Rate of Correction of Hypernatremia and Health Outcomes in Critically Ill Patients

Fluid dynamics of life: exploring the physiology and importance of water in the critical illness

Water acknowledged as a vital component for life and the universal solvent, is crucial for diverse physiological processes in the human body. While essential for survival, the human body lacks the capacity to produce water, emphasizing the need for regular ingestion to maintain a homeostatic environment. The human body, predominantly composed of water, exhibits remarkable biochemical properties, playing a pivotal role in processes such as protein transport, thermoregulation, the cell cycle, and acid–base balance. This review delves into comprehending the molecular characteristics of water and its interactions within the human body. The article offers valuable insights into the intricate relationship between water and critical illness. Through a comprehensive exploration, it seeks to enhance our understanding of water’s pivotal role in sustaining overall human health.

Updates in hyponatremia and hypernatremia

PURPOSE OF REVIEW

Hyponatremia and hypernatremia are commonly encountered electrolyte abnormalities that require timely and careful intervention, as they can be associated with significant morbidity and mortality.

RECENT FINDINGS

This review article addresses the etiology, presentation, diagnosis, and management of both hyponatremia and hypernatremia, emphasizing the latest advancements and emerging trends in pediatric care.

SUMMARY

A methodical approach is needed to accurately assess and treat hyponatremia and hypernatremia. Both conditions continue to rely on serum and urine testing, however newer tests such as copeptin and stimulated testing may hold promise to further refine testing in the future.

Systemic and iatrogenic factors contribute to the development of severe hypernatraemia in vulnerable inpatients

OBJECTIVES

To determine all-cause in-hospital mortality associated with severe hypernatraemia and the causes, comorbidities, time to treatment, discharge destination and postdischarge mortality.

DESIGN

Retrospective observational cohort study.

PATIENTS

Severe hypernatraemia, (sodium concentration ≥ 155 mmol/L), at any time during a tertiary hospital admission in Melbourne, Australia, 1 January 2019 to 31 December 2019 (pre-COVID19).

MEASUREMENTS

Deaths, Charlson Comorbidity Index (CCI), hypernatraemia causes, time to treatment, discharge destination.

RESULTS

One hundred and one inpatients: 64 community-acquired, 37 hospital-acquired. In-hospital mortality was 38%, but cumulative mortality was 65% by 1 month after discharge, with only a minor further increase at 6 and 12 months. After adjusting for peak sodium concentration, the community acquired group had significantly reduced odds of in-hospital mortality (odds ratio 0.15, 95% confidence interval [0.04-0.54], p = .003). Iatrogenic factors were present in 57% (21/37) of the hospital-acquired group. Only 55% of all cases received active sodium directed treatment. Time to start treatment did not affect outcomes. High levels of comorbidity were present, median CCI (IQR) was 6 (5-8) in the community and 5 (4-7) in the hospital group. Dementia prevalence was higher in the community group, 66% (42/64) versus 19% (7/37) (p = .001). Infection was the most common precipitant with 52% (33/64) in the community and 32% (12/37) in the hospital group. Of the survivors, 32% who had been living independently required residential care after discharge.

CONCLUSIONS

Mortality was high and loss of independence in survivors common. To potentially improve outcomes, hypernatraemia-specific guidelines should be formulated and efforts made to reduce system and iatrogenic factors.

[Dysnatremias - concepts and clinical work-up]

Osmotic gradients over cell membranes lead to water movement into or out of cells. An intact osmoregulation prevents osmotic gradients, thereby protecting cells from swelling or shrinking. Na+ is the major cation in the extracellular fluid (ECF) and the major determinant of the osmolarity in the ECF, including plasma. Therefore, the plasma-Na+ concentration needs to be tightly regulated. An excess of electrolyte-free water decreases the concentration of osmolytes leading to hyponatremia. In contrast, a free water deficit increases the osmolyte concentration leading to hypernatremia. Pathophysiology-oriented approaches to dysnatremic patients help both clinicians and patients. Therapeutic interventions depend on the differentiation between acute and chronic, asymptomatic, and symptomatic dysnatremia, and on the patient's extracellular volume status. The therapeutic armamentarium for hyponatremia consists of water restriction, hypertonic infusions, urea, V2 receptor-blockers, and sodium-glucose cotransporter 2 (SGLT2) inhibitors. Patients with hypernatremia are treated with electrolyte-free water or hypotonic sodium-containing solutions depending on their volume status. Basic concepts in the management of dysnatremic patients are discussed.

Association of postoperative hypernatremia with outcomes after elective craniotomy

STUDY OBJECTIVE

Hypernatremia is a treatable biochemical disorder associated with significant morbidity and mortality in patients undergoing surgery. However, its impact on patients who undergo elective craniotomy is not well understood. This study aimed to investigate the prognostic implications of postoperative hypernatremia on the 30-day mortality of patients undergoing elective craniotomy.

DESIGN

Retrospective cohort study.

SETTING

The Department of Neurosurgery of a high-volume center.

PATIENTS

Adult patients undergoing elective craniotomy except those with pituitary tumors, intracerebral hemorrhage, subarachnoid hemorrhage, or traumatic brain injury.

INTERVENTIONS

None.

MEASUREMENTS

Perioperative laboratory data were collected for all study participants, including sodium levels, neutrophil count, serum albumin, lymphocyte count, and blood glucose. These measurements were obtained as part of routine clinical care and provided valuable information for data analysis.

MAIN RESULTS

Of the 10,223 identified elective craniotomy patients who met our inclusion and exclusion criteria, 14.9% (1519) developed postoperative hypernatremia. This population's overall postoperative 30-day mortality rate was 1.7% (175). After performing an adjusted logistic regression analysis, we found that the odds of 30-day mortality increased gradually with increasing severity of hypernatremia: 2.9 deaths (OR, 3.79; 95% CI, 2.46-5.85) in patients with mild hypernatremia, 13.9 deaths (OR, 17.73; 95% CI, 11.17-28.12) in those with moderate hypernatremia, and 38.3 deaths (OR, 67.00; 95% CI, 40.44-111.00) in those with severe hypernatremia.

