Management of hyponatremia

Assessment of pre-, peri-, and post-surgical practices for elective colorectal patients in a model 4 hospital in Ireland

INTRODUCTION

The ERAS protocol is a set of international guidelines established to expedite patients' discharge after colorectal surgery. It does this by aiming to prevent postoperative complications early, and return the patient to normal function allowing earlier discharge. Complications such as PONV, DVT, ileus and pain are common after surgery to name a few, and delay discharge. Early treatment and prevention of these complications however is suggested to aid a patients' return to home at earlier rates than traditional practice.

METHODS

A prospective chart review and questionnaire was performed on patients undergoing colorectal surgery in UHL in a 6-month period from February to September 2023. Patients were approached on the 3rd day postoperatively and informed about the project. Exclusion criteria included patients who went to HDU or ICU postoperatively.

RESULTS

In total, 33 patients were recruited. A target of greater than 70% compliance was reached for a variety of the elements of the ERAS protocol such as laparoscopic surgery, preoperative assessments, nutritional drinks, LMWH, oral intake within 24 h of surgery, and intraoperative antiemetics. Unsatisfactory compliance was found with documentation of postoperative antibiotics use of preoperative gabapentin.

CONCLUSION

UHL has a satisfactory compliance of over 70% with a large variety of elements of the ERAS protocol. Areas of improvement required include postoperative antibiotic and preoperative gabapentin usage. With the collective effort of the multidisciplinary team, along with education, the ERAS protocol can successfully be applied and implemented in a model 4 hospital in Ireland.

Vaptans for oedematous and hyponatraemic disorders in childhood: A systematic literature review

AIMS

The aim of this study was to systematically review the use of vaptans (nonpeptide vasopressin receptor antagonists) in children.

METHODS

Through a database search (Web of Science, the National Library of Medicine, Excerpta Medica), we identified case series and case reports and extracted clinical and laboratory data.

RESULTS

Twenty-six articles, published since 2008, reported on 226 patients. Among 115 children with hyponatraemic (n = 63) and oedematous disorders (n = 52), a 48 hour course of tolvaptan with an initial dose of 0.38 ± 0.27 mg/kg was administered in 106 cases, while intravenous conivaptan was reported in nine cases. An increase (P < .02) in urine output was shown in both oedematous (from 3.2 ± 2.0 to 5.3 ± 6.7 mL/kg/day) and hyponatraemic (from 3.0 ± 1.5 to 4.4 ± 2.3 mL/kg/day) patients. In these latter, sodium increased from 125 ± 6 to 133 ± 6 mmol/L (P < .0001). The increase in sodium level correlated with its basal value, but not with the administered vaptan dose. Among 111 children undergoing cardiac surgery, after tolvaptan 0.21 ± 0.01 mg/kg/day, mostly combined with conventional diuretics, an increase in diuresis by 41 ± 4% was seen within 24 hours (P < .0001). Similarly, a single add-on dose of tolvaptan 0.45 mg/kg allowed a reduced additional intravenous furosemide administration (0.26 ± 0.23 vs 0.62 ± 0.48 mg/kg, P < .005). Side effects were rarely reported, and included excessive thirst and xerostomia in seven, skin rash in one and elevated aminotransferases in one patient(s).

CONCLUSION

Vaptans appear to be safe for oedematous and hyponatraemic disorders also in children. Although they increase diuresis and natraemia, no superiority to traditional diuretics and sodium supplements has been demonstrated. Reported side effects are rare and non-serious.

Differential diagnosis between syndrome of inappropriate antidiuretic hormone secretion and cerebral/renal salt wasting syndrome in children over 1 year: proposal for a simple algorithm

Hyponatremia, especially if acute and severe, can be a life-threatening condition. Several conditions can trigger hyponatremia. In this review, we will discuss two conditions that can determine euvolemic hyponatremia: the cerebral/renal salt wasting (CRSW) syndrome and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH), including the two subtypes: reset osmostat (RO) and nephrogenic syndrome of inappropriate antidiuresis (NSIAD) and their differential diagnoses. Despite the passage of over 70 years since its first description, to date, the true etiopathogenesis of CRSW syndrome, a rare cause of hypovolemic/euvolemic hyponatremia, is almost unknown. SIADH, including RO and NSIAD, is sometimes difficult to differentiate from CRSW syndrome; in its differential diagnosis, the clinical approach based on the evaluation of the extracellular volume (ECV) was proven insufficient. We therefore suggest a simple diagnostic algorithm based on the assessment of the degree of hyponatremia, urinary osmolality, and the assessment of the fraction of urate excretion (FEUa) in conditions of hyponatremia and after serum sodium correction, to be applied in children over 1 year of life.

