1
|
Wagner B, Ing TS, Roumelioti ME, Sam R, Argyropoulos CP, Lew SQ, Unruh ML, Dorin RI, Degnan JH, Tzamaloukas AH. Hypernatremia in Hyperglycemia: Clinical Features and Relationship to Fractional Changes in Body Water and Monovalent Cations during Its Development. J Clin Med 2024; 13:1957. [PMID: 38610721 PMCID: PMC11012913 DOI: 10.3390/jcm13071957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/14/2024] Open
Abstract
In hyperglycemia, the serum sodium concentration ([Na]S) receives influences from (a) the fluid exit from the intracellular compartment and thirst, which cause [Na]S decreases; (b) osmotic diuresis with sums of the urinary sodium plus potassium concentration lower than the baseline euglycemic [Na]S, which results in a [Na]S increase; and (c), in some cases, gains or losses of fluid, sodium, and potassium through the gastrointestinal tract, the respiratory tract, and the skin. Hyperglycemic patients with hypernatremia have large deficits of body water and usually hypovolemia and develop severe clinical manifestations and significant mortality. To assist with the correction of both the severe dehydration and the hypovolemia, we developed formulas computing the fractional losses of the body water and monovalent cations in hyperglycemia. The formulas estimate varying losses between patients with the same serum glucose concentration ([Glu]S) and [Na]S but with different sums of monovalent cation concentrations in the lost fluids. Among subjects with the same [Glu]S and [Na]S, those with higher monovalent cation concentrations in the fluids lost have higher fractional losses of body water. The sum of the monovalent cation concentrations in the lost fluids should be considered when computing the volume and composition of the fluid replacement for hyperglycemic syndromes.
Collapse
Affiliation(s)
- Brent Wagner
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
- Kidney Institute of New Mexico, University of New Mexico Health Sciences Center, Albuquerque, NM 87122, USA
- Raymond G. Murphy Veterans Affairs Medical Center, Albuquerque, NM 87108, USA
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL 60153, USA
| | - Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital, University of California in San Francisco School of Medicine, San Francisco, CA 94110, USA;
| | - Christos P. Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA; (B.W.); (M.-E.R.); (C.P.A.)
| | - Susie Q. Lew
- Department of Medicine, School of Medicine and Health Sciences, George Washington University, Washington, DC 20037, USA;
| | - Mark L. Unruh
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87122, USA;
| | - Richard I. Dorin
- Department of Medicine, Division of Endocrinology, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico, Albuquerque, NM 87108, USA;
| | - James H. Degnan
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM 87131, USA;
| | - Antonios H. Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM 87108, USA
| |
Collapse
|
2
|
Paarvanova B, Tacheva B, Savova G, Karabaliev M, Georgieva R. Hemolysis by Saponin Is Accelerated at Hypertonic Conditions. Molecules 2023; 28:7096. [PMID: 37894578 PMCID: PMC10609376 DOI: 10.3390/molecules28207096] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/06/2023] [Accepted: 10/12/2023] [Indexed: 10/29/2023] Open
Abstract
Saponins are a large group of organic amphiphilic substances (surfactants) mainly extracted from herbs with biological activity, considered as one of the main ingredients in numerous remedies used in traditional medicine since ancient times. Anti-inflammatory, antifungal, antibacterial, antiviral, antiparasitic, antitumor, antioxidant and many other properties have been confirmed for some. There is increasing interest in the elucidation of the mechanisms behind the effects of saponins on different cell types at the molecular level. In this regard, erythrocytes are a very welcome model, having very simple structures with no organelles. They react to changing external conditions and substances by changing shape or volume, with damage to their membrane ultimately leading to hemolysis. Hemolysis can be followed spectrophotometrically and provides valuable information about the type and extent of membrane damage. We investigated hemolysis of erythrocytes induced by various saponin concentrations in hypotonic, isotonic and hypertonic media using measurements of real time and end-point hemolysis. The osmotic pressure was adjusted by different concentrations of NaCl, manitol or a NaCl/manitol mixture. Unexpectedly, at a fixed saponin concentration, hemolysis was accelerated at hypertonic conditions, but was much faster in NaCl compared to mannitol solutions at the same osmotic pressure. These findings confirm the colloid-osmotic mechanism behind saponin hemolysis with pore formation with increasing size in the membrane.