CONCLUSIONS

Hypernatremia is common after elective craniotomy, and its presence is associated with increased mortality and complications, particularly in cases of severe hypernatremia. These results emphasize the significance of risk evaluation in neurosurgical patients and propose the advantages of closely monitoring serum sodium levels in high-risk individuals. Future randomized controlled trials could provide more insight into the effect of treating postoperative hypernatremia in these patients.

Rate of Correction and All-Cause Mortality in Patients With Severe Hypernatremia

Importance

Hypernatremia is common among hospitalized patients and is associated with high mortality rates. Current guidelines suggest avoiding fast correction rates but are not supported by robust data.

Objective

To investigate whether there is an association between hypernatremia correction rate and patient survival.

Design, Setting, and Participants

This retrospective cohort study examined data from all patients admitted to the Tel Aviv Medical Center between 2007 and 2021 who were diagnosed with severe hypernatremia (serum sodium ≥155 mmol/L) at admission or during hospitalization. Statistical analysis was performed from April 2022 to August 2023.

Exposure

Patients were grouped as having fast correction rates (>0.5 mmol/L/h) and slow correction rates (≤0.5 mmol/L/h) in accordance with current guidelines.

Main Outcomes and Measures

All-cause 30-day mortality.

Results

A total of 4265 patients were included in this cohort, of which 2621 (61.5%) were men and 343 (8.0%) had fast correction rates; the median (IQR) age at diagnosis was 78 (64-87) years. Slow correction was associated with higher 30-day mortality compared with fast correction (50.7% [1990 of 3922] vs 31.8% [109 of 343]; P < .001). These results remained significant after adjusting for demographics (age, gender), Charlson comorbidity index, initial sodium, potassium, and creatinine levels, hospitalization in an ICU, and severe hyperglycemia (adjusted odds ratio [aOR], 2.02 [95% CI, 1.55-2.62]), regardless of whether hypernatremia was hospital acquired (aOR, 2.19 [95% CI, 1.57-3.05]) or documented on admission (aOR, 1.64 [95% CI, 1.06-2.55]). There was a strong negative correlation between absolute sodium correction during the first 24 hours following the initial documentation of severe hypernatremia and 30-day mortality (Pearson correlation coefficient, -0.80 [95% CI, -0.93 to -0.50]; P < .001). Median (IQR) hospitalization length was shorter for fast correction vs slow correction rates (5.0 [2.1-14.9] days vs 7.2 [3.5-16.1] days; P < .001). Prevalence of neurological complications was comparable for both groups, and none were attributed to fast correction rates of hypernatremia.

Conclusions and Relevance

This cohort study of patients with severe hypernatremia found that rapid correction of hypernatremia was associated with shorter hospitalizations and significantly lower patient mortality without any signs of neurologic complications. These results suggest that physicians should consider the totality of evidence when considering the optimal rates of correction for patients with severe hypernatremia.

Hormones and Aging: An Endocrine Society Scientific Statement

Multiple changes occur across various endocrine systems as an individual ages. The understanding of the factors that cause age-related changes and how they should be managed clinically is evolving. This statement reviews the current state of research in the growth hormone, adrenal, ovarian, testicular, and thyroid axes, as well as in osteoporosis, vitamin D deficiency, type 2 diabetes, and water metabolism, with a specific focus on older individuals. Each section describes the natural history and observational data in older individuals, available therapies, clinical trial data on efficacy and safety in older individuals, key points, and scientific gaps. The goal of this statement is to inform future research that refines prevention and treatment strategies in age-associated endocrine conditions, with the goal of improving the health of older individuals.

Massive Chronic Hypernatremia Associated With Failure to Thrive in a Pediatric Patient

Hypernatremia is a severe, potentially life-threatening condition that can manifest with altered mental status, coma, seizure, and even death. Values above 190 mmol/L are seldom reported in young pediatric patients and often have poor outcomes. We present a case of severe chronic hypernatremia secondary to failure to thrive (FTT) in a toddler, which led to significant pathology including bilateral metabolic strokes. A 21-month-old female was found unresponsive and brought to the hospital. The patient's childhood was complicated by prematurity, poor weight gain, and persistent postprandial emesis. On examination, the patient was tachycardic and obtunded. Her weight was below the first percentile. Initial laboratory results showed a sodium level of 197 mmol/L with marked dehydration. Normal saline boluses were given followed by maintenance fluids with the goal of sodium decrementation by 0.5 mmol/hour; nephrology assisted with fluid and electrolyte correction calculations. Imaging revealed metabolic strokes involving the brainstem and thalami. During hospitalization, hypokalemia and hypophosphatemia complicated the treatment course. Over the next 21 days, electrolytes normalized. She tolerated nasogastric feeding, gradually improved as she gained weight, and was discharged. Chronic hypernatremia must be fixed judiciously as rapid correction can cause significant harm. This unusual case reminds providers that florid electrolyte dyscrasias may be secondary to FTT and can lead to significant neurological sequelae. Careful fluid selection and calculations should be performed in these cases. Chronic hypernatremia should be considered in children with FTT with altered mental status, and the gradual correction of electrolytes should be performed to minimize patient harm.

Critical Care of the Burn Patient

Care of the critically ill burned patient must integrate a multidisciplinary care team composed of burn care specialists. As resuscitative mortality decreases more patients are surviving to experience multisystem organ failure relating to complications of their injuries. Clinicians must be aware of physiologic changes following burn injury and the implicated impacts on management strategy. Promoting wound closure and rehabilitation should be the backdrop for which management decisions are made.

Age-Associated Abnormalities of Water Homeostasis

Deficits in renal function, thirst, and responses to osmotic and volume stimulation have been repeatedly demonstrated in older populations. The lessons learned over the past six decades serve to emphasize the fragile nature of water balance characteristic of aging. Older individuals are at increased risk for disturbances of water homeostasis due to both intrinsic disease and iatrogenic causes. These disturbances have real-life clinical implications in terms of neurocognitive effects, falls, hospital readmission and need for long-term care, incidence of bone fracture, osteoporosis, and mortality.

Dysnatremia in COVID-19 Patients-An Analysis of the COLOS Study

BACKGROUND

Sodium imbalance is one of the most common electrolyte disturbances encountered in the medical practice, and it may present with either hyponatremia or hypernatremia. Both sodium abnormalities are related with unfavorable outcomes.