Exploration of predictors of benefit from nivolumab monotherapy for patients with pretreated advanced gastric and gastroesophageal junction cancer: post hoc subanalysis from the ATTRACTION-2 study

BACKGROUND

The phase 3 ATTRACTION-2 study demonstrated that nivolumab monotherapy was superior to placebo for patients with pretreated advanced gastric or gastroesophageal junction cancer, but early progression of tumors in some patients was of concern.

METHODS

This post hoc analysis statistically explored the baseline characteristics of the ATTRACTION-2 patients and extracted a single-factor and double-factor combinations associated with early disease progression or early death. In the extracted patient subgroups, the 3-year restricted mean survival times of progression-free survival and overall survival were compared between the nivolumab and placebo arms.

RESULTS

Two single factors (age and peritoneal metastasis) were extracted as independent predictors of early progression, but none of them, as a single factor, stratified patients into two subgroups with significant differences in restricted mean survival time. In contrast, two double-factor combinations (serum sodium level and white blood cell count; serum sodium level and neutrophil-lymphocyte ratio) stratifying patients into two subgroups with significant differences in the restricted mean survival time were extracted. Additional exploratory analysis of a triple-factor combination showed that patients aged < 60 years with peritoneal metastasis and low serum sodium levels (approximately 7% of all patients) might receive less benefit from nivolumab, and patients aged ≥ 60 years with no peritoneal metastasis and normal serum sodium levels might receive higher benefit.

CONCLUSIONS

A combination of age, peritoneal metastasis, and serum sodium level might predict benefit from nivolumab as salvage therapy in advanced gastric or gastroesophageal junction cancer patients, especially less benefit for patients having all three risk factors.

Level of natremia as an index of the condition of the organism of animals under stress

In the diagnosis of stressful conditions in humans and other animals, ionic indicators remain practically unused. In this work, we studied the changes in the concentrations of sodium ions in the blood plasma of freshwater fish under stress caused by stressors of different quality and quantity. Most of the experiments were carried out on adult bream (Abramis brama L) from the Rybinsk Reservoir. Separate experiments were duplicated on adult individuals of roach (Rutilus rutilus L.), pike (Esox lucius L.), and blue bream (Abramis ballerus L.). The concentration of cations in the blood plasma was determined using a Flapho-4 flame photometer. Under the action of mild and short-term stressors of different qualities, the sodium concentration in the internal environment altered toward an increase in concentration gradients on the cell membrane (eustress or physiological stress). Hypernatremia was approximately 10%. Under the action of strong and/or prolonged stressors of different strength, the sodium concentration in the internal environment changed toward a decrease in concentration gradients on the cell membrane (distress or pathological stress). Hyponatremia was 50% in the conditions of acute lethal stress, 20% in subacute lethal stress, 10% or more in chronic lethal stress. During strong acute reversible stress, hyponatremia could reach 30%. Analysis of the material on mammals allowed us to conclude that the adaptation mechanisms in fish and higher vertebrates are similar. In this work, for the first time, the state of the system of electrolyte balance of animals under stress was analyzed from the standpoint of the leading role of ionic concentration gradients on the cell membrane (mainly sodium) in the energetics (level of disequilibrium) of the organism. We propose a concept that in normal and extreme conditions fish use two different defense reactions (or adaptation strategies): active and passive, consisting, respectively, in increasing or decreasing the level of disequilibrium (energy) in the organism. The hyponatremia recorded by numerous authors, which accompanies diseases in humans, is evidently a nonspecific reaction of the organism and serves as an indicator of reduced energy of the organism. It is suggested that the sodium level in the internal environment of the organism be used for diagnosing the stress state of animals.

Successful Treatment with Percutaneous Balloon Kyphoplasty for Syndrome of Inappropriate Secretion of Antidiuretic Hormone Associated with Vertebral Compression Fracture: A Case Report

BACKGROUND The etiology of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is highly variable. With little evidence, much of the guidance and recommendations available for management are based on clinical judgement. Although percutaneous balloon kyphoplasty can effectively relieve the severe pain associated with osteoporotic vertebral compression fractures that do not respond to conventional treatments, the effect of balloon kyphoplasty on SIADH associated with vertebral compression fracture remains unknown. CASE REPORT A 72-year-old woman was admitted to our hospital due to severe pain associated with lumbar compression fracture and pain-related SIADH. Since her pain could not be relieved by analgesics, she underwent percutaneous balloon kyphoplasty, a minimally invasive procedure intended to relieve pain. After the surgery, the patient's pain almost completely disappeared and her sodium level was gradually corrected within 3 days without any adverse events. CONCLUSIONS Percutaneous balloon kyphoplasty is a novel treatment option for SIADH associated with vertebral compression fracture. In the case presented here, it rapidly reduced pain and disability and also improved severe pain-associated SIADH without adverse effects. It may offer an alternative to pain regimens consisting of drugs, such as duloxetine, pregabalin, and opioids, that may exacerbate SIADH and hyponatremia. This case suggests treatment for new-onset or worsening hyponatremia in patients with vertebral compression fracture.

