National University Boramae Hospital, Seoul, Republic of Korea
| | - Ho Jun Chin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Ki Young Na
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jung Bok Lee
- Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Seon Ha Baek
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea. .,Department of Internal Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong-si, Republic of Korea.
| | - Sejoong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Acute Psychosis as Main Manifestation of Central Pontine Myelinolysis. Case Rep Neurol Med 2017; 2017:1471096. [PMID: 28392953 PMCID: PMC5368399 DOI: 10.1155/2017/1471096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 02/14/2017] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
Central pontine myelinolysis (CPM) is an acute demyelinating neurological disorder affecting primarily the central pons and is frequently associated with rapid correction of hyponatremia. Common clinical manifestations of CPM include spastic quadriparesis, dysarthria, pseudobulbar palsy, and encephalopathy of various degrees; however, coma, “locked-in” syndrome, or death can occur in most severe cases. Rarely, CPM presents with neuropsychiatric manifestations, such as personality changes, acute psychosis, paranoia, hallucinations, or catatonia, typically associated with additional injury to the brain, described as extrapontine myelinolysis (EPM). We present a patient with primarily neuropsychiatric manifestations of CPM, in the absence of focal neurologic deficits or radiographic extrapontine involvement. A 51-year-old female without significant medical history presented with dizziness, frequent falls, diarrhea, generalized weakness, and weight loss. Physical examination showed no focal neurological deficits. Laboratory data showed severe hyponatremia, which was corrected rather rapidly. Subsequently, the patient developed symptoms of an acute psychotic illness. Initial brain magnetic resonance imaging (MRI) was unremarkable, although a repeat MRI two weeks later revealed changes compatible with CPM. This case demonstrates that acute psychosis might represent the main manifestation of CPM, especially in early stages of the disease, which should be taken into consideration when assessing patients with acute abnormalities of sodium metabolism.
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Rondon-Berrios H, Argyropoulos C, Ing TS, Raj DS, Malhotra D, Agaba EI, Rohrscheib M, Khitan ZJ, Murata GH, Shapiro JI, Tzamaloukas AH. Hypertonicity: Clinical entities, manifestations and treatment. World J Nephrol 2017; 6:1-13. [PMID: 28101446 PMCID: PMC5215203 DOI: 10.5527/wjn.v6.i1.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/17/2016] [Accepted: 11/02/2016] [Indexed: 02/06/2023] Open
Abstract
Hypertonicity causes severe clinical manifestations and is associated with mortality and severe short-term and long-term neurological sequelae. The main clinical syndromes of hypertonicity are hypernatremia and hyperglycemia. Hypernatremia results from relative excess of body sodium over body water. Loss of water in excess of intake, gain of sodium salts in excess of losses or a combination of the two are the main mechanisms of hypernatremia. Hypernatremia can be hypervolemic, euvolemic or hypovolemic. The management of hypernatremia addresses both a quantitative replacement of water and, if present, sodium deficit, and correction of the underlying pathophysiologic process that led to hypernatremia. Hypertonicity in hyperglycemia has two components, solute gain secondary to glucose accumulation in the extracellular compartment and water loss through hyperglycemic osmotic diuresis in excess of the losses of sodium and potassium. Differentiating between these two components of hypertonicity has major therapeutic implications because the first component will be reversed simply by normalization of serum glucose concentration while the second component will require hypotonic fluid replacement. An estimate of the magnitude of the relative water deficit secondary to osmotic diuresis is obtained by the corrected sodium concentration, which represents a calculated value of the serum sodium concentration that would result from reduction of the serum glucose concentration to a normal level.