OBJECTIVE

Elucidation of the prevalence of dysnatremia among COVID-19 patients and its impact on 30- and 90-day mortality and need for ICU admission was the goal.

DESIGN AND PARTICIPANTS

A single-center, retrospective, observational study was conducted. A total of 2026 adult, SARS-CoV-2 positive patients, admitted to Wroclaw University Hospital between 02.2020 and 06.2021, were included. On admission, patients were divided into groups: normonatremic (N), hyponatremic (L), and hypernatremic (H). Acquired data was processed, and Cox hazards regression and logistic regression were implemented.

KEY RESULTS

Hyponatremia on admission occurred in 17.47% (n = 354) of patients and hypernatremia occurred in 5.03% (n = 102). Dysnatremic patients presented with more comorbidities, used more drugs, and were statistically more often admitted to the ICU. Level of consciousness was the strongest predictor of ICU admission (OR = 1.21, CI: 1.16-1.27, p < 0.001). Thirty-day mortality was significantly higher in both the L and H groups (28.52%, p = 0.0001 and 47.95%, p < 0.0001, respectively), in comparison to 17.67% in the N group. Ninety-day mortality showed a similar trend in all study groups: 34.37% in the L group (p = 0.0001), 60.27% (p < 0.0001) in the H group, and 23.32% in the N group. In multivariable analyses, hypo- and hypernatremia were found to be independent predictors of 30- and 90-day mortality.

CONCLUSIONS

Both hypo- and hypernatremia are strong predictors of mortality and disease severity in COVID-19 patients. Extraordinary care should be taken when dealing with hypernatremic, COVID-positive patients, as this group exhibits the highest mortality rates.

Salt and Water: A Review of Hypernatremia

Serum sodium disorders are generally a marker of water balance in the body. Thus, hypernatremia is most often caused by an overall deficit of total body water. Other unique circumstances may lead to excess salt, without an impact on the body's total water volume. Hypernatremia is commonly acquired in both the hospital and community. As hypernatremia is associated with increased morbidity and mortality, treatment should be initiated promptly. In this review, we will discuss the pathophysiology and management of the main types of hypernatremia, which can be categorized as either a loss of water or gain of sodium that can be mediated by renal or extrarenal mechanisms.

Correcting Hypernatremia in Children

BACKGROUND

In children with hypernatremia, current clinical guidelines recommend a reduction in serum sodium of 0.5 mmol/L per hour or less to avoid complications of cerebral edema. However, no large-scale studies have been conducted in the pediatric setting to inform this recommendation. Therefore, this study aimed to report the association between the rate of correction of hypernatremia, neurological outcomes, and all-cause mortality in children.

METHODS

A retrospective cohort study was conducted from 2016 to 2019 at a quaternary pediatric center in Melbourne, Victoria, Australia. All children with at least one serum sodium level ≥150 mmol/L were identified through interrogation of the hospital's electronic medical record. Medical notes, neuroimaging reports, and electroencephalogram results were reviewed for evidence of seizures and/or cerebral edema. The peak serum sodium level was identified and correction rates over the first 24 hours and overall were calculated. Unadjusted and multivariable analyses were used to examine the association between the rate of sodium correction and neurological complications, the requirement for neurological investigation, and death.

RESULTS

There were 402 episodes of hypernatremia among 358 children over the 3-year study period. Of these, 179 were community-acquired and 223 developed during admission. A total of 28 patients (7%) died during admission. Mortality was higher in children with hospital-acquired hypernatremia, as was the frequency of intensive care unit admission and hospital length of stay. Rapid correction (>0.5 mmol/L per hour) occurred in 200 children and was not associated with greater neurological investigation or mortality. Length of stay was longer in children who received slow correction (<0.5 mmol/L per hour).

CONCLUSIONS

Our study did not find any evidence that rapid sodium correction was associated with greater neurological investigation, cerebral edema, seizures, or mortality; however, slow correction was associated with a longer hospital length of stay.

Nomogram Prediction Model of Hypernatremia on Mortality in Critically Ill Patients

Objective

To investigate the value of hypernatremia in the intensive care unit (ICU) for the risk prediction of mortality in severe patients.

Methods

Clinical data of critically ill patients admitted to the ICU of Beijing Friendship Hospital, were collected for retrospective analysis. Univariate and multivariate logistic regression analyses were employed to analyze the influencing factors. Nomograms predicting the mortality were constructed with R software and validated with repeated sampling.

Results

A total of 442 cases were eligible for this study. Hypernatremia within 48 hours of ICU admission, change in sodium concentration (CNa+) within 48 hours, septic shock, APACHE II score, hyperlactatemia within 48 hours, use of continuous renal replacement therapy (CRRT) within 48 hours, and the use of mechanical ventilation (MV) within 48 hours of ICU admission were all identified as independent risk factors for death within 28 days of ICU admission. These predictors were included in a nomogram of 28-day mortality in severe patients, which was constructed using R software.

Conclusion

The nomogram could predict the individualized risk of 28-day mortality based on the above factors. The model has better discrimination and accuracy and has high clinical application value.

Safely correct hyponatremia with continuous renal replacement therapy: A flexible, all-purpose method based on the mixing paradigm

Treating chronic hyponatremia by continuous renal replacement therapy (CRRT) is challenging because the gradient between a replacement fluid's [sodium] and a patient's serum sodium can be steep, risking too rapid of a correction rate with possible consequences. Besides CRRT, other gains and losses of sodium- and potassium-containing solutions, like intravenous fluid and urine output, affect the correction of serum sodium over time, known as osmotherapy. The way these fluids interact and contribute to the sodium/potassium/water balance can be parsed as a mixing problem. As Na/K/H₂ O are added, mixed in the body, and drained via CRRT, the net balance of solutes must be related to the change in serum sodium, expressible as a differential equation. Its solution has many variables, one of which is the sodium correction rate, but all variables can be evaluated by a root-finding technique. The mixing paradigm is proved to replicate the established equations of osmotherapy, as in the special case of a steady volume. The flexibility to solve for any variable broadens our treatment options. If the pre-filter replacement fluid cannot be diluted, then we can compensate by calculating the CRRT blood flow rate needed. Or we can deduce the infusion rate of dextrose 5% water, post-filter, to appropriately slow the rise in serum sodium. In conclusion, the mixing model is a generalizable and practical tool to analyze patient scenarios of greater complexity than before, to help doctors customize a CRRT prescription to safely and effectively reach the serum sodium target.