Collapse
Affiliation(s)
- Boyana Paarvanova
- Department of Physics and Biophysics, Faculty of Medicine, Trakia University, 11 Armeiska, 6000 Stara Zagora, Bulgaria
| | - Bilyana Tacheva
- Department of Physics and Biophysics, Faculty of Medicine, Trakia University, 11 Armeiska, 6000 Stara Zagora, Bulgaria
| | - Gergana Savova
- Department of Physics and Biophysics, Faculty of Medicine, Trakia University, 11 Armeiska, 6000 Stara Zagora, Bulgaria
| | - Miroslav Karabaliev
- Department of Physics and Biophysics, Faculty of Medicine, Trakia University, 11 Armeiska, 6000 Stara Zagora, Bulgaria
| | - Radostina Georgieva
- Department of Physics and Biophysics, Faculty of Medicine, Trakia University, 11 Armeiska, 6000 Stara Zagora, Bulgaria
- Institute of Transfusion Medicine, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| |
Collapse
|
3
|
Büyükkaragöz B, Bakkaloğlu SA. Serum osmolality and hyperosmolar states. Pediatr Nephrol 2023; 38:1013-1025. [PMID: 35779183 DOI: 10.1007/s00467-022-05668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/26/2022] [Accepted: 06/14/2022] [Indexed: 11/26/2022]
Abstract
Serum osmolality is the sum of the osmolalities of every single dissolved particle in the blood such as sodium and associated anions, potassium, glucose, and urea. Under normal conditions, serum sodium concentration is the major determinant of serum osmolality. Effective blood osmolality, so-called blood tonicity, is created by the endogenous (e.g., sodium and glucose) and exogenous (e.g., mannitol) solutes that are capable of creating an osmotic gradient across the membranes. In case of change in effective blood osmolality, water shifts from the compartment with low osmolality into the compartment with high osmolarity in order to restore serum osmolality. The difference between measured osmolality and calculated osmolarity forms the osmolal gap. An increase in serum osmolal gap can stem from the presence of solutes that are not included in the osmolarity calculation, such as hypertonic treatments or toxic alcoholic ingestions. In clinical practice, determination of serum osmolality and osmolal gap is important in the diagnosis of disorders related to sodium, glucose and water balance, kidney diseases, and small molecule poisonings. As blood hypertonicity exerts its main effects on the brain cells, neurologic symptoms varying from mild neurologic signs and symptoms to life-threatening outcomes such as convulsions or even death may occur. Therefore, hypertonic states should be promptly diagnosed and cautiously managed. In this review, the causes and treatment strategies of hyperosmolar conditions including hypernatremia, diabetic ketoacidosis, hyperglycemic hyperosmolar syndrome, hypertonic treatments, or intoxications are discussed in detail to increase awareness of this important topic with significant clinical consequences.
Collapse
Affiliation(s)
- Bahar Büyükkaragöz
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey.
| | - Sevcan A Bakkaloğlu
- Department of Pediatric Nephrology, Gazi University, 06560, Besevler, Ankara, Turkey
| |
Collapse
|
4
|
Rohrscheib M, Sam R, Raj DS, Argyropoulos CP, Unruh ML, Lew SQ, Ing TS, Levin NW, Tzamaloukas AH. Edelman Revisited: Concepts, Achievements, and Challenges. Front Med (Lausanne) 2022; 8:808765. [PMID: 35083255 PMCID: PMC8784663 DOI: 10.3389/fmed.2021.808765] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
The key message from the 1958 Edelman study states that combinations of external gains or losses of sodium, potassium and water leading to an increase of the fraction (total body sodium plus total body potassium) over total body water will raise the serum sodium concentration ([Na]S), while external gains or losses leading to a decrease in this fraction will lower [Na]S. A variety of studies have supported this concept and current quantitative methods for correcting dysnatremias, including formulas calculating the volume of saline needed for a change in [Na]S are based on it. Not accounting for external losses of sodium, potassium and water during treatment and faulty values for body water inserted in the formulas predicting the change in [Na]S affect the accuracy of these formulas. Newly described factors potentially affecting the change in [Na]S during treatment of dysnatremias include the following: (a) exchanges during development or correction of dysnatremias between osmotically inactive sodium stored in tissues and osmotically active sodium in solution in body fluids; (b) chemical binding of part of body water to macromolecules which would decrease the amount of body water available for osmotic exchanges; and (c) genetic influences on the determination of sodium concentration in body fluids. The effects of these newer developments on the methods of treatment of dysnatremias are not well-established and will need extensive studying. Currently, monitoring of serum sodium concentration remains a critical step during treatment of dysnatremias.