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18
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Icin T, Medic-Stojanoska M, Ilic T, Kuzmanovic V, Vukovic B, Percic I, Kovacev-Zavisic B. Multiple Causes of Hyponatremia: A Case Report. Med Princ Pract 2017; 26:292-295. [PMID: 28268230 PMCID: PMC5588416 DOI: 10.1159/000468938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 03/07/2017] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To present a case with 4 different potential causes of hyponatremia. CLINICAL PRESENTATION AND INTERVENTION The patient presented with the following symptoms: nausea, vomiting, diarrhea, and dark urine after drinking large amounts of fluids that included alcohol and caffeine. Laboratory, microbiological, and morphological examinations revealed the existence of severe hyponatremia and acute poststreptococcal glomerulonephritis. The patient developed acute symptomatic seizures and coma. Gradual normalization of the sodium level led to a recovery of consciousness. CONCLUSION Treatment with hypertonic sodium, fluid restriction, and antibiotics led to a complete recovery. In the case of multiple causes of hyponatremia, it is necessary to treat all causes.
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Affiliation(s)
- Tijana Icin
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
- *Tijana Icin, Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Hajduk Veljkova 1-3, RS-21000 Novi Sad (Serbia), E-Mail
| | - Milica Medic-Stojanoska
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Tatjana Ilic
- Clinic of Nephrology and Clinical Immunology, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Vladimir Kuzmanovic
- Department of Internal Medicine, General Hospital, Sremska Mitrovica, Serbia
| | - Bojan Vukovic
- Clinic of Emergency Center, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Ivanka Percic
- Clinic of Emergency Center, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
| | - Branka Kovacev-Zavisic
- Clinic of Endocrinology, Diabetes and Metabolic Diseases, Clinical Center of Vojvodina, Novi Sad, Sremska Mitrovica, Serbia
- Faculty of Medicine, University of Novi Sad, Novi Sad, Sremska Mitrovica, Serbia
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Therapeutic Approach to the Management of Severe Asymptomatic Hyponatremia. Case Rep Nephrol 2017; 2017:1371804. [PMID: 28819575 PMCID: PMC5551525 DOI: 10.1155/2017/1371804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/02/2017] [Indexed: 11/17/2022] Open
Abstract
Hyponatremia is an electrolyte imbalance encountered commonly in the hospital and ambulatory settings. It can be seen in isolation or present as a complication of other medical conditions. It is therefore a challenge to determine the appropriate therapeutic intervention. An understanding of the etiology is key in instituting the right treatment. Clinicians must not be too hasty to correct a random laboratory value without first understanding the physiologic principle. We present such a case of a patient who presented with sodium of 98 mmol/L, the lowest recorded in the current literature, and yet was asymptomatic. Following appropriate management driven by an understanding of the underlying pathophysiologic mechanism, the patient was managed to full recovery without any clinically significant neurological sequelae.
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20
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Argyropoulos C, Rondon-Berrios H, Raj DS, Malhotra D, Agaba EI, Rohrscheib M, Khitan Z, Murata GH, Shapiro JI, Tzamaloukas AH. Hypertonicity: Pathophysiologic Concept and Experimental Studies. Cureus 2016; 8:e596. [PMID: 27382523 PMCID: PMC4895078 DOI: 10.7759/cureus.596] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/01/2016] [Indexed: 01/01/2023] Open
Abstract
Disturbances in tonicity (effective osmolarity) are the major clinical disorders affecting cell volume. Cell shrinking secondary to hypertonicity causes severe clinical manifestations and even death. Quantitative management of hypertonic disorders is based on formulas computing the volume of hypotonic fluids required to correct a given level of hypertonicity. These formulas have limitations. The major limitation of the predictive formulas is that they represent closed system calculations and have been tested in anuric animals. Consequently, the formulas do not account for ongoing fluid losses during development or treatment of the hypertonic disorders. In addition, early comparisons of serum osmolality changes predicted by these formulas and observed in animals infused with hypertonic solutions clearly demonstrated that hypertonicity creates new intracellular solutes causing rises in serum osmolality higher than those predicted by the formulas. The mechanisms and types of intracellular solutes generated by hypertonicity and the effects of the solutes have been studied extensively in recent times. The solutes accumulated intracellularly in hypertonic states have potentially major adverse effects on the outcomes of treatment of these states. When hypertonicity was produced by the infusion of hypertonic sodium chloride solutions, the predicted and observed changes in serum sodium concentration were equal. This finding justifies the use of the predictive formulas in the management of hypernatremic states.