Evaluation and management of hypernatremia in adults: clinical perspectives

Hypernatremia is an occasionally encountered electrolyte disorder, which may lead to fatal consequences under improper management. Hypernatremia is a disorder of the homeostatic status regarding body water and sodium contents. This imbalance is the basis for the diagnostic approach to hypernatremia. We summarize the eight diagnostic steps of the traditional approach and introduce new biomarkers: exclude pseudohypernatremia, confirm glucose-corrected sodium concentrations, determine the extracellular volume status, measure urine sodium levels, measure urine volume and osmolality, check ongoing urinary electrolyte free water clearance, determine arginine vasopressin/copeptin levels, and assess other electrolyte disorders. Moreover, we suggest six steps to manage hypernatremia by replacing water deficits, ongoing water losses, and insensible water losses: identify underlying causes, distinguish between acute and chronic hypernatremia, determine the amount and rate of water administration, select the type of replacement solution, adjust the treatment schedule, and consider additional therapy for diabetes insipidus. Physicians may apply some of these steps to all patients with hypernatremia, and can also adapt the regimens for specific causes or situations.

Management for Electrolytes Disturbances during Continuous Renal Replacement Therapy

Despite the lack of proven superiority in mortality compared to intermittent hemodialysis, continuous renal replacement therapy (CRRT) is the preferred renal replacement therapy modality for critically ill patients with acute kidney injury (AKI) due to better hemodynamic stability and steady correction of electrolytes disturbances and volume overload. Multiple and complex electrolyte disorders in patients with AKI can be managed effectively with CRRT because controlled and predictable correction is feasible. Thus, CRRT has an advantage with safety over conventional hemodialysis, especially in patients with both renal dysfunction and electrolyte disorder that require a sophisticated treatment with avoidance of rapid correction. On the contrary, CRRT can potentially lead to paradoxical disturbance of electrolytes such as hypokalemia or hypophosphatemia, especially in patients under high dose or prolonged duration of CRRT treatment. These electrolytes related complications can be prevented with close monitoring followed by the appropriate use of CRRT fluids. Although there is a lack of solid evidence and standardized guideline for CRRT prescriptions, optimal management of various electrolyte disturbances can be achieved with individualized and tailored dialysate and replacement fluid prescriptions. Several commercially available CRRT solutions with varying compositions provide flexibility to manage electrolyte disorders and maintain the stability of electrolyte. In this review, we discuss various prescription methods to manage common electrolyte imbalances as well as preventative strategies to maintain electrolyte homeostasis during CRRT providing detailed protocols used in our center. This review may contribute to future research that can lead to the development of clinical practice guidelines.

Diagnosis and treatment of brain injury complicated by hypernatremia

Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.

Natraemia variations induced by acute dialysis in critically ill patients: a database study

Natraemia is often abnormal in critically ill patients and may change rapidly during renal replacement therapy (RRT). This database study in a single intensive care unit (ICU) evaluated natraemia before and after the first RRT session for acute kidney injury. Of 252 patients who required RRT in 2018-2020, 215 were included. Prevalences were 53.9% for hyponatraemia (≤ 135 mmol/L) and 3.7% for hypernatraemia (> 145 mmol/L). Dialysate sodium was ≥ 145 mmol/L in 83% of patients. Median dialysis sodium gradient was 12 mmol/L, with a value above 16 mmol/L in 25% of patients. Median natraemia increased from 135 before to 140 mmol/L after RRT, the median hourly increase being faster than recommended, at 1.0 mmol/L [0.2-1.7]. By multivariate analysis, the only variable significantly associated with the RRT-induced natraemia change was the dialysis sodium gradient [odds ratio, 1.66; 95% confidence interval 1.39-2.10]. Pearson's correlation coefficient between the gradient and the natraemia change was 0.57. When performing RRT in ICU patients, in addition to the haemodynamic considerations put forward in recommendations, the dialysis sodium gradient deserves careful attention in order to control natraemia variations. Studies to devise a formula for predicting natraemia variations might prove helpful to confirm our results.

Prognostic value of dysnatremia for survival in neuroendocrine neoplasm patients

OBJECTIVE

Hyponatremia and hypernatremia are common electrolyte abnormalities in patients with malignancy and have been independently associated with worse survival outcomes. To date, there are no data on the impact of dysnatremia on survival outcomes in patients with neuroendocrine neoplasms (NENs).

DESIGN

This study involves retrospective cohort analysis from a tertiary care center of NEN patients treated with peptide receptor radionuclide therapy (PRRT) with a cumulative activity of at least 3.7 GBq 177Lu-DOTATATE between the years 2000 and 2015.

METHODS

Comparison of overall survival of patients with the occurrence of hyponatremia (serum sodium < 135 mmol/L) or hypernatremia (serum sodium > 145 mmol/L) before starting or during PRRT was perfomed.

RESULTS

A total of 649 patients were included. Hyponatremia occurred in 57 patients during the observation period and was associated with a shorter median overall survival (95% CI) of 25 months (14-36) compared to 55 months (48-61) of the 512 normonatremic patients (P < 0.001), adjusted hazard ratio (HR): 1.48 (95% CI: 1.04-2.12). Overall survival time was reduced regardless of whether hyponatremia was present at baseline or during PRRT. In contrast, hypernatremia occurred in 80 patients and was associated with a longer median overall survival (95% CI) of 94 months (47-140) compared with the 512 normonatremic patients (P = 0.018), adjusted HR: 0.61 (95% CI: 0.40-0.92). This association was driven by the patients with hypernatremia during PRRT. No association between dysnatremia and progression-free survival after PRRT was observed.

CONCLUSIONS

The occurrence of hypo- or hypernatremia in PRRT-treated NET patients is associated with opposing outcomes with regard to overall survival. Sodium levels might have a prognostic role in these patients.

