Hypernatremia

Ion-Mediated Structural Discontinuities in Phospholipid Vesicles

Despite intense research, methods for controlling soft matter's spontaneous self-assembly into well-defined layers remain a significant challenge. We observed ion-induced structural discontinuities of phospholipid vesicles that can be exploited for controlled self-assembly of soft materials, using DOPC and NaCl as a model system. The observations were made for the 0.25 wt % lipid concentration. We used dynamic light scattering, zeta-potential measurement, cryo-electron microscopy, small-angle X-ray, and small-angle neutron scattering to understand the reason for the discontinuities. For salt concentrations below 8 mM, we observed a decrease in the liposome diameter with increased NaCl concentration. Above 8 mM, we measured a discontinuity; the radius increases within a very narrow salt concentration range within less than 0.1 mM and then decreases for values greater than 8 mM. At 75 mM, the radius becomes constant until it grows again at around 500 mM. Microscopy and scattering experiments show a transition from unilamellar to bilamellar at 8 mM and to trilamellar at 75 mM. At 500 mM, we found a heterogeneous liposome system with many different bilayer numbers. All the experimental observations indicate that declining solvent quality and increasing osmotic pressure direct lipids to expel preferentially to the inner compartment. Upon reaching a critical concentration, excess lipids can form a new bilayer. This spontaneous self-assembly process causes simultaneous shrinkage of the aqueous core and expansion of the vesicle. This approach opens an intriguing path for controlling the self-assembly of bioinspired colloids.

Microalgae-Based Disinfectant Formulation for Aseptic Processing of Ethiopian Ingredient-Sourced Functional Bread and Its Molecular Docking Analysis to Reduce Hypernatremia

The global prevalence of food-borne infections has become a major concern. Food-borne pathogens like Campylobacter jejuni, Salmonella enterica, and Clostridium botulinum cause food poisoning and even mortality, necessitating the maintenance of aseptic conditions during food processing. The sterilization of food processing facilities often requires chemical and heat treatment. The formulation of many chemical-based disinfectants includes chemicals generating toxic and carcinogenic by-products. The microalgae like Chlorella spp. reportedly exhibit antimicrobial activity and therefore, can be used for formulating safer and eco-friendly natural sanitizers. This study aims to aseptically prepare functional bread using Ethiopian ingredients, highlighting the application of microalgae-based disinfectant formulation and various disinfection techniques. The functional bread was designed to be potentially effective in reducing hypernatremia condition which is indicative of high levels of sodium in serum that can cause an array of symptoms including deaths in serious cases. The physico-chemical and sensory properties of the designed functional bread were analyzed. The interaction of phytochemicals in the ingredients with the target receptor (Vasopressin V2 receptor) and their drug-likeness were determined using molecular docking and Lipinski's rule of five analyses. The results suggest that the designed functional bread incorporating Ethiopian ingredients may serve as an effective dietary strategy to prevent hypernatremia. Aseptic processing of the bread ensures longer shelf life and prevention of spoilage by food pathogens.

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.

[Dysnatremia]

Changes in serum sodium concentrations are frequently encountered by anesthesiologists, are complex and are often inadequately treated. Feared consequences include neurological complications, such as cerebral hemorrhage, cerebral edema and coma. Dysnatremia is always accompanied disturbances in the water balance. Accordingly, these are routinely classified based on the tonicity; however, in the daily routine and especially in the acute setting, the volume status and extracellular volume are often difficult to assess. Severe symptomatic hyponatremia with impending cerebral edema is treated by administration of hypertonic saline solution. If the rise in serum sodium is too rapid, there is a risk of central pontine myelinolysis. In a second step, the cause of the hyponatremia can be investigated and the appropriate treatment can be initiated. In the case of hypernatremia, the etiology of the disorder must be clarified before treatment. The goal is to compensate for the water deficiency by correcting the cause, specific volume therapy and, if necessary, drug support. A slow and controlled compensation must be closely monitored in order to avoid neurological complications. An algorithm has been developed that provides an overview of the dysnatremias, aids with making the diagnosis and gives recommendations for treatment measures in the clinical routine.

Severe hypernatremia in hyperglycemic conditions; managing it effectively: A case report

BACKGROUND

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are common acute complications of diabetes mellitus with a high risk of mortality. When combined with hypernatremia, the complications can be even worse. Hypernatremia is a rarely associated with DKA and HHS as both are usually accompanied by normal sodium or hyponatremia. As a result, a structured and systematic treatment approach is critical. We discuss the therapeutic approach and implications of this uncommon presentation.