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Affiliation(s)
- Christos Argyropoulos
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Helbert Rondon-Berrios
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh Medical School
| | | | | | - Emmanuel I Agaba
- Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Mark Rohrscheib
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Zeid Khitan
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Glen H Murata
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico
| | - Joseph I Shapiro
- The Joan C Edwards College of Medicine of Marshall University, Huntington, WV
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21
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Argyropoulos C, Rondon-Berrios H, Raj DS, Malhotra D, Agaba EI, Rohrscheib M, Khitan Z, Murata GH, Shapiro JI, Tzamaloukas AH. Hypertonicity: Pathophysiologic Concept and Experimental Studies. Cureus 2016; 8:e506. [PMID: 27026831 PMCID: PMC4807920 DOI: 10.7759/cureus.506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Disturbances in tonicity (effective osmolarity) are the major clinical disorders affecting cell volume. Cell shrinking secondary to hypertonicity causes severe clinical manifestations and even death. Quantitative management of hypertonic disorders is based on formulas computing the volume of hypotonic fluids required to correct a given level of hypertonicity. These formulas have limitations. The major limitation of the predictive formulas is that they represent closed system calculations and have been tested in anuric animals. Consequently, the formulas do not account for ongoing fluid losses during development or treatment of the hypertonic disorders. In addition, early comparisons of serum osmolality changes predicted by these formulas and observed in animals infused with hypertonic solutions clearly demonstrated that hypertonicity creates new intracellular solutes causing rises in serum osmolality higher than those predicted by the formulas. The mechanisms and types of intracellular solutes generated by hypertonicity and the effects of the solutes have been studied extensively in recent times. The solutes accumulated intracellularly in hypertonic states have potentially major adverse effects on the outcomes of treatment of these states. When hypertonicity was produced by the infusion of hypertonic sodium chloride solutions, the predicted and observed changes in serum sodium concentration were equal. This finding justifies the use of the predictive formulas in the management of hypernatremic states.
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Affiliation(s)
- Christos Argyropoulos
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Helbert Rondon-Berrios
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh Medical School
| | | | | | - Emmanuel I Agaba
- Department of Medicine, Jos University Teaching Hospital, Jos, Plateau State, Nigeria
| | - Mark Rohrscheib
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Zeid Khitan
- Department of Medicine, Division of Nephrology, University of New Mexico School of Medicine
| | - Glen H Murata
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico
| | - Joseph I Shapiro
- The Joan C Edwards College of Medicine of Marshall University, Huntington, WV
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22
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Canaday S, Rompala J, Rowles J, Fisher J, Holt D. Chronic Severe Hyponatremia and Cardiopulmonary Bypass: Avoiding Osmotic Demyelination Syndrome. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2015; 47:228-230. [PMID: 26834285 PMCID: PMC4730166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/09/2015] [Indexed: 06/05/2023]
Abstract
Serum sodium concentration affects every cell in the body with respect to cellular tonicity. Hyponatremia is the most frequent electrolyte abnormality encountered, occurring at clinical admission in 22% of elderly patients. Any rapid correction of chronic severe hyponatremia can result in rapid cellular shrinking due to loss of intracellular free water. This is commonly associated with paralysis and severe brain damage due to osmotic demyelination syndrome (ODS). ODS occurs because the body has the ability to compensate for cellular fluid shifts due to chronic hyponatremia (by a decrease in brain concentration of several ions, amino acids, and organic osmolytes). Thus, the neurons are often at a functional state of fluid balance despite the sodium imbalance. The initiation of cardiopulmonary bypass (CPB) can introduce between 1 and 2 L of priming solution containing a normal sodium concentration creating a rapid rise in sodium concentration within the extracellular fluid. This abrupt change establishes a situation where intracellular free water can be lost resulting in cellular shrinking and ODS. In presenting this case study, we hope to add to the current literature with a specific isotonic approach to treating the chronically severe hyponatremic patient pre-CPB, during CPB, and post-CPB.