Efficacy and safety of rapid intermittent bolus compared with slow continuous infusion in patients with severe hypernatremia (SALSA II trial): a study protocol for a randomized controlled trial

Background

Methods

Conclusion

Sodium and Potassium Dysregulation in the Patient With Cancer

Sodium and potassium disorders are pervasive in patients with cancer. The causes of these abnormalities are wide-ranging, are often primary or second-order consequences of the underlying cancer, and have prognostic implications. The approach to hyponatremia should focus on cancer-related etiologies, such as syndrome of inappropriate antidiuretic hormone, to the exclusion of other causes. Hypernatremia in non-iatrogenic forms is generally due to water loss rather than excessive sodium intake. Debilitated or dependent patients with cancer are particularly vulnerable to hypernatremia. Hypokalemia can occur in patients with cancer due to gastrointestinal disturbances, resulting from decreased intake or increased losses. Renal losses can occur as a result of excessive mineralocorticoid secretion or therapy-related nephrotoxicity. The approach to hyperkalemia should be informed by historical and laboratory clues, and pseudohyperkalemia is particularly common in patients with hematological cancers. Hyperkalemia can be seen in primary or metastatic disease that interrupts the adrenal axis. It can also develop as a consequence of immunotherapy, which can cause adrenalitis or hypophysitis. Tumor lysis syndrome (TLS) is defined by the development of hyperkalemia and is a medical emergency. Awareness of the electrolyte abnormalities that can befall patients with cancer is vital for its prompt recognition and management.

Hypernatremia in the intensive care unit

PURPOSE OF REVIEW

Hypernatremia is a relatively frequent electrolyte disorder seen in critically ill patients. As many as 27% of patients in intensive care units (ICUs) develop hypernatremia of variable severity during an ICU stay. Debate among specialists often ensues as to whether to correct hypernatremia or not. Some practitioners, particularly intensivists, believe that correction of hypernatremia with fluids may cause expansion of the extracellular fluid volume (ECFV) thereby worsening ventilation and impeding extubation. Other practitioners, including many nephrologists, do not expect correction of hypernatremia to lead to clinically apparent ECFV expansion, and fear other deleterious effects of hypernatremia. In this review we address the controversy regarding appropriate practice.

RECENT FINDINGS

There are no randomized, clinical trials (RCTs) to guide the administration of electrolyte-free fluid administration in hypernatremic patients. However, there are associations, demonstrated in the literature, suggesting that hypernatremia of any severity will increase the mortality and length of stay in these patients. These associations generally support the practice of correction of hypernatremia. In addition, our knowledge of the distribution of total body water influences us towards correcting hypernatremia as an appropriate therapy. We do not expect that adequate RCTs addressing this question will be performed.

SUMMARY

Allowing persistence of any degree of hypernatremia is associated with increased mortality, length of stay (LOS) and postdischarge mortality. We expect that proper use of electrolyte-free water intake will avoid adverse outcomes.

The Effect of Fibrates on Kidney Function and Chronic Kidney Disease Progression: A Systematic Review and Meta-Analysis of Randomised Studies

Aim: Fibrates have proven efficacy in cardiovascular risk reduction and are commonly used, in addition to statins, to control hypertriglyceridaemia. Their use is often limited due to reduction in glomerular filtration rate at treatment initiation. However, recent studies suggest benign changes in kidney function and improvement of proteinuria, an established early marker of microvascular disease and kidney disease progression. We summarize the evidence from existing trials and provide a summary of effects of fibrates, alone or in combination, on kidney disease progression and proteinuria. Methods and Results: Systematic review and meta-analysis of randomized, controlled trials (PROSPERO CRD42020187764). Out of 12,243 potentially eligible studies, 29 were included in qualitative and quantitative analysis, with a total of 20,176 patients. Mean creatinine increased by 1.05 (95% CI (0.63 to 1.46)) units in patients receiving fibrates vs. comparator, and this was similar in all other subgroups. eGFR showed a bigger decrease in the fibrates arm (SMD −1.99; 95% CI (−3.49 to −0.48)) when all studies were pooled together. Notably, short-term serum creatinine and eGFR changes remained constant in the long-term. Pooled estimates show that fibrates improve albuminuria progression, RR 0.86; 95% CI (0.76 to 0.98); albuminuria regression, RR 1.19; 95% CI (1.08 to 1.310). Conclusions: Fibrates improve albuminuria in patients with and without diabetes when used to treat hyperlipidaemia. The modest creatinine increase should not be a limiting factor for fibrate initiation in people with preserved renal function or mild CKD. The long-term effects on kidney disease progression warrant further study.

Hypernatremia subgroups among hospitalized patients by machine learning consensus clustering with different patient survival

BACKGROUND

The objective of this study was to characterize hypernatremia patients at hospital admission into clusters using an unsupervised machine learning approach and to evaluate the mortality risk among these distinct clusters.

METHODS

We performed consensus cluster analysis based on demographic information, principal diagnoses, comorbidities, and laboratory data among 922 hospitalized adult patients with admission serum sodium of > 145 mEq/L. We calculated the standardized difference of each variable to identify each cluster's key features. We assessed the association of each hypernatremia cluster with hospital and 1-year mortality.

RESULTS

There were three distinct clusters of patients with hypernatremia on admission: 318 (34%) patients in cluster 1, 339 (37%) patients in cluster 2, and 265 (29%) patients in cluster 3. Cluster 1 consisted of more critically ill patients with more severe hypernatremia and hypokalemic hyperchloremic metabolic acidosis. Cluster 2 consisted of older patients with more comorbidity burden, body mass index, and metabolic alkalosis. Cluster 3 consisted of younger patients with less comorbidity burden, higher baseline eGFR, hemoglobin, and serum albumin. Compared to cluster 3, odds ratios for hospital mortality were 15.74 (95% CI 3.75-66.18) for cluster 1, and 6.51 (95% CI 1.48-28.59) for cluster 2, whereas hazard ratios for 1-year mortality were 6.25 (95% CI 3.69-11.46) for cluster 1 and 4.66 (95% CI 2.73-8.59) for cluster 2.

CONCLUSION

Our cluster analysis identified three clinically distinct phenotypes with differing mortality risk in patients hospitalized with hypernatremia.

Increased short-term and long-term mortality in community- and hospital-acquired hypernatraemia and in patients with delayed serum sodium correction

BACKGROUND

This study examined the short-term and long-term mortality of community- and hospital-acquired hypernatraemia in a large cohort of general hospitalised patients, and the impact of delayed serum sodium correction in hypernatraemic patients.