Collapse
Affiliation(s)
- Mark Rohrscheib
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Ramin Sam
- Department of Medicine, Zuckerberg San Francisco General Hospital and Trauma Center, University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Dominic S Raj
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Christos P Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Mark L Unruh
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Nathan W Levin
- Mount Sinai Icahn School of Medicine, New York, NY, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center and University of New Mexico School of Medicine, Albuquerque, NM, United States
| |
Collapse
|
5
|
Arzhan S, Lew SQ, Ing TS, Tzamaloukas AH, Unruh ML. Dysnatremias in Chronic Kidney Disease: Pathophysiology, Manifestations, and Treatment. Front Med (Lausanne) 2021; 8:769287. [PMID: 34938749 PMCID: PMC8687113 DOI: 10.3389/fmed.2021.769287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/04/2021] [Indexed: 12/29/2022] Open
Abstract
The decreased ability of the kidney to regulate water and monovalent cation excretion predisposes patients with chronic kidney disease (CKD) to dysnatremias. In this report, we describe the clinical associations and methods of management of dysnatremias in this patient population by reviewing publications on hyponatremia and hypernatremia in patients with CKD not on dialysis, and those on maintenance hemodialysis or peritoneal dialysis. The prevalence of both hyponatremia and hypernatremia has been reported to be higher in patients with CKD than in the general population. Certain features of the studies analyzed, such as variation in the cut-off values of serum sodium concentration ([Na]) that define hyponatremia or hypernatremia, create comparison difficulties. Dysnatremias in patients with CKD are associated with adverse clinical conditions and mortality. Currently, investigation and treatment of dysnatremias in patients with CKD should follow clinical judgment and the guidelines for the general population. Whether azotemia allows different rates of correction of [Na] in patients with hyponatremic CKD and the methodology and outcomes of treatment of dysnatremias by renal replacement methods require further investigation. In conclusion, dysnatremias occur frequently and are associated with various comorbidities and mortality in patients with CKD. Knowledge gaps in their treatment and prevention call for further studies.
Collapse
Affiliation(s)
- Soraya Arzhan
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Susie Q. Lew
- Department of Medicine, George Washington University, Washington, DC, United States
| | - Todd S. Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - Antonios H. Tzamaloukas
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Research Service, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
| | - Mark L. Unruh
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
- Medicine Service, Division of Nephrology, Raymond G. Murphy Veteran Affairs (VA) Medical Center, Albuquerque, NM, United States
| |
Collapse
|
6
|
Koç Ş. A possible follow-up method for diabetic heart failure patients. Int J Clin Pract 2021; 75:e14794. [PMID: 34482595 DOI: 10.1111/ijcp.14794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Plasma osmolarity is maintained through various mechanisms. The osmolarity of the aqueous humor around the crystalline lens is correlated with plasma osmolarity. A vacuole can be formed in the lens upon changes in osmolarity. The sodium-glucose cotransporter 2 inhibitors (SGLT2i) are new in the treatment of heart failure. They can cause osmotic diuresis but do not affect plasma osmolarity. OBJECTIVE It is unclear if the presence or absence of lens vacuole changes can monitor diabetic heart failure and SGLT2i treatment efficacy. METHODS Web of Science, PubMed and Scopus databases were searched for relevant articles about osmolarity, diabetes, transient receptor potential vanilloid channel, diabetic heart failure, lens vacuoles up to May 2021. MAIN MESSAGE The effect of SGLT2i on osmosis underlies its benefit to heart failure, but this in turn affects many other mechanisms. Failure to experience osmolarity changes will reduce the negative changes in terms of heart failure affected by osmolarity. A practical observable method is needed. CONCLUSIONS There is a possibility of using lens vacuoles in the follow-up of diabetic heart failure patients.