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Affiliation(s)
- Susan Canaday
- Department of Cardiothoracic Surgery, Confluence Health: Central Washington Hospital, Wenatchee, Washington
| | - John Rompala
- Staff Anesthesiologist, Portland VA Medical Center, Department of Anesthesia and Perioperative Medicine, Oregon State University, Portland, Oregon
| | - John Rowles
- Cardiac Surgeon, Chairman Department of Surgery, Confluence Health: Central Washington Hospital, Wenatchee, Washington
| | - Josh Fisher
- Department of Cardiothoracic Surgery, Confluence Health: Central Washington Hospital, Wenatchee, Washington
| | - David Holt
- Program Director, Clinical Perfusion Education, School of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska
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Tasdemir V, Oguz AK, Sayın I, Ergun I. Hyponatremia in the outpatient setting: clinical characteristics, risk factors, and outcome. Int Urol Nephrol 2015; 47:1977-83. [PMID: 26490555 DOI: 10.1007/s11255-015-1134-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 10/07/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE Hyponatremia is a common disorder and hyponatremia in the outpatient setting is not extensively studied. Our aim was to investigate the characteristics of hyponatremia in ambulatory patients. METHODS Seventy-six adult outpatients with hyponatremia were enrolled in this prospective study. Demographic features, presenting symptoms and signs, associating morbidities, medications, laboratory findings, mortalities, and length of hospital stay, were recorded. RESULTS Mean age was 74.7 ± 12.7 years, and 52 (68.4 %) were female whereas 24 (31.6 %) were male. Mean sodium concentration was 123.6 ± 6.6 mEq/L. Leading cause was thiazide diuretic use (n = 37, 48.7 %) and approximately half of the patients (n = 40, 52.6 %) had a multifactorial etiology. Severe hyponatremia (sodium < 125 mEq/L) was identified in 37 (48.7 %). Thiazide diuretic use, vomiting, and apathy were independent predictors of severe hyponatremia. Eight (10.5 %) patients had a mortal course. A relatively younger age, male gender, presenting sign of lethargy, associating morbidities of malignancy, chronic liver disease, and hypoalbuminemia were risk factors for mortality. CONCLUSIONS Hyponatremia is prevalent among elderly, especially in women and with thiazide diuretics. Apart from the trend toward sodium depletion observed in healthy elderly which occurs due to changes in the tubular handling of sodium, a multifactorial etiology including thiazides seems to predict the occurrence and the severity of hyponatremia. Hyponatremia may be a significant cause of mortality in seniors. A relatively younger age, male gender, association of cirrhosis, malignancy, and hypoalbuminemia predict mortality. In elderly outpatients, identification of the risk factors for hyponatremia and close monitoring are imperative to reduce the related mortality and morbidity.
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Affiliation(s)
- Vildan Tasdemir
- Department of Internal Medicine, Ufuk University School of Medicine, Ankara, Turkey
| | - Ali Kemal Oguz
- Department of Internal Medicine, Ufuk University School of Medicine, Ankara, Turkey
| | - Irmak Sayın
- Department of Internal Medicine, Ufuk University School of Medicine, Ankara, Turkey
| | - Ihsan Ergun
- Division of Nephrology, Department of Internal Medicine, Ufuk University School of Medicine, Dr. Rıdvan Ege Hospital, Konya Bulvarı No: 86-88, Balgat, Çankaya, 06520, Ankara, Turkey.
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24
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Kwak MK, Choi D, Lee JH, Kim HJ, Park HK, Suh KI, Yoo MH, Byun DW. Relationship between Decrease in Serum Sodium Level and Bone Mineral Density in Osteoporotic Fracture Patients. J Bone Metab 2015; 22:9-15. [PMID: 25774359 PMCID: PMC4357637 DOI: 10.11005/jbm.2015.22.1.9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2015] [Revised: 02/24/2015] [Accepted: 02/25/2015] [Indexed: 02/03/2023] Open
Abstract
Background Recently, it has been suggested that decrease in serum sodium level is associated with osteoporosis. However, no study in Korea has reported the association of decrease in serum sodium level with osteoporosis. In this study, we investigated the relationship between the decrease in serum sodium level and severity of osteoporotic fracture in patients. Methods We enrolled 290 subjects who were admitted and operated at Soonchunhyang University Hospital due to major fractures. For the control group, we enrolled 1,027 subjects who visited a health promotion center. We carried a 1:1 matching with age and sex from the case group. Results In a total of 164 age- and sex-matched subjects, serum sodium level was significantly lower in the fracture group than in the non-fracture group (P=0.001). Serum sodium level was significantly lower in the severe osteoporosis group than that in the non-severe osteoporosis group (P=0.002). Old age and decrease in serum sodium level were independent risk factors of osteoporosis (odds ratio [OR]=1.088, P=0.008, confidence interval [CI]=[1.022-1.157]; OR= 0.840, P=0.037, CI=0.713-0.989). Conclusions Serum sodium level was significantly lower in the fracture group than that in the non-fracture group and in the severe osteoporosis group than that in the non-severe osteoporosis group. Based on our results, the decrease in serum sodium level could be an independent risk factor for osteoporosis.