METHODS

Adult patients admitted to Mayo Clinic Rochester from 2011 to 2013 were examined. The patients with admission serum sodium ≥138 mEq/L and at least 2 serum sodium measurements during hospitalisation were included. Hypernatraemia was defined as serum sodium ≥143 mEq/L. The patients were categorised into three groups based on serum sodium at admission and during hospitalisation: (a) normal serum sodium, (b) community-acquired hypernatraemia and (c) hospital-acquired hypernatraemia. Outcomes included hospital mortality and 1-year mortality after hospital discharge amongst hospital survivors.

RESULTS

Of 25 781 eligible patients, 45% had normal serum sodium, 20% had community-acquired hypernatraemia and 35% had hospital-acquired hypernatraemia. In adjusted analysis, odds ratios (ORs) of community- and hospital-acquired hypernatraemia for hospital mortality were 4.91 (95% CI 3.47-6.94) and 4.11 (95% CI 2.94-5.73), whereas hazard ratio (HR) for 1-year mortality was 1.76 (95% CI 1.56-1.98) and 1.61 (95% CI 1.45-1.79), respectively. Hospital-acquired hypernatraemia had a higher hospital mortality but not 1-year mortality than community-acquired hypernatraemia. In patients with community-acquired hypernatraemia, 36% remained hypernatraemic by hospital day 3. Hospital mortality (OR 3.01; 95% CI 2.71-5.83) and 1-year mortality (HR 1.51; 95% CI 1.26-1.81) were significantly increased in patients with persistent hypernatraemia, compared with those with serum sodium correction into optimal range of 138-142 mEq/L.

CONCLUSION

Hypernatraemia, regardless of acquisition origin, is associated with elevated short-term and long-term mortality. Hospital-acquired hypernatraemia was more common and had a higher short-term mortality than community-acquired hypernatraemia. Failure to correct hypernatraemia by hospital day 3 is associated with increased mortality.

Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State

BACKGROUND

Hyperglycemic hyperosmolar state is a life-threatening complication of diabetes mellitus. Therefore, it is important for emergency physicians to be aware of this unique diagnosis and treatment considerations.

OBJECTIVE

This manuscript reviews the emergency department evaluation and management of the adult patient with hyperglycemic hyperosmolar state.

DISCUSSION

Hyperglycemic hyperosmolar state is diagnosed by an elevated glucose, elevated serum osmolality, minimal or absent ketones, and a neurologic abnormality, most commonly altered mental status. Treatment involves fluid resuscitation and correction of electrolyte abnormalities. It is important to monitor these patients closely to avoid overcorrection of osmolality, sodium, and other electrolytes. These patients are critically ill and generally require admission to an intensive care unit.

CONCLUSIONS

Hyperglycemic hyperosmolar state is associated with significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.

Elevated serum sodium in recipients of liver transplantation has a substantial impact on outcomes

Dysnatremias are a rare but significant event in liver transplantation. While recipient pre-transplant hypernatremia has been demonstrated to increase post-transplant mortality, the degree of hypernatremia and the impact of its resolution have been less well characterized. Here, we used multivariate Cox regression with a comprehensive list of donor and recipient factors in order to conduct a robust multivariate retrospective database study of 54,311 United Network for Organ Sharing (UNOS) liver transplant patients to analyze the effect of pre-transplant serum sodium on post-transplant mortality, post-transplant length of hospitalization, and post-transplant graft survival. Mortality and graft failure increased in a stepwise fashion with increasing pre-transplant hypernatremia: 145 -150 mEq/L (HR = 1.118 and HR = 1.113), 150-155 mEq/L (HR = 1.324 and HR = 1.306), and > 155 mEq/L (HR = 1.623 and HR = 1.661). Pre-transplant hypo- and hypernatremia also increased length of post-transplant hospitalization: < 125 mEq/L (HR = 1.098), 125-130 mEq/L (HR = 1.060), 145 -150 mEq/L (HR = 1.140), and 150-155 mEq/L (HR = 1.358). Resolution of hypernatremia showed no significant difference in mortality compared with normonatremia, while unresolved hypernatremia significantly increased mortality (HR = 1.254), including a durable long-term increased mortality risk for patients with creatinine < 2 mg/dL and MELD < 25. Pre-transplant hypernatremia serves as a morbid prognostic indicator for post-transplant morbidity and mortality.

Management of dysnatremias with continuous renal replacement therapy

Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end-stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.

Hyponatraemia and hypernatraemia: Disorders of Water Balance in Neurosurgery

Disorders of tonicity, hyponatraemia and hypernatraemia, are common in neurosurgical patients. Tonicity is sensed by the circumventricular organs while the volume state is sensed by the kidney and peripheral baroreceptors; these two signals are integrated in the hypothalamus. Volume is maintained through the renin-angiotensin-aldosterone axis, while tonicity is defended by arginine vasopressin (antidiuretic hormone) and the thirst response. Edelman found that plasma sodium is dependent on the exchangeable sodium, potassium and free-water in the body. Thus, changes in tonicity must be due to disproportionate flux of these species in and out of the body. Sodium concentration may be measured by flame photometry and indirect, or direct, ion-sensitive electrodes. Only the latter method is not affected by changes in plasma composition. Classification of hyponatraemia by the volume state is imprecise. We compare the tonicity of the urine, given by the sodium potassium sum, to that of the plasma to determine the renal response to the dysnatraemia. We may then assess the activity of the renin-angiotensin-aldosterone axis using urinary sodium and fractional excretion of sodium, urate or urea. Together, with clinical context, these help us determine the aetiology of the dysnatraemia. Symptomatic individuals and those with intracranial catastrophes require prompt treatment and vigilant monitoring. Otherwise, in the absence of hypovolaemia, free-water restriction and correction of any reversible causes should be the mainstay of treatment for hyponatraemia. Hypernatraemia should be corrected with free-water, and concurrent disorders of volume should be addressed. Monitoring for overcorrection of hyponatraemia is necessary to avoid osmotic demyelination.