CASE SUMMARY

A 62-year-old man with no known past medical history presented to emergency department with altered mental status. Initial work up in emergency room showed severe hyperglycemia with a glucose level of 1093 mg/dL and severe hypernatremia with a serum sodium level of 169 mEq/L. He was admitted to the intensive care unit (ICU) and was started on insulin drip as per DKA protocol. Within 12 h of ICU admission, blood sugar was 300 mg/dL. But his mental status didn’t show much improvement. He was dehydrated and had a corrected serum sodium level of > 190 mEq/L. As a result, dextrose 5% in water and ringer's lactate were started. He was also given free water via an nasogastric (NG) tube and IV Desmopressin to improve his free water deficit, which improved his serum sodium to 140 mEq/L.

CONCLUSION

The combination of DKA, HHS and hypernatremia is rare and extremely challenging to manage, but the most challenging part of this condition is selecting the correct type of fluids to treat these conditions. Our case illustrates that desmopressin and free water administration via the NG route can be helpful in this situation.

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.

Treatment of hyponatremia in children with acute bacterial meningitis

Purpose

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

Methods

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

Results

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

Conclusion

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

Relationship Between Initial Urine Output and Mortality in Patients Hospitalized in Cardiovascular Intensive Care Units: More Is Not Better

Backgrounds

Decreased urine output (UO) is associated with adverse outcomes in certain patients, but this effect in patients admitted for cardiovascular diseases is still unproven. Moreover, the relationship between increased UO and prognosis is also unclear.

Objective

To investigate the relationship between decreased or increased UO and outcomes in patients with the cardiovascular intensive care unit (CICU).

Methods

This study was a retrospective cohort analysis based on the medical information mart for intensive care III (MIMIC-III) database. The patients' data were extracted from the Beth Israel Deaconess Medical Center (Boston, MA) between 2001 and 2012. With the initial 24-h UO range from 0.5 to 1.0 ml/kg/h as the reference, participants were divided into the several groups. The primary outcome was 30-day mortality. The secondary outcomes were 90-day mortality, ICU mortality, hospital mortality, use of mechanical ventilation (MV), and vasopressor agents in the first 24-h of ICU. The association between UO and mortality was assessed by multivariable logistic regression.

Results

A total of 13,279 patients admitted to CICU were included. Low UO (< 0.5 ml/kg/h) was strongly associated with 30-day mortality (unadjusted OR = 3.993, 95% CI: 3.447–4.625, p < 0.001), and very high UO (≥ 2.0 ml/kg/h) was also a significantly risk factor for 30-day mortality (Unadjusted OR = 2.069, 95% CI: 1.701–2.516, p < 0.001) compared with the reference. The same effects also were shown in the multivariable logistic regression, adjusted by age, gender, vital signs, common comorbidities, and use of diuretics, with an adjusted OR of 2.023 (95% CI: 1.693–2.417, p < 0.001) for low UO and 1.771 (95% CI: 1.389–2.256, p < 0.001) for very high UO. Moreover, both decreased UO and increased UO were risk factors for 90-day mortality, ICU mortality, hospital mortality, use of MV and vasopressor agents.

Conclusion

The decreased and increased UO both were significantly associated with short-term mortality, the relationship between UO and mortality was U-shape rather than linear.

Hypernatremia During Intravenous Treatment With Fosfomycin: A Retrospective Medical Record Review Study and an Analysis of Spontaneous Reports in the EudraVigilance Database

Background: Hypernatremia is a serious event that can occur during intravenous (IV) treatment with fosfomycin, and it can also be caused by a wrong drug preparation. Considering the clinical significance of hypernatremia, we decided to carry out two studies by using two different data sources with the aim to evaluate cases of IV fosfomycin-induced hypernatremia.

Methods: A retrospective medical record review was performed from June 2017 to June 2019 using data from two hospitals in Southern Italy. The information collected was related to the patients, the antibiotic treatment regimen, type of adverse drug reaction (ADR), hypernatremia severity classification, and drug withdrawal due to ADRs. Moreover, a pharmacovigilance study was performed from the date of the European marketing authorization of fosfomycin to October 11, 2021, using data reported on the European website of suspected ADRs. Information related to the patient characteristics, treatment, hypernatremia, and type of reporter was retrieved.

Results: From the retrospective medical record review, a total of 62 patients (48 men and 14 women) in treatment with fosfomycin were identified, of which 17 experienced ADRs. Specifically, 11 patients experienced hypernatremia. During the period from June 2017 to June 2018, a total of 63.7% of hypernatremia events were related to the wrong reconstitution of the drug. According to these results, a surveillance and training campaign about the correct drug reconstitution was managed. However, from June 2018 to June 2019, we still had four new hypernatremia cases. Drug withdrawal occurred in only one patient with hypernatremia. From the pharmacovigilance study, a total of 25 cases of IV fosfomycin-induced hypernatremia were retrieved. No substantial difference was found for patients’ distribution by sex. Most cases were classified as serious (68%) and reported “Recovered/resolved” as the outcome (44%). In the majority of cases, fosfomycin was the only suspected drug reported (72%).