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Affiliation(s)
- Mi Kyung Kwak
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Dughyun Choi
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Jae Hyuk Lee
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hye Jeong Kim
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyeong Kyu Park
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Kyo Il Suh
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Myung Hi Yoo
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Dong Won Byun
- Departement of Internal Medicine, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
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25
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Geoghegan P, Koch CD, Wockenfus AM, Harrison AM, Dong Y, Kashani KB, Karon BS. Agreement between whole blood and plasma sodium measurements in profound hyponatremia. Clin Biochem 2015; 48:525-8. [PMID: 25773258 DOI: 10.1016/j.clinbiochem.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Revised: 03/02/2015] [Accepted: 03/03/2015] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We compared two different methods of whole blood sodium measurement to plasma sodium measurement using samples in the profoundly hyponatremic range (Na < 120 mmol/L). DESIGN AND METHODS Whole blood pools with a range of low sodium values were generated using combinations and dilutions of pooled electrolyte-balanced lithium heparin samples submitted for arterial blood gas analysis. Each pool was analyzed five times on a Radiometer 827 blood gas analyzer and iSTAT analyzer. Pools were centrifuged to produce plasma, which was analyzed five times on a Roche Cobas c501 chemistry analyzer. An additional 40 fresh (analyzed on day of collection) excess lithium heparin arterial blood gas samples from 36 patients were analyzed on the Radiometer 827, iSTAT, and Cobas c501 as described above. The setting was a tertiary referral center. Blood samples were collected from a combination of patients in the intensive care unit, operating theaters and emergency room. RESULTS All methods demonstrated excellent precision, even in the profoundly hyponatremic measurement range (Na < 120 mmol/L using a plasma reference method). However, agreement between the methods varied with the degree of hyponatremia. In the profoundly hyponatremic range, Radiometer whole blood sodium values were nearly identical to plasma reference sodium, while iSTAT whole blood sodium showed a consistent positive bias relative to plasma sodium in this range. CONCLUSION If whole blood direct sodium measurements are compared with plasma sodium in profoundly hyponatremic patients consideration should be given to the use of Radiometer blood gas analyzers over iSTAT since the latter shows a positive bias relative to a plasma comparative method.
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Affiliation(s)
- Pierce Geoghegan
- Department of Anaesthesia and Critical Care, Tallaght Hospital, Dublin, Ireland; Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA.