Collapse
Affiliation(s)
- Şahbender Koç
- University of Health Sciences, Keçiören Education and Training Hospital, Ankara, Turkey
| |
Collapse
|
7
|
Sugar, Sodium, and Water: A Recipe for Disaster. Ann Am Thorac Soc 2021; 17:1016-1020. [PMID: 32735168 DOI: 10.1513/annalsats.202004-360cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
8
|
Fernandez Martinez A, Barajas Galindo D, Ruiz Sanchez J. Management of hyponatraemia and hypernatraemia during the Covid-19 pandemic: a consensus statement of the Spanish Society for Endocrinology (Acqua Neuroendocrinology Group). Rev Endocr Metab Disord 2021; 22:317-324. [PMID: 33547563 PMCID: PMC7864617 DOI: 10.1007/s11154-021-09627-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2021] [Indexed: 02/01/2023]
Abstract
SARS-COV2 infection has swiftly become a pandemic disease of historic relevance and widely variable outcomes. This variable prognosis is related both to uneven damage, among others, to lungs, heart and kidneys, and to a multisystemic inflammatory reaction. All these factors are known to disrupt water balance and potentially induce hyponatraemia or hypernatraemia. Water balance disorders are known mortality and morbidity risk factors in several clinical scenarios and their proper management, though often complex and hazardous, can reduce mortality and length of hospitalization. Clinical uncertainty over COVID-19 outcome, the variety of organs involved in both the infection and water balance and difficulties in clinical examination due to risk of contagion might obstruct proper management of dysnatremic disorders. Thus, the Acqua Neuroendocrinology Group of the Spanish Society for Endocrinology (SEEN) has endeavoured to provide evidence and expert based recommendations on the management of hyponatraemia and hypernatraemia in COVID-19 patients.
Collapse
|
9
|
Ing TS, Ganta K, Bhave G, Lew SQ, Agaba EI, Argyropoulos C, Tzamaloukas AH. The Corrected Serum Sodium Concentration in Hyperglycemic Crises: Computation and Clinical Applications. Front Med (Lausanne) 2020; 7:477. [PMID: 32984372 PMCID: PMC7479837 DOI: 10.3389/fmed.2020.00477] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Todd S Ing
- Department of Medicine, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, United States
| | - Kavitha Ganta
- Medicine Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Gautam Bhave
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Susie Q Lew
- Department of Medicine, George Washington University School of Medicine, Washington, DC, United States
| | | | - Christos Argyropoulos
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM, United States
| | - Antonios H Tzamaloukas
- Research Service, Department of Medicine, Raymond G. Murphy Veterans Affairs Medical Center, University of New Mexico School of Medicine, Albuquerque, NM, United States
| |
Collapse
|
10
|
Leong XF, Cheng M, Jong B, Hwang NC, Roscoe A. Sodium Abnormalities in Cardiac Surgery With Cardiopulmonary Bypass in Adults: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3374-3384. [PMID: 32888797 DOI: 10.1053/j.jvca.2020.07.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 11/11/2022]
Abstract
Perioperative sodium abnormalities or dysnatremia is not uncommon in patients presenting for cardiac surgery and is associated with increased morbidity and mortality. Both the disease process of heart failure and its treatment may contribute to abnormalities in serum sodium concentration. Serum sodium is the main determinant of serum osmolality, which in turn affects cell volume. Brain cells are particularly vulnerable to changes in serum osmolality because of the nondistensible cranium. The potentially catastrophic neurologic sequelae of rapidly correcting chronic dysnatremia and the time-sensitive nature of cardiac surgery can make the management of these patients challenging. The use of cardiopulmonary bypass to facilitate surgery adds another layer of complexity in the intraoperative management of sodium and water balance. This narrative review examines the definition and classification of dysnatremia. It also covers the etiology and pathophysiology of dysnatremia, implications during cardiac surgery requiring cardiopulmonary bypass, and the perioperative management of dysnatremia.
Collapse
Affiliation(s)
- Xin Fang Leong
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Maureen Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Bronte Jong
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Nian Chih Hwang
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore
| | - Andrew Roscoe
- Department of Anaesthesiology, Singapore General Hospital, Singapore; Department of Cardiothoracic Anaesthesia, National Heart Centre, Singapore.