The use of vitreous renal chemistries in the discrimination of postmortem fresh water drowning

Background:

The World Health Organization (WHO) has estimated drowning as the leading cause of unintentional death in the world, with 372,000 deaths reported annually. Not all drowning are unintentional; some could be disguised to cover up an act of heinous criminality. This study was aimed at using some vitreous renal function biochemical parameters as a discriminant of postmortem fresh water drowning. Twelve albino rabbits constituted the sample size as validated by Mead’s formula. The study was divided into three groups; the control, postmortem-drowned and truly drowned as mimicked using an artificial fresh water pond. Vitreous humours were extracted using Coe method. The vitreous renal chemistries were analysed using diacetyl monoxime, Jaffe’s test, uricase and ion-selective electrode (ISE) methods respectively.

Result:

The mean of vitreous creatinine, urea, uric acid, Na+, K+, Cl−, Ca2+, glucose and CO2 of the control, postmortem-drowned and truly drowned groups were compared using One-way Anova (post-hoc-LSD) with the aid of SPSS Inc., Chicago, IL, USA; Version 18–21 package. The findings revealed a significant increase in concentrations of vitreous creatinine, glucose, Ca2+ and K+ of the drowned death group, whereas vitreous concentrations of CO2 and urea significantly decreased when compared to the controls and/or postmortem-drowned death.

Conclusion:

The study has shown that some of the studied vitreous biochemical parameters could be used as an ancillary tool in discriminating death due to fresh water drowning from that of disguised or postmortem-drowned death.

Perspectives From an Onconephrology Interest Group: Conference Report

INTRODUCTION AND OBJECTIVE

Onconephrology is a new and evolving field that deals with kidney complications in patients with cancer as well as the management of cancer in patients with preexisting kidney disease. With increasing numbers of patients with cancer with kidney-related complications, the field has garnered increased attention. Thus, an annual Greater Toronto Area Onconephrology Interest Group symposium was held in May 2019. The objective of the meeting was to demonstrate the junctures between oncology and nephrology by highlighting recent data regarding (1) kidney impairment in solid organ malignancies, (2) management and treatment of kidney cancer, (3) kidney impairment in hematologic malignancies, (4) malignancy and kidney transplantation, and (5) hyponatremia in patients with cancer.

METHODS AND SOURCES OF INFORMATION

Through a structured presentation, the group explored key topics discussed at a Kidney Disease Improving Global Outcomes (KDIGO) Controversies Conference on Onconephrology. Expert opinions, clinical trial findings, and publication summaries were used to illustrate patient and treatment-related considerations in onconephrology.

KEY FINDINGS

Kidney complications in patients with cancer are a central theme in onconephrology. An estimated 12% to 25% of patients with solid organ malignancies have chronic kidney disease (CKD), although in certain cancers, the prevalence of CKD is higher. Kidney impairment is also a common complication of some hematologic malignancies. The incidence of renal failure in patients with multiple myeloma is estimated at 18% to 56% and light chain cast nephropathy is seen in approximately 30% of these patients. In addition, there appears to be a bidirectional relationship between kidney cancer and CKD, with some data sets suggesting the risk increases as kidney function declines. Cancer is also of concern in patients with preexisting kidney disease. Kidney transplant recipients have a greater risk of cancer and a higher risk of cancer-related mortality. Kidney complications have also been associated with novel cancer therapies, such as immune checkpoint inhibitors and chimeric antigen receptor (CAR) T-cell therapy. An estimated 2% to 4% of patients initiating an immune checkpoint inhibitor may develop nephrotoxicity, whereas up to 40% of patients on CAR T-cell therapy experience cytokine release syndrome (CRS). Tumor lysis syndrome and electrolyte abnormalities, such as hyponatremia, have also been reported with CAR T-cell therapy. While the incidence and prevalence of hyponatremia vary depending on the cancer type and serum sodium cutoff point, hyponatremia may be seen in up to 46% of patients hospitalized in cancer centers.

CONCLUSIONS

Onconephrology is a developing field and the themes arising from this meeting indicate a need for greater collaboration between oncologists and nephrologists. Educational symposia and onconephrology fellowship programs may allow for improved cancer care for patients with kidney disease.