| | - Christopher D Koch
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Amy M Wockenfus
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Andrew M Harrison
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Medical Scientist Training Program, Mayo Clinic, Rochester, MN, USA
| | - Yue Dong
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kianoush B Kashani
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (M.E.T.R.I.C.), Mayo Clinic, Rochester, MN, USA; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Brad S Karon
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Lenz K, Buder R, Kapun L, Voglmayr M. Treatment and management of ascites and hepatorenal syndrome: an update. Therap Adv Gastroenterol 2015; 8:83-100. [PMID: 25729433 PMCID: PMC4314304 DOI: 10.1177/1756283x14564673] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ascites and renal dysfunction are frequent complications experienced by patients with cirrhosis of the liver. Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and is one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves assessment of its granulocyte count and protein concentration to exclude complications such as infection or malignoma and to allow risk stratification for the development of spontaneous peritonitis. Although sodium restriction and diuretics remain the cornerstone of the management of ascites, many patients require additional therapy when they become refractory to this treatment. In this situation, the treatment of choice is repeated large-volume paracentesis. Alteration in splanchnic hemodynamics is one of the most important changes underlying the development of ascites. Further splanchnic dilation leads to changes in systemic hemodynamics, activating vasopressor agents and leading to decreased renal perfusion. Small alterations in renal function influence the prognosis, which depends on the cause of renal failure. Prerenal failure is evident in about 70% of patients, whereas in about 30% of patients the cause is hepatorenal syndrome (HRS), which is associated with a worse prognosis. Therefore, effective therapy is of great clinical importance. Recent data indicate that use of the new definition of acute kidney injury facilitates the identification and treatment of patients with renal insufficiency more rapidly than use of the current criteria for HRS. In this review article, we evaluate approaches to the management of patients with ascites and HRS.
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Affiliation(s)
- Kurt Lenz
- Department of Internal and Intensive Care Medicine, Konventhospital Barmherzige Brüder Linz, Seilerstätte 2, Linz, A-4020, Austria
| | - Robert Buder
- Department of Internal and Intensive Care Medicine, Konventhospital Barmherzige Brüder Linz, Austria
| | | | - Martin Voglmayr
- Department of Internal and Intensive Care Medicine, Konventhospital Barmherzige Brüder Linz, Austria
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Oh JY, Shin JI. Syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt wasting syndrome: similarities and differences. Front Pediatr 2015; 2:146. [PMID: 25657991 PMCID: PMC4302789 DOI: 10.3389/fped.2014.00146] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 12/23/2014] [Indexed: 01/20/2023] Open
Abstract
Hyponatremia (sodium levels of <135 mEq/L) is one of the most common electrolyte imbalances in clinical practice, especially in patients with neurologic diseases. Hyponatremia can cause cerebral edema and brain herniation; therefore, prompt diagnosis and proper treatment is important in preventing morbidity and mortality. Among various causes of hyponatremia, diagnosing syndrome of inappropriate antidiuretic hormone secretion (SIADH) and cerebral/renal salt wasting syndrome (C/RSW) is difficult due to many similarities. SIADH is caused by excess of renal water reabsorption through inappropriate antidiuretic hormone secretion, and fluid restriction is the treatment of choice. On the other hand, C/RSW is caused by natriuresis, which is followed by volume depletion and negative sodium balance and replacement of water and sodium is the mainstay of treatment. Determinating volume status in hyponatremic patients is the key point in differential between SIADH and C/RSW. However, in most situations, differential diagnosis of these two diseases is difficult because they overlap in many clinical and laboratory aspects, especially to assess differences in volume status of these patients. Although distinction between the SIADH and C/RSW is difficult, improvement of hypouricemia and an increased fractional excretion of uric acid after the correction of hyponatremia in SIADH, not in C/RSW, may be one of the helpful points in discriminating the two diseases. In this review, we compare these two diseases regarding the pathophysiologic mechanisms, diagnosis, and therapeutic point of view.
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Affiliation(s)
- Ji Young Oh
- Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Il Shin
- Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Management of severe hyponatremia: infusion of hypertonic saline and desmopressin or infusion of vasopressin inhibitors? Am J Med Sci 2015; 348:432-9. [PMID: 25247759 PMCID: PMC4206391 DOI: 10.1097/maj.0000000000000331] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Rapid correction of severe hyponatremia carries the risk of osmotic demyelination. Two recently introduced methods of correction of hyponatremia have diametrically opposite effects on aquaresis. Inhibitors of vasopressin V2 receptor (vaptans) lead to the production of dilute urine, whereas infusion of desmopressin causes urinary concentration. Identification of the category of hyponatremia that will benefit from one or the other treatment is critical. In general, vaptans are effective in hyponatremias presenting with concentrated urine and, with the exception of hypovolemic hyponatremia, can be used as their primary treatment. Desmopressin is effective in hyponatremias presenting with dilute urine or developing urinary dilution after saline infusion. In this setting, desmopressin infusion helps prevent overcorrection of the hyponatremia. Monitoring of the changes in serum sodium concentration as a guide to treatment changes is imperative regardless of the initial treatment of severe hyponatremia.