| |
Collapse
|
11
|
Yang J, Zhang H, Sun S, Wang X, Guan Y, Mi Q, Zeng W, Xiang H, Zhu H, Zou X, You Y, Xiang Y, Gao Q. Autophagy and Hsp70 activation alleviate oral epithelial cell death induced by food-derived hypertonicity. Cell Stress Chaperones 2020; 25:253-264. [PMID: 31975220 PMCID: PMC7058754 DOI: 10.1007/s12192-020-01068-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 12/12/2019] [Accepted: 01/06/2020] [Indexed: 01/16/2023] Open
Abstract
Stable intracellular and intercellular osmolarity is vital for all physiological processes. Although it is the first organ that receives food, the osmolarity around the mouth epithelium has never been systematically investigated. We found that oral epithelial cells are a population of ignored cells routinely exposed to hypertonic environments mainly composed of saline, glucose, etc. in vivo after chewing food. By using cultured oral epithelial cells as an in vitro model, we found that the hypotonic environments caused by both high NaCl and high glucose induced cell death in a dose- and time-dependent manner. Transcriptomics revealed similar expression profiles after high NaCl and high glucose stimulation. Most of the common differentially expressed genes were enriched in "mitophagy" and "autophagy" according to KEGG pathway enrichment analysis. Hypertonic stimulation for 1 to 6 h resulted in autophagosome formation. The activation of autophagy protected cells from high osmolarity-induced cell death. The activation of Hsp70 by the pharmacological activator handelin significantly improved the cell survival rate after hypertonic stimulation. The protective role of Hsp70 activation was partially dependent on autophagy activation, indicating a crosstalk between Hsp70 and autophagy in hypertonic stress response. The extract of the handelin-containing herb Chrysanthemum indicum significantly protected oral epithelial cells from hypertonic-induced death, providing an inexpensive way to protect against hypertonic-induced oral epithelial damage. In conclusion, the present study emphasized the importance of changes in osmolarity in oral health for the first time. The identification of novel compounds or herbal plant extracts that can activate autophagy or HSPs may contribute to oral health and the food industry.
Collapse
Affiliation(s)
- Ji Yang
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China
| | - Huijie Zhang
- Key Laboratory of Human Aging in Jiangxi Province, Human Aging Research Institute, Nanchang University, No. 999 Xuefu Road, Nanchang, 330031, China
| | - Sujiao Sun
- Medical Cosmetology Teaching and Research Section, School of Clinical Medicine, Dali University, No.32 Jiashibo Road, Dali, 532901, China
| | - Xue Wang
- School of Pharmaceutical Science &Yunnan Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, No. 1168 West Chunrong Road, Kunming, 650504, China
| | - Ying Guan
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China
| | - Qili Mi
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China
| | - Wanli Zeng
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China
| | - Haiying Xiang
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China
| | - Huadong Zhu
- Key Laboratory of Human Aging in Jiangxi Province, Human Aging Research Institute, Nanchang University, No. 999 Xuefu Road, Nanchang, 330031, China
| | - Xin Zou
- Key Laboratory of Human Aging in Jiangxi Province, Human Aging Research Institute, Nanchang University, No. 999 Xuefu Road, Nanchang, 330031, China
| | - Yunfei You
- Key Laboratory of Human Aging in Jiangxi Province, Human Aging Research Institute, Nanchang University, No. 999 Xuefu Road, Nanchang, 330031, China
| | - Yang Xiang
- Key Laboratory of Human Aging in Jiangxi Province, Human Aging Research Institute, Nanchang University, No. 999 Xuefu Road, Nanchang, 330031, China.
| | - Qian Gao
- Technology Center of China Tobacco Yunnan Industrial Co. Ltd., No. 41 Keyi Road, Kunming, 650106, China.
| |
Collapse
|
12
|
Dialysis-associated hyperglycemia: manifestations and treatment. Int Urol Nephrol 2020; 52:505-517. [PMID: 31955362 DOI: 10.1007/s11255-019-02373-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 12/23/2019] [Indexed: 12/15/2022]
Abstract
PURPOSE Dialysis-associated hyperglycemia (DAH), is associated with a distinct fluid and electrolyte pathophysiology. The purpose of this report was to review the pathophysiology and provide treatment guidelines for DAH. METHODS Review of published reports on DAH. Synthesis of guidelines based on these reports. RESULTS The following fluid and solute abnormalities have been identified in DAH: (a) hypoglycemia: this is a frequent complication of insulin treatment and its prevention requires special attention. (b) Elevated serum tonicity. The degree of hypertonicity in DAH is lower than in similar levels of hyperglycemia in patients with preserved renal function. Typically, correction of hyperglycemia with insulin corrects the hypertonicity of DAH. (c) Extracellular volume abnormalities ranging from pulmonary edema associated with osmotic fluid shift from the intracellular into the extracellular compartment as a consequence of gain in extracellular solute (glucose) to hypovolemia from osmotic diuresis in patients with residual renal function or from fluid losses through extrarenal routes. Correction of DAH by insulin infusion reverses the osmotic fluid transfer between the intracellular and extracellular compartments and corrects the pulmonary edema, but can worsen the manifestations of hypovolemia, which require saline infusion. (d) A variety of acid-base disorders including ketoacidosis correctable with insulin infusion and no other interventions. (e) Hyperkalemia, which is frequent in DAH and is more severe when ketoacidosis is also present. Insulin infusion corrects the hyperkalemia. Extreme hyperkalemia at presentation or hypokalemia developing during insulin infusion require additional measures. CONCLUSIONS In DAH, insulin infusion is the primary management strategy and corrects the fluid and electrolyte abnormalities. Patients treated for DAH should be monitored for the development of hypoglycemia or fluid and electrolyte abnormalities that may require additional treatments.