Approach to the Management of Hypernatraemia in Older Hospitalised Patients

Hypernatraemia is associated with high morbidity and mortality and is more common in patients of older age, nursing home residents and those with cognitive impairment and restricted mobility. The most common cause in hospital settings is water dehydration due to reduced intake although other causes should be identified. Once identified, prompt management is necessary to avoid delayed correction as prolonged hypernatremia is associated with increased hospital stay and mortality. Comprehensive history-taking and physical examination, basic investigations and medication review are essential to identify causative and remediable factors in those admitted with hypernatraemia. Accurate calculation of fluid deficit and ongoing losses is essential in order to ensure adequate fluid replacement, The administration of appropriate, usually hypotonic, fluids is also essential to the timely restoration of eunatraemia. Although evidence of definite harm resulting from rapid correction is lacking, a serum sodium reduction rate of <12 mmol/l day is advised with the caveat that close monitoring of electrolytes is required to ensure the desired correction rate is being achieved. Medical and nursing professionals should have access to a local hospital protocol to guide management of patients with hypernatraemia to improve patient outcomes and mitigate the risk of harm, particularly from under-recognition and slow correction.

Onconephrology: The intersections between the kidney and cancer

Onconephrology is a new subspecialty of nephrology that recognizes the important intersections of kidney disease with cancer. This intersection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, paraneoplastic glomerulonephritis, and the interactions of chronic kidney disease with cancer. Data clearly demonstrate that, when patients with cancer develop acute or chronic kidney disease, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. This highlights the imperative for collaborative care between oncologists and nephrologists in recognizing and treating kidney disease in patients with cancer. In response to this need, specific training programs in onconephrology as well as dedicated onconephrology clinics have appeared. This comprehensive review covers many of the critical topics in onconephrology, with a focus on acute kidney injury, chronic kidney disease, drug-induced nephrotoxicity, kidney disease in stem cell transplantation, and electrolyte disorders in patients with cancer.

Association Between ICU-Acquired Hypernatremia and In-Hospital Mortality: Data From the Medical Information Mart for Intensive Care III and the Electronic ICU Collaborative Research Database

Objectives

Describe the relationship between ICU-acquired hypernatremia and in-hospital mortality and investigate the optimal hypernatremia correction rate.

Design Setting Participants and Measurements

Observational study including two individual ICU cohorts. We used the Medical Information Mart for Intensive Care III v. 1.4 database consists of all ICU patients admitted to the Beth Israel Deaconess Medical Center in Boston from 2001 to 2012 (n = 46,476). The electronic ICU v. 2.0 database consists of all ICU patients admitted to 208 distinct hospitals across the United States from 2014 to 2015 (n = 200,859). We included all adult patients admitted to an ICU with two consecutive sodium samples within normal range (135-145 mmol/L) and without two consecutive hyponatremic samples (< 135 mmol/L) during the ICU stay.

Results

Of 23,445 patients identified in Medical Information Mart for Intensive Care III, 9% (n = 2,172) developed hypernatremia during their ICU stay. In electronic ICU, 88,160 patients were identified and 7% (n = 5,790) developed hypernatremia. In both cohorts, patients with hypernatremia had a higher mortality (Medical Information Mart for Intensive Care III: 20% vs 42%; p < 0.01 and electronic ICU: 6% vs 22%; p < 0.01), with hypernatremia increasing the risk of in-hospital mortality (Medical Information Mart for Intensive Care III: odds ratio, 1.15; 95% CI, 1.13-1.17 and electronic ICU: odds ratio, 1.11; 95% CI, 1.10-1.12) and over time using a Cox regression. Rapid sodium correction rate (> 0.5 mmol/L/hr) was associated with an increased in-hospital mortality in both cohorts (Medical Information Mart for Intensive Care III: odds ratio, 1.08; 95% CI, 1.03-1.13 and electronic ICU: odds ratio, 1.10; 95% CI, 1.06-1.13). In the electronic ICU cohort, rapid correction rates were associated with a significant difference in in-hospital mortality, but there was no statistically significant association in the Medical Information Mart for Intensive Care III cohort.

Conclusions

ICU-acquired hypernatremia is associated with increased in-hospital mortality. Furthermore, a rapid sodium correction rates may be harmful. This suggests it is important to both prevent ICU-acquired hypernatremia and to avoid rapid correction rates if a patient becomes hypernatremic.

Improving on the Adrogué-Madias Formula

The Adrogué-Madias (A-M) formula is correct as written, but technically, it only works when adding 1 L of an intravenous (IV) fluid. For all other volumes, the A-M algorithm gives an approximate answer, one that diverges further from the truth as the IV volume is increased. If 1 L of an IV fluid is calculated to change the serum sodium by some amount, then it was long assumed that giving a fraction of the liter would change the serum sodium by a proportional amount. We challenged that assumption and now prove that the A-M change in [sodium] ([Na]) is not scalable in a linear way. Rather, the Δ[Na] needs to be scaled in a way that accounts for the actual volume of IV fluid being given. This is accomplished by our improved version of the A-M formula in a mathematically rigorous way. Our equation accepts any IV fluid volume, eliminates the illogical infinities, and most importantly, incorporates the scaling step so that it cannot be forgotten. However, the nonlinear scaling makes it harder to obtain a desired Δ[Na]. Therefore, we reversed the equation so that clinicians can enter the desired Δ[Na], keeping the rate of sodium correction safe, and then get an answer in terms of the volume of IV fluid to infuse. The improved equation can also unify the A-M formula with the corollary A-M loss equation wherein 1 L of urine is lost. The method is to treat loss as a negative volume. Because the new equation is just as straightforward as the original formula, we believe that the improved form of A-M is ready for immediate use, alongside frequent [Na] monitoring.

A mathematical approach to severe hyponatremia and hypernatremia in renal replacement therapies

Severe dysnatremias are perplexing problems in patients undergoing renal replacement therapy on a chronic or acute basis. The ability to manipulate sodium concentration in the dialysate or replacement solutions is limited. Compounding dialysate or replacement fluids to alter sodium concentration could result in errors. Rapid correction of hyponatremia or hypernatremia due to equilibrium with dialysate or replacement solutions could lead to osmotic demyelination syndrome or cerebral edema respectively. Continuous renal replacement therapy is the preferred dialysis modality in patients with severe dysnatremias. In this article, we present simple formulas to determine the rate of hypotonic or hypertonic solutions needed to mitigate rapid correction of dysnatremias. These formulas can be used readily by the clinician at bedside.

The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications

In hyperglycemia, hypertonicity results from solute (glucose) gain and loss of water in excess of sodium plus potassium through osmotic diuresis. Patients with stage 5 chronic kidney disease (CKD) and hyperglycemia have minimal or no osmotic diuresis; patients with preserved renal function and diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) have often large osmotic diuresis. Hypertonicity from glucose gain is reversed with normalization of serum glucose ([Glu]); hypertonicity due to osmotic diuresis requires infusion of hypotonic solutions. Prediction of the serum sodium after [Glu] normalization (the corrected [Na]) estimates the part of hypertonicity caused by osmotic diuresis. Theoretical methods calculating the corrected [Na] and clinical reports allowing its calculation were reviewed. Corrected [Na] was computed separately in reports of DKA, HHS and hyperglycemia in CKD stage 5. The theoretical prediction of [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu] in most clinical settings, except in extreme hyperglycemia or profound hypervolemia, was supported by studies of hyperglycemia in CKD stage 5 treated only with insulin. Mean corrected [Na] was 139.0 mmol/L in 772 hyperglycemic episodes in CKD stage 5 patients. In patients with preserved renal function, mean corrected [Na] was within the eunatremic range (141.1 mmol/L) in 7,812 DKA cases, and in the range of severe hypernatremia (160.8 mmol/L) in 755 cases of HHS. However, in DKA corrected [Na] was in the hypernatremic range in several reports and rose during treatment with adverse neurological consequences in other reports. The corrected [Na], computed as [Na] increase by 1.6 mmol/L per 5.6 mmol/L decrease in [Glu], provides a reasonable estimate of the degree of hypertonicity due to losses of hypotonic fluids through osmotic diuresis at presentation of DKH or HHS and should guide the tonicity of replacement solutions. However, the corrected [Na] may change during treatment because of ongoing fluid losses and should be monitored during treatment.

Progression to Severe Hypernatremia in Hospitalized General Medicine Inpatients: An Observational Study of Hospital-Acquired Hypernatremia

Background and objectives: Hypernatremia can be community or hospital-acquired, and there may be specific factors unique to the hospital environment, such as intravenous fluid treatment, which contribute to hypernatremia. The aim of this study was to determine the factors associated with the progression from moderate to severe hospital-acquired hypernatremia among patients admitted under general medicine. Materials and Methods: In this retrospective, single-center cohort study (2012 to 2017), we used ICD-10 coding and medical records to identify adult patients who developed moderate hypernatremia and followed them for progression to severe hypernatremia. We profiled the serum biochemistry and the volume and composition of prescribed intravenous fluids. We applied logistic regression to determine the factors associated with the progression to severe hypernatremia, using the patients with moderate hypernatremia as reference. Results: Of the 180 medical inpatients (median age of 81 years) with moderate hospital-acquired hypernatremia, 9.4% progressed to severe hypernatremia. Normal saline comprised 76% of intravenous fluid volume administered prior to onset of moderate hypernatremia. After the onset, 38% of fluid volume prescribed remained normal saline. The factors independently associated with progression to severe hypernatremia included chronic kidney disease stage (odds ratio 2.38, 95% CI: 1.26-4.50, P = 0.008) and serum creatinine increase (per 10 µmol/L, OR 1.29, 95% CI: 1.07-1.57, P = 0.009). Conclusions: Patients with chronic kidney disease and acute kidney injury may have an increased risk of severe hospital-acquired hypernatremia.

Extremely Severe Hypernatremia Caused by Wrong Belief in a Patient with Cervical Cancer

A 56-year old female patient who was undergoing follow-up for cervical cancer in our oncology center was presented to the emergency center with anxiety and excessive thirst. The initial serum sodium level of the patient exceeded 200mEq/L, rising up to 238mEq/L during hospitalization. The extremely severe hypernatremia was caused by patient's wrong belief that bay salt would cure the cancer. The patient was treated with hypotonic solution and finally with appropriate hydration, she was fully recovered without any neurological complications.

Predictive Factors and Microbial Spectrum for Infectious Complications after Hepatectomy with Cholangiojejunostomy in Perihilar Cholangiocarcinoma

Background: Despite advances in surgical techniques and peri-operative management, post-operative infectious complications still are common after perihilar cholangiocarcinoma (PHCC). This study investigated the predictive factors and microbial spectrum for infections after hepatectomy with cholangiojejunostomy performed to treat PHCC. Methods: A total of 70 consecutive patients, who underwent hepatectomy with cholangiojejunostomy by the same surgeons at a tertiary referral medical center between September 2010 and January 2019, were enrolled. Clinical data were reviewed for multivariable analysis to find independent risk factors for infectious complications. Microorganisms isolated from bile and infection sites were counted to explore the microbial spectrum. Results: A total of 43 patients (61.4%) suffered post-operative infections (33 with surgical site infection [SSI], four with bacteremia, three with pneumonia, 10 with cholangitis, and two with fungus infectious stomatitis), and 28 of them (65.1%) had a positive bile culture. Four independent risk factors were identified: male sex (odds ratio [OR] 12.737; 95% confidence interval [CI] 2.298-70.611; p = 0.004), red blood cell (RBC) count <3.8 × 10¹²/L (OR 5.085; 95% CI 1.279-20.211; p = 0.021), total cholesterol (TC) <2.90 mmol/L (OR 5.715; 95% CI 1.534-21.299; p = 0.009), and serum Na⁺ >145 mmol/L (OR 10.387; 95% CI 1.559-69.201; p = 0.016) on post-operative day (POD) 1. A total of 217 and 196 microorganisms were cultured from 311 and 627 specimens, respectively, collected from pre-/intra-operative bile and possible infection sites. Staphylococcus, Enterococcus, Acinetobacter, Streptococcus, and Escherichia were the most common findings of bile culture. The first five organisms most frequently isolated from infection sites were Enterococcus, Staphylococcus, Klebsiella, Acinetobacter, and Candida. A total of 18 patients (64.3%) had at least one species isolated from infection sites that had appeared in a previous bile culture. Conclusions: Male sex, erythrocytopenia, hypocholesterolemia, and hypernatremia on POD 1 are independent risk factors for infectious complications. For patients without positive bile cultures, third-generation cephalosporins could be considered as the prophylactic antibiotic. It is important to monitor the pathogens throughout the hospital stay.