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Sun Y, Mills D, Ing TS, Shapiro JI, Tzamaloukas AH. Body sodium, potassium and water in peritoneal dialysis-associated hyponatremia. Perit Dial Int 2015; 34:253-9. [PMID: 24863873 DOI: 10.3747/pdi.2012.00201] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE This report presents a method quantitatively analyzing abnormalities of body water and monovalent cations (sodium plus potassium) in patients on peritoneal dialysis (PD) with true hyponatremia. METHODS It is well known that in the face of euglycemia serum sodium concentration is determined by the ratio between the sum of total body sodium plus total body potassium on the one hand and total body water on the other. We developed balance equations that enabled us to calculate excesses or deficits, relative to the state of eunatremia and dry weight, in terms of volumes of water and volumes of isotonic solutions of sodium plus potassium when patients presented with hyponatremia. We applied this method retrospectively to 5 episodes of PD-associated hyponatremia (serum sodium concentration 121-130 mEq/L) and compared the findings of the method with those of the clinical evaluation of these episodes. RESULTS Estimates of the new method and findings of the clinical evaluation were in agreement in 4 of the 5 episodes, representing euvolemic hyponatremia (normal total body sodium plus potassium along with water excess) in 1 patient, hypovolemic hyponatremia (deficit of total body sodium plus potassium along with deficit of total body water) in 2 patients, and hypervolemic hyponatremia (excess of total body sodium along with larger excess of total body water) in 1 patient. In the 5(th) patient, in whom the new method suggested the presence of water excess and a relatively small deficit of monovalent cations, the clinical evaluation had failed to detect the cation deficit. CONCLUSIONS Evaluation of imbalances in body water and monovalent cations in PD-associated hyponatremia by the method presented in this report agrees with the clinical evaluation in most instances and could be used as a guide to the treatment of hyponatremia. Prospective studies are needed to test the potential clinical applications of this method.
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Affiliation(s)
- Yijuan Sun
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USARaymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
| | - David Mills
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
| | - Todd S Ing
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
| | - Joseph I Shapiro
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
| | - Antonios H Tzamaloukas
- Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USARaymond G. Murphy VA Medical Center, Albuquerque, New Mexico, USA; University of New Mexico School of Medicine, Albuquerque, New Mexico, USA; Department of Medicine, Loyola University Chicago, Maywood, Illinois, USA; and Joan C. Edwards School of Medicine, Marshall University, Huntington, West Virginia, USA
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Andersen C, Afshari A. Impact of perioperative hyponatremia in children: A narrative review. World J Crit Care Med 2014; 3:95-101. [PMID: 25374805 PMCID: PMC4220142 DOI: 10.5492/wjccm.v3.i4.95] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Revised: 09/13/2014] [Accepted: 10/27/2014] [Indexed: 02/06/2023] Open
Abstract
For more than 50 years, hypotonic fluids (crystalloids) have been the standard for maintenance fluid used in children. In the last decade, several studies have evaluated the risk of hyponatremia associated with the use of hypotonic vs isotonic fluids, which has lead to an intense debate. Children undergoing surgery have several stimuli for release of antidiuretic hormone, which controls renal water handling, including pain, nausea, vomiting, narcotic use and blood loss. The body’s primary defense against the development of hyponatremia is the ability of the kidneys to excrete free water and dilute urine. Increased levels of antidiuretic hormone can result in hyponatremia, defined as a plasma sodium level < 136 mmol/L, which causes cells to draw in excess water and swell. This manifests as central nervous system symptoms such as lethargy, irritability and seizures. The risk for symptomatic hyponatremia is higher in children than in adults. It represents an emergency condition, and early diagnosis, prompt treatment and close monitoring are essential to reduce morbidity and mortality. The widespread use of hypotonic fluids in children undergoing surgery is a matter of concern and more focus on this topic is urgently needed. In this paper, we review the literature and describe the impact of perioperative hyponatremia in children.