Collapse
|
13
|
Tzamaloukas AH, Khitan ZJ, Glew RH, Roumelioti ME, Rondon-Berrios H, Elisaf MS, Raj DS, Owen J, Sun Y, Siamopoulos KC, Rohrscheib M, Ing TS, Murata GH, Shapiro JI, Malhotra D. Serum Sodium Concentration and Tonicity in Hyperglycemic Crises: Major Influences and Treatment Implications. J Am Heart Assoc 2019; 8:e011786. [PMID: 31549572 PMCID: PMC6806024 DOI: 10.1161/jaha.118.011786] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Antonios H Tzamaloukas
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | - Zeid J Khitan
- Joan C. Edwards School of Medicine Marshall University Huntington WV
| | - Robert H Glew
- University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Moses S Elisaf
- University of Ioannina School of Medicine Ioannina Greece
| | - Dominic S Raj
- George Washington University School of Medicine Washington DC
| | - Jonathan Owen
- University of New Mexico School of Medicine Albuquerque NM
| | - Yijuan Sun
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM.,University of New Mexico School of Medicine Albuquerque NM
| | | | | | - Todd S Ing
- Stritch School of Medicine Loyola University Chicago Maywood IL
| | - Glen H Murata
- Raymond G. Murphy Veterans Affairs Medical Center Albuquerque NM
| | - Joseph I Shapiro
- Joan C. Edwards School of Medicine Marshall University Huntington WV
| | | |
Collapse
|
14
|
Norris OC, Schermerhorn T. The mean cell volume difference (dMCV) reflects serum hypertonicity in diabetic dogs. PLoS One 2019; 14:e0219864. [PMID: 31335875 PMCID: PMC6650031 DOI: 10.1371/journal.pone.0219864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/02/2019] [Indexed: 12/29/2022] Open
Abstract
Serum hypertonicity may develop during diabetes mellitus due to hyperglycemia and other biochemical changes. Hypertonicity may produce detrimental cellular and systemic effects and has been identified as a serum marker for some clinical disorders. In non-diabetic dogs, the mean cell volume difference, a novel erythrocyte measure, is increased by serum hypertonicity. However, it is not known whether hyperglycemic hypertonicity produces a similar change. The hypothesis that the mean cell volume difference could detect serum hypertonicity in diabetes was investigated in a group of thirty-two dogs with naturally-occurring diabetes mellitus that were prospectively recruited over a 1-year period from the outpatient population of a veterinary teaching hospital. The effect of hyperglycemia on the mean cell volume difference and the ability of the mean cell volume difference to predict serum hypertonicity were examined. Serum hyperosmolality and hypertonicity due to hyperglycemia was present in 91% and 94% of dogs, respectively. Hyperglycemia was the principal cause identified for serum hypertonicity and hyperosmolality. Using a cut-off value of ≥ 3 μm3 for the mean cell volume difference, serum hypertonicity ≥ 320 mmol/kg was identified with 79% sensitivity and 61% specificity. The dMCV correlated with changes in serum glucose, tonicity, and measured osmolality. Dogs with a mean cell volume difference ≥ 3 μm3 were at risk for serum tonicity ≥ 320 mmol/kg (risk ratio = 2.2) and serum glucose ≥ 13.9 mmol/L (risk ratio = 2.3). In conclusion, the mean cell volume difference is a useful surrogate marker for detecting serum hypertonicity in diabetic dogs and elevated mean cell volume difference is associated with increased risks for clinically relevant serum hypertonicity and hyperglycemia.
Collapse
Affiliation(s)
- Olga C. Norris
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, United States of America
| | - Thomas Schermerhorn
- Department of Clinical Sciences, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas, United States of America
- * E-mail:
| |
Collapse
|
15
|
Vigil D, Kien C, Gibb J, Glew RH, Tzamaloukas AH. Symptomatic Hyperglycemia in a Patient with Dialysis Ascites. Am J Med Sci 2019; 357:512-516. [PMID: 30975430 DOI: 10.1016/j.amjms.2019.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 02/07/2019] [Accepted: 02/15/2019] [Indexed: 12/27/2022]
Abstract
An anuric woman with ascites rapidly developed extreme hyperglycemia and seizures after hemodialysis. During development of hyperglycemia, the decrease in serum sodium concentration (Δ[Na]) was nearly twice the value predicted by a formula accounting for the degree of hyperglycemia and the intracellular-to-extracellular volume ratio. The prediction assumed that ascitic fluid is part of the extracellular volume. Potential contributors to the development of seizures include the rapid development of severe hypertonicity, a remote history of seizure disorder and development of dialysis disequilibrium syndrome. Observations in peritoneal dialysis suggest that fluid with sodium concentration lower than in the ascitic fluid is transferred from the abdominal cavity into the blood during rapid development of hyperglycemia. In this case, Δ[Na], which determines the tonicity level expected after correction of hyperglycemia, resulted from exit of both intracellular and ascitic fluid into the extracellular compartment and, therefore, ascitic fluid functions as an extension of the intracellular fluid.
Collapse
Affiliation(s)
- Darlene Vigil
- Division of Nephrology, Department of Medicine; Renal Section
| | - Cassandra Kien
- Barret's Honor College, Arizona State University, Tempe, Arizona
| | - James Gibb
- Division of Nephrology, Department of Medicine
| | - Robert H Glew
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Antonios H Tzamaloukas
- Division of Nephrology, Department of Medicine; Research Service, Raymond G. Murphy VA Medical Center, Albuquerque, New Mexico.
| |
Collapse
|
16
|
Chung S, Kim S, Son M, Kim M, Koh ES, Shin SJ, Ko SH, Kim HS. Empagliflozin Contributes to Polyuria via Regulation of Sodium Transporters and Water Channels in Diabetic Rat Kidneys. Front Physiol 2019; 10:271. [PMID: 30941057 PMCID: PMC6433843 DOI: 10.3389/fphys.2019.00271] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 02/28/2019] [Indexed: 12/12/2022] Open
Abstract
Besides lowering glucose, empagliflozin, a selective sodium-glucose cotransporter-2 (SGLT2) inhibitor, have been known to provide cardiovascular and renal protection due to effects on diuresis and natriuresis. However, the natriuretic effect of SGLT2 inhibitors has been reported to be transient, and long-term data related to diuretic change are sparse. This study was performed to assess the renal effects of a 12-week treatment with empagliflozin (3 mg/kg) in diabetic OLETF rats by comparing it with other antihyperglycemic agents including lixisenatide (10 μg/kg), a glucagon-like peptide receptor-1 agonist, and voglibose (0.6 mg/kg), an α-glucosidase inhibitor. At 12 weeks of treatment, empagliflozin-treated diabetic rats produced still high urine volume and glycosuria, and showed significantly higher electrolyte-free water clearance than lixisenatide or voglibose-treated diabetic rats without significant change of serum sodium level and fractional excretion of sodium. In empagliflozin-treated rats, renal expression of Na+-Cl- cotransporter was unaltered, and expressions of Na+/H+ exchanger isoform 3, Na+-K+-2Cl- cotransporter, and epithelial Na+ channel were decreased compared with control diabetic rats. Empagliflozin increased an expression of aquaporin (AQP)7 but did not affect AQP3 and AQP1 protein expressions in diabetic kidneys. Despite the increased expression in vasopressin V2 receptor, protein and mRNA levels of AQP2 in empagliflozin-treated diabetic kidneys were significantly decreased compared to control diabetic kidneys. In addition, empagliflozin resulted in the increased phosphorylation of AQP2 at S261 through the increased cyclin-dependent kinases 1 and 5 and protein phosphatase 2B. These results suggest that empagliflozin may contribute in part to polyuria via its regulation of sodium channels and AQP2 in diabetic kidneys.