Clinical utility of ultra-rapid whole-genome sequencing in an infant with atypical presentation of WT1-associated nephrotic syndrome type 4

Relatively little is known about phenotypic variability in nonsyndromic nephropathy associated with the gene encoding the WT1 transcription factor. We report a 12-mo-old female who presented with vomiting, diarrhea, and fatigue in the setting of renal failure and malignant hypertension. Trio ultra-rapid whole-genome sequencing identified a novel, likely pathogenic, de novo missense variant (c.485T > A, p.Val162Asp) in WT1 in 46 h, consistent with a diagnosis of nephrotic syndrome type 4 (NPHS4; OMIM 256370). This disorder typically presents with nephrotic syndrome (gross proteinuria, hypoalbuminemia, and edema). Rapid diagnosis had an immediate impact on her clinical management in the pediatric intensive care unit. Diagnostic renal biopsy was avoided, and placement of permanent dialysis access, a gastrostomy tube, and bilateral nephrectomy were accelerated. This report expands the presenting phenotype of nonsyndromic nephrotic syndrome and/or renal failure due to heterozygous variants in WT1 (NPHS4). It also highlights the relationship between time to genomic diagnosis and clinical utility in critically ill infants.

Effects of correction equation for actual sodium concentration on the reduction in frequency of reports on pseudohyponatremia

Background

Serum sodium concentration could be spuriously reduced by excess glucose or lipid; thus, hyponatremia should be reassessed before reporting in order to exclude the possibility of pseudohyponatremia.

Methods

In this study, we used the calculation of corrected serum sodium concentration in hyperglycemic or lipemic samples and evaluated its effect on the reduction in frequency of reports on pseudohyponatremia. We retrospectively analyzed 1-year data from the laboratory information system.

Results

From August 2017 to July 2018, hyponatremia was initially noted in 30,465 results, of which 6614 results reported hyperglycemia. Corrected sodium concentrations were calculated using the results with glucose >170 mg/dL or lipemia index ≥3. The reported frequency of hyponatremia before and after correction of sodium concentration was reduced by 42.9%. Moreover, only 51.9% of the patients with severe hyponatremia had “true” severe hyponatremia. After applying the formula, the degree of hyponatremia was unchanged in only 45.8% of the total results.

Conclusions

Our report on the corrected sodium concentration reduced the frequency of pseudohyponatremia in hyperglycemic samples. Calculation of corrected sodium concentration is a useful tool to help clinicians establish appropriate care and treatment plans. Further prospective study is required to validate to our system in a real clinical practice.

Reset Osmostat: Facts and Controversies

Reset osmostat (RO) consists of a change in the normal plasma osmolality threshold (reduction or increase), which consequently induces chronic dysnatremia (hyponatremia or hypernatremia). Although the early papers on RO state that hyponatremic patients with this condition are usually not symptomatic, the current view is that most patients with hyponatremia are symptomatic and should be treated. RO has been associated with a myriad of clinical conditions and has clear diagnostic criteria which are crucial to arrive at the correct diagnosis and treatment.

Hyponatremia during hospitalization and in-hospital mortality in patients hospitalized from heart failure

Background

To date, the majority of studies on hyponatremia focussed on hyponatremia at admission, and came from developed countries. This study aimed to identify the prevalence of hyponatremia during hospitalization in patients hospitalized for HF and its association with in-hospital mortality.

Methods

This was an observational study using retrospective data from patients’ records between 2010–2013. It focused on those patients carrying an ICD-10 code of 150.0(Congestive Heart Failure) as their primary diagnosis.

Hyponatremia during hospitalization was defined as serum sodium level lower than 135 mEq/L obtained from a blood chemistry measurement on the next days after admission. Patients’ characteristics were examined and the association between hyponatremia during hospitalization and in-hospital mortality was analyzed.

Results

Among 464 patients hospitalized for HF, hyponatremia during hospitalization was observed in 22 % of patients with 44 % of this group had normal serum sodium level on admission.

Hyponatremia during hospitalization was associated with lower blood pressure on admission, both systolic and diastolic, peripheral oedema, ascites and fatigue. Patients having history of hospitalization for cardiac diseases and renal failure were higher in patients developing hyponatremia during hospitalization. In this group, amiodarone, heparin, insulin and antibiotics were administered more frequently. Factors potentially increase the risk of hyponatremia during hospitalization include history of fatigue (OR = 3.23, 95 % CI 1.79–5.82), presence of ascites (4.14, 1.84–9.31), and administration of heparin (3.85, 1.78–8.31) and antibiotics (3.08, 1.71–5.53). Length of hospital stay was significantly longer in patients with hyponatremia during hospitalization and in-hospital mortality was also higher compared to non-hyponatremic patients, 7.7 % and 29.1 %, respectively.

Conclusion

This study found that the prevalence of hyponatremia during hospitalization in patients hospitalized for HF was almost the same as hyponatremia on admission and administration of heparin and antibiotics can potentially worsen hyponatremia during hospitalization. In this study population, hyponatremia during hospitalization was found to be associated with in-hospital mortality.