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Rondon-Berrios H, Agaba EI, Tzamaloukas AH. Hyponatremia: pathophysiology, classification, manifestations and management. Int Urol Nephrol 2014; 46:2153-65. [PMID: 25248629 DOI: 10.1007/s11255-014-0839-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 09/04/2014] [Indexed: 12/17/2022]
Abstract
Hyponatremia has complex pathophysiology, is frequent and has potentially severe clinical manifestations, and its treatment is associated with high risks. Hyponatremia can be hypertonic, isotonic or hypotonic. Hypotonic hyponatremia has multiple etiologies, but only two general mechanisms of development, defective water excretion, usually because of elevated serum vasopressin levels, or excessive fluid intake. The acute treatment of symptomatic hypotonic hyponatremia requires understanding of its targets and risks and requires continuous monitoring of the patient's clinical status and relevant serum biochemical values. The principles of fluid restriction, which is the mainstay of management of all types of hypotonic hyponatremia, should be clearly understood and followed. Treatment methods specific to various categories of hyponatremia are available. The indications and risks of these treatments should also be well understood. Rapid correction of chronic hypotonic hyponatremia may lead to osmotic demyelination syndrome, which has severe clinical manifestations, and may lead to permanent neurological disability or death. Prevention of this syndrome should be a prime concern of the treatment of hypotonic hyponatremia.
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Affiliation(s)
- Helbert Rondon-Berrios
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, A915 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA,
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Abstract
Dysnatremias occur simultaneously with disorders in water balance. The first priority is to correct dehydration; once the patient is euvolemic, the sodium level can be reassessed. In unstable patients with hyponatremia, the clinician should rapidly administer hypertonic saline. In unstable patients with hypernatremia, the clinician should administer isotonic intravenous fluid. In stable patients with either hyponatremia or hypernatremia, the clinician should aim for correction over 24 to 48 hours, with the maximal change in serum sodium between 8 to 12 mEq/L over the first 24 hours. This rate of correction decreases the chances of cerebral edema or osmotic demyelination syndrome.
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Affiliation(s)
- Theresa R Harring
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
| | - Nathan S Deal
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA
| | - Dick C Kuo
- Section of Emergency Medicine, Ben Taub General Hospital, Baylor College of Medicine, Emergency Center, 1504 Taub Loop, Room EC 61, Houston, TX 77030, USA.
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Lee JJ, Lee ST, Jung KH, Chu K, Lee SK. Anti-LGI1 Limbic Encephalitis Presented with Atypical Manifestations. Exp Neurobiol 2013; 22:337-40. [PMID: 24465150 PMCID: PMC3897696 DOI: 10.5607/en.2013.22.4.337] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 12/19/2013] [Accepted: 12/19/2013] [Indexed: 01/25/2023] Open
Abstract
Anti-leucine-rich glioma inactivated-1 (LGI1) limbic encephalitis (LE) is a rare neurological disorder that has a subacute course of progressive encephalopathy and fasciobrachial dystonic seizures. We report a patient with anti-LGI1 LE that presented with atypical manifestations that complicated the diagnosis. A 62-year-old woman presented with a chronic course of memory disturbance and a subsequent relapse with an altered mental status after 10 months. The patient reported frequent chest pain of squeezing and dull nature, typically lasting 10-30 seconds. The chest pain was related to partial seizures, which were confirmed by video-EEG monitoring. Anti-LGI1 antibody was identified in serum and CSF. The patient's symptoms improved by immune modulation treatment. Patients with anti-LGI1 LE can experience atypical partial seizures, and a chronic relapsing course. Clinical suspicions and video-EEG monitoring are helpful for the early diagnosis and effective immune modulation.
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Affiliation(s)
- Jung-Ju Lee
- Department of Neurology, Eulji General Hospital, Eulji University College of Medicine, Seoul 139-872, Korea
| | - Soon-Tae Lee
- Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Keun-Hwa Jung
- Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Kon Chu
- Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
| | - Sang Kun Lee
- Department of Neurology, Comprehensive Epilepsy Center, Biomedical Research Institute, Seoul National University Hospital, Seoul 110-744, Korea
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