Collapse
Affiliation(s)
- Sungjin Chung
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Soojeong Kim
- Department of Biochemistry, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Mina Son
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Minyoung Kim
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seok Joon Shin
- Division of Nephrology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Seung-Hyun Ko
- Division of Endocrinology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ho-Shik Kim
- Department of Biochemistry, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| |
Collapse
|
17
|
Gibb J, Xu Z, Rohrscheib M, Tzamaloukas AH. Hyperglycemic Crisis in an Anuric Peritoneal Dialysis Patient with Profound and Symptomatic Hypertonicity. Cureus 2018; 10:e2566. [PMID: 29974021 PMCID: PMC6029734 DOI: 10.7759/cureus.2566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
An anuric peritoneal dialysis patient with diabetes mellitus, congestive heart failure, and anasarca developed severe hyperglycemia with hypertonicity causing profound neurological manifestations after prolonged and continuous use of hypertonic (4.25%) dextrose dialysate. She expired with hypotensive shock from a new myocardial infarction soon after completion of treatment with insulin infusion. The degree of the presenting hypertonicity far exceeded the value expected from the degree of hyperglycemia. We identified prolonged peritoneal dialysis with hypertonic solutions and profound extracellular volume expansion as the causes of the excessive hypertonicity. Hyperglycemia developing in diabetic patients treated for anasarca by peritoneal dialysis after continuous use of hypertonic dextrose dialysate is associated with the risk of excessive hypertonicity with severe clinical manifestations.
Collapse
Affiliation(s)
- James Gibb
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Zhi Xu
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Mark Rohrscheib
- Department of Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | | |
Collapse
|
18
|
Roumelioti ME, Ing TS, Rondon-Berrios H, Glew RH, Khitan ZJ, Sun Y, Malhotra D, Raj DS, Agaba EI, Murata GH, Shapiro JI, Tzamaloukas AH. Principles of quantitative water and electrolyte replacement of losses from osmotic diuresis. Int Urol Nephrol 2018; 50:1263-1270. [PMID: 29511980 DOI: 10.1007/s11255-018-1822-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/04/2018] [Indexed: 02/08/2023]
|
19
|
Roumelioti ME, Glew RH, Khitan ZJ, Rondon-Berrios H, Argyropoulos CP, Malhotra D, Raj DS, Agaba EI, Rohrscheib M, Murata GH, Shapiro JI, Tzamaloukas AH. Fluid balance concepts in medicine: Principles and practice. World J Nephrol 2018; 7:1-28. [PMID: 29359117 PMCID: PMC5760509 DOI: 10.5527/wjn.v7.i1.1] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.
Collapse
Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Robert H Glew
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan Edwards School of Medicine, Marshall University, Huntington, WV 25701, United States
| | - Helbert Rondon-Berrios
- Division of Renal and Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Dominic S Raj
- Division of Renal Disease and Hypertension, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Emmanuel I Agaba
- Division of Nephology, Department of Medicine, Jos University Medical Center, Jos, Plateau State 930001, Nigeria
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Glen H Murata
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
| | | | - Antonios H Tzamaloukas
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
| |
Collapse
|
20
|
Abstract
The population of elderly individuals is increasing worldwide. With aging, various hormonal and kidney changes occur, both affecting water homeostasis. Aging is a risk factor for chronic kidney disease (CKD) and many features of CKD are reproduced in the aging kidney. Dehydration and hyperosmolarity can be triggered by diminished thirst perception in this population. Elderly with dementia are especially susceptible to abnormalities of their electrolyte and body water homeostasis and should be (re-)assessed for polypharmacy. Hypo- and hypernatremia can be life threatening and should be diagnosed and treated promptly, following current practice guidelines. In severe cases of acute symptomatic hyponatremia, a rapid bolus of 100 to 150 ml of intravenous 3% hypertonic saline is appropriate to avert catastrophic outcomes; for asymptomatic hyponatremia, a very gradual correction is preferred. In summary, the body sodium (Na+) balance is regulated by a complex interplay of environmental and individual factors. In this review, we attempt to provide an overview on this topic, including dehydration, hyponatremia, hypernatremia, age-related kidney changes, water and sodium balance, and age-related changes in the vasopressin and renin-angiotensin-aldosterone system.
Collapse
Affiliation(s)
- Christian A Koch
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, University of Mississippi Medical Center, Jackson, MS, USA.
- G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS, USA.
- Cancer Institute, University of Mississippi Medical Center, Jackson, MS, USA.
| | - Tibor Fulop
- FMC Extracorporeal Life Support Center, Fresenius Medical Care; Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
- Department of Medicine, Division of Nephrology, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| |
Collapse
|