Conclusion: Our results show that training campaigns on the correct drug preparation need to be strengthened to allow a reduction of hypernatremia cases. Moreover, when close monitoring and management is performed by the infectious disease (ID) specialist and hospital pharmacist, there also is a reduction in antibiotic withdrawal due to hypernatremia.

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

Hypernatremia at a Tertiary Hospital Intensive Care Unit in South Africa

Background

Hypernatremia in the critical care setting is a major cause of morbidity and mortality. However, data pertaining to this has not been evaluated in South African hospitals. The aim of this study was to evaluate hypernatremia with regards to its prevalence, associated factors, and outcomes at an academic hospital intensive care unit (ICU) in Johannesburg, South Africa.

Methods

The ICU charts of patients admitted to the Charlotte Maxeke Johannesburg Academic Hospital adult general ICU from June 1, 2016 to May 31, 2017 were retrospectively reviewed. Subjects were categorized into three groups namely, ICU-acquired hypernatremia (IAH), pre-admission hypernatremia (PAH), and normonatremia. Data was compared between the three groups.

Results

Of the 833 subjects that were enrolled, 310 (37.2%) were hypernatremic. IAH was present in 144 (17.2%) and PAH in 166 (19.9%) subjects. Hypernatremia was significantly (p <0.05) associated with a higher rate of altered mental status, higher Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II) scores, a higher rate and duration of mechanical ventilation, a greater need for inotropic/vasopressor support, longer ICU stay and higher ICU mortality.

Conclusion

Hypernatremia in ICU patients remains a significant contributor to morbidity, mortality, and ICU length of stay. The prevalence of hypernatremia was much higher than that reported in higher-income countries.

Comparative quantitation of aquaporin-2 and arginine vasopressin receptor-2 localizations among chronic kidney disease and healthy kidney in dogs

BACKGROUND AND AIM

Aquaporin-2 (AQP2) and arginine vasopressin receptor-2 (AVPR2) are proteins that control water homeostasis in principal cells. Chronic kidney disease (CKD) is defined as the impairment and irreversible loss of kidney function and/or structure, which causes water imbalances and polyuria. The study aimed to know the expression of AQPs and AVPR2 in the kidneys of a canine with CKD.

MATERIALS AND METHODS

The kidneys were collected from two dog carcasses from Small Animal Teaching Hospital, Faculty of Veterinary Medicine, Chiang Mai University. The kidney tissue was prepared for immunohistochemistry and investigated the expression and localization of tissue's AQP2 and AVPR2. For statistical analysis, the Mann-Whitney U-test was applied to the data.

RESULTS

By immunohistochemistry, AQP2 was expressed strongly in the basolateral and apical membranes of the principal cells, whereas AVPR2 was localized in the principal cell's basolateral membrane in both renal cortex and renal medulla. In the normal kidney, the semi-quantitative immunohistochemistry for the percentage of protein expression of AQP2 and AVPR2 was 5.062±0.4587 and 4.306±0.7695, respectively. In contrast, protein expression of AQP2 and AVPR2 in CKD was found to be 1.218±0.1719 and 0.8536±0.1396, respectively. The data shows that the percentage of AQP2 and AVPR2 expression was decreased, corresponding to a 4-fold and 5-fold in CKD (p<0.001).

CONCLUSION

Our findings revealed that CKD was a marked decrease in AQP2 and AVPR2 expression. The central role of specific AQP2 and AVPR2 in regulating water homeostasis will provide correlations in case of CKD with polyuria.

Hypernatremia Risk Factors And Prognostic Impact In Burn Patients: A Case Control Study

Hypernatremia is associated with poor outcomes in critically ill patients. Hypernatremia risk factors in burned patients are not well studied. We aimed to identify hypernatremia risk factors and to evaluate outcomes in burned patients admitted to our burns intensive care unit. A case control study was conducted in adult burned patients hospitalized between January 1st 2017 and December 31st 2019. Cases who developed hypernatremia (>145 meq/L) during hospitalization were matched 1:1 with controls based on age and total burn surface area. There were 57 cases and 57 controls with a mean age of 41 ± 18 years. The majority of patients had major burns (n=99, 86.8%). The time onset of hypernatremia was seven days post burn. Compared to controls, the case group mostly consisted of transferred patients with longer time from injury to intensive care unit admission. Inhalation injury, mechanical ventilation, intravenous fosfomycin and colistin were associated with hypernatremia. Admission to the intensive care unit after six hours post-burn was the independent risk factor (OR=4.5). Hypernatremia was associated with longer length of stay and with higher mortality. We conclude that delayed management, inhalation injury, mechanical ventilation, fosfomycin and colistin administration are the main hypernatremia risk factors in burned patients.

Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